URAC , ACHC, TJC Healthcare Accreditation Consultant Formula for Success

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The initial consultation is normally done by phone, and we can teleconference. 

During this consulting conversation 1A Solution will provide information about the specific accrediting organizations, whether it be URAC, TJC, VIPPS, NABP, VIPPS, CHAP, or ACHC. 

We will also provide information on your organization's predetermined accreditation needs.  Each organization is unique and their needs will vary based on information obtained during the initial phone conversation. 

The initial consultant conference is at no charge.

A consultant with expertise in your organization's business line(s) of services will be assigned to you. We find this provides consistency and develops a professional personal relationship with your consultant that allows for openness as you both journey into the accreditation process. The organizations avoid being passed from one staff member to another, aiding in consistency and success. 

The assigned healthcare accreditation consultant will contact the organization to get to know you and the organization, as well as to obtain additional information to develop a projected timeline to draft a map for success with accreditation.

Your expert consultant will request written documentation for review, such as policies and procedures, admission packets, consents, outcome data, and other documents. This will help to reduce the length of the on-site survey during the consultant's visit, so that time may be spent more efficiently.

Your expert consultant will conduct a pre-accreditation survey utilizing the various agency standards and standard elements. The on-site visit will mimic the real survey process by the accrediting agency. Each standard will be reviewed for compliance. Patient tracking, to include home visits (if applicable), will be conducted, as well as staff interviews including relevant questions that may be posed, or similar questions posed by the accrediting agency surveyor.  

The consultant will conduct mock sessions to discuss leadership, patient care, and performance improvement [quality improvement program]. 

In addition, the consultant will look over any records that have not been reviewed to include patient records, human resource files, and conduct a facility tour.

During the onsite visits, recommendations will be made that will address deficiencies as well as the organizational strengths or quality improvement that reflect the organization's commitment to quality of care. 

During the exit conference, the consultant will summarize deficiencies that need immediate action with recommendations, a timeline for completion addressing the deficiencies.

The consultant performs an onsite mock/gap survey to evaluate the organization's practice of the application and compliance with the standards of CHAP, TJC, URAC, VIPPS, or ACHC. Also, the consultant can work with your staff to be prepared to respond to questions that normally are asked of the field staff by a surveyor.

During this time the consultant can also assist the agency to identify the agency strengths to capitalize on during discussions with the accrediting surveyor. 

The consultation includes a facility assessment also, to ensure all the correct posting for federal, state, and CHAP, TJC, URAC, VIPPS, or ACHC specific requirements are met. 

They will also conduct audits of the contract, human resource, charts, Infection Control, Safety, Equipment, Emergency Preparedness, Medication, Clinical and Information Management programs.

The summary is prepared using findings based on each of the standards of URAC, TJC, VIPPS, NABP, VIPPS, CHAP, or ACHC.  The consultant will assist you with prioritizing. Also, the consultant will be able to identify the best practice that can be discussed in the open conference, or any deficiencies. Your consultant will be able to identify  best practices that can be present during the actual onsite survey.

During the site visit, the surveyor will score each standard and each substandard with the same process as the accrediting agency. The surveyor will prioritize deficiencies from high priority to very low priority. For each deficiency, there will be a recommended plan of corrective action. 

The consultant will summarize the findings, potential known deficiencies, and the accreditation agency post-survey process.

Your consultant will follow the organization’s process from the onset of application, to submission of appropriate documentation for the self study. The consultant will conduct regular phone conversations to enter questions, provide guidance and direction as needed by the organization. 

The consultant will be available during the actual survey from the accrediting agency for support and direction during this intense, and often stressful time, if allowed.  Your consultant, being familiar with your organization and having been physically at your location, as well as being familiar with the standards and the accreditation language, can direct you on how to address the situation or concern. 

Your consultant will provide post-survey support to include any possible deficiencies that might be found during the on-site survey by the accrediting agency. Your consultant will assist you in developing a plan of corrective action to submit to the accrediting agency and indicator of measure, if required.

It is vital that the plan of correction be precise and address the who, what, how, when and a plan (when required) to maintain compliance. Each accrediting agency varies in the time after the submission of the plan of corrective action for committee review. The times can be 2 to 30 days. If a single deficiency is rejected, this will delay the process, thus a loss of revenue. 

Accreditation Solutions offers continued support for services from the time of accreditation to the time of reaccreditation based on the uniqueness and request of the organization.