Transcript New Accreditation Manager Training
New Accreditation Manager Training
Jim Ferrell Caleb Asbridge Lynn Odenthal
“When we understand that slide, we’ll have won the war,” General McChrystal dryly remarked, one of his advisers recalled, as the room erupted in laughter.
Why Me?
Drafted? Volunteer?
Promoted?
Why Me?
What are the skills you need to be a successful Accreditation Manager?
Organized Detail Oriented Persistent People Skills
Tools of the trade
Tools of the trade
Tools of the trade
The ACA Team At Your Site
The ACA Team At Your Site Teams are successful when they are focused, have a short cycle time, and are supported by the executives.
Tom Bouchard
The ACA Team At Your Site Accreditation Manager 100 200 300 400 500
Support From Above Can I have support for this expensive project?
Who are you again?
Support From Above https://aca.org/standards/benefits.asp
Can I have support for this project that will keep you out of court?
I am allergic to legal action! Go man go!
Basic File Construction
What you need to know
Overview: Basic accreditation file construction How to demonstrate standard compliance Protocol/Primary Documentation Process Indicator/Secondary Documentation Preparation of Documents for review
Time to Shine
Benefits of Solid Audit Files Smoother Audit Ensure Positive Results Show Positive Operations
Before you begin: 2 Hole Punches Buy Folders Label folders and tabs
3 minutes per file MAX
The Goal: Show Compliance
ACA File Components
Identifying Parts of the ACA File Three Parts of the ACA File Compliance Checklist Protocol/Primary Documentation Process Indicator/Secondary Documentation
The Compliance Checklist The “Check Sheet” Lists The Standard Facility Status of the Standard Protocol/Primary Documentation Process Indicator/Secondary Documentation Comments
The Compliance Checklist Maintain Consistency Rate the File Signature Page
Ask to Make Copies: Auditors will take checksheets
Policies: “written policy, procedure and practice,” or Performance Based Standards
General File Guidelines Follow a person or process Make it clear to outsiders Address process changes Show integrity in paperwork
Thin is in….
Cover and Pertinent pages of policy Pertinent documentation pages Only provide what is necessary to prove compliance.
Highlighting
Make sure your auditors can find what you are showing them.
Bullets Standards with bullet points must be clearly labeled in the files.
Assign numbers to the bullet points and then label the numbers throughout the file.
Demonstrating Compliance with the Standard
Proving a Standard?
Showing that the facility has the policy, procedures, and/or processes to demonstrate compliance with the standard.
We must prove the standard in documentation and action
How to Prove a standard (Demonstrate Compliance) Show Policy & Procedure where applicable Show, through Process Indicator/Secondary documentation, how the facility meets and documents the standard Address each point of the standard Leave no room for question Address the standard Choose appropriate documentation**
What to do with Protocol/Primary Documentation
Protocol/Primary Documentation inserted into the file by level of authority Federal Laws State Revised Code DAS Rules and Policy Agency Policy Procedures Standard Operating Procedures (SOP) Local Operating Procedures (LOP)
Protocol/Primary Documentation HINTS Do not insert the whole policy or procedure Always insert the cover page and signature page Then only include pages that cover parts of the standard
Protocol/Primary Documentation HINTS Highlight (yellow) the sections within the policy & procedure section that relate specifically to the ACA standard language Use the most current dated Policy and Procedure. If a policy or procedure have been revised during a 3 year audit cycle, it is not necessary to place all versions in the ACA file If there is more than one document included in the primary section, then distinguish the different documents on the checklist and within the particular sections with some sort of tabs or divider system labeling documents, P-1, P-2, P-3, etc.
If you are performance based If your site uses “performance-based” standards, then a policy or procedure is always placed in the Protocol/Primary section within the ACA file. However, if your site has not gone performance-based and the standard does not call for written policy or procedure, then the Protocol/Primary documentation is optional.
What to do with Protocol/Primary Documentation Collect all Protocol/Primary Documentation relevant to the standard READ (yes, READ) the entire Policy, Procedure, etc.
Familiarize yourself and your staff with the Policy, etc.
Aligning the Standard and the Primary Documentation The facility must meet both the Standard and the Policy Sometimes your agency requires more stringent practices than ACA ACA will judge you on YOUR OWN policies, even if they exceed the standard
Examples of Commonly More Restrictive Policy Key Control Tool Control Chemical Control ***Check your work After gathering documentation, re-read both Standard and Policy and make sure all points are met.
Good vs. Bad Documentation
Own the file and the documents within
Good Secondary Documentation Good Documentation Complete Legible Professional Contains a date including a month, day and year Copied straight and clean Demonstrates policy compliance Correct form by policy
Process Indicator/Secondary Documentation
Process Indicator/Secondary Documentation (a.k.a. B-side) Facility Forms or Notes to the Auditor used to demonstrate the process for the standard Process Indicator/Secondary s are only a snapshot of a process and should be “good.”
Process Indicator/Secondary HINTS Do not over document a standard When a standard denotes time (daily, weekly, monthly), provide three consecutive examples
Inspect the Process Indicator/Secondary documentation: Read it: Is it appropriate Does it say too much?
Inspect the Process Indicator/Secondary documentation: Are all parts of the document legible?
No crooked copies No torn corners or edges No coffee spills No black marks
Inspect the Process Indicator/Secondary documentation: No 3 hole punches No doodling on documents Do not use original documents, No 2-sided documentation No Blank forms!
Completed forms should have: Names Signatures Dates No date gaps in inventory logs No date gaps in seclusion log entries If it is not a seven day operation, then write “day off” beside the date on the form; do not leave the line blank
Tricks to Process Indicator/Secondary Documentation Show and follow the Process Address each point of the standard in the order of the standard.
Represent both Male and Female Operations if applicable for your facility
Outside Agency Inspections Inspection Violations inter-office communication Updated Inspections
Photos Look at it Does it prove?
Does it tattle?
Label Photos Take new Photos
Every Day is An ACA Day!
Inspect what you
expect!
The Three P’s Policy —Tells the auditor what you intend to do.
Procedure —Tells the auditor how you plan to do it.
Practice —Shows the auditor that you do it regularly.
Example Standard 4-JCF-1B-01: The facility conforms to applicable federal, state and/or local fire safety codes. Fire safety inspections are conducted at the following intervals: 1) An annual inspection is conducted by the authority having jurisdiction or other qualified person(s); 2) A monthly inspection is conducted by a qualified fire and safety officer;
Policy The Kentucky Department of Juvenile Justice requires that all facilities conform to applicable federal, state and local fire safety codes. Fire safety inspections are to be conducted annually, monthly, and weekly to ensure proper compliance.
Procedure Each facility will arrange for an annual inspection by the State Fire Marshal (SFM). Any violations noted by the SFM shall be corrected within the required timeframes. Any need for major corrective action shall be reported to regional management and the Quality Assurance Branch.
A qualified Fire Safety Officer (FSO) shall conduct a monthly inspection of the building and grounds and document this inspection. The completed report shall be provided to the Superintendent for review and coordination of corrective action. All corrective action shall be documented.
A facility staff trained in applicable fire safety codes by the FSO shall complete a weekly inspection of the building and grounds and document this inspection. The completed report shall be provided to the FSO for coordination of corrective action with a copy provided to the Superintendent.
Practice What would you use to document this standard is being met?
What is Your Role?
Obtain copies of annual Fire Marshal report and corrective action In some places, coordinate the Fire Marshal visit or send reminders to the responsible party Obtain copies of monthly and weekly reports and corrective action Notify facility management if reports or corrective action are not completed
What is Your Role?
Understand the standard Make a list of what you need —reports, forms, etc.
Keep a calendar —Know when you need each item Make assignments —Know who you need each item from Be persistent in obtaining documentation
Resources CAMA — ACA — www.mycama.org
www.aca.org
Standards and Accreditation Staff Kathy Black-Dennis, Director Terri Jackson, Specialist Pam Eckler, Specialist State Juvenile & Adult Correctional Support Staff Fellow Accreditation Managers