HOW DO WE PREPARE OUR ORGANIZATION?

Congratulations on making the decision to become, or remain, COA accredited! We've learned a lot over 30 years of working with you, our partners, and we'd like to share the best of what we've learned about how to prepare your organization for accreditation.

• Assign sections or sub-sections to a staff member who will be responsible for ensuring the appropriate review and formulation of improvement/action plans for standards in those sections. Most organizations have more than one person involved in the review of standards, but COA suggests that one person be designated as ultimately accountable for each section or sub-section.
• Conduct training for team members on how to use the standards to assess current practice. Training should include: the structure of the standards, related content within each section (notes, related standards, NA's), how to read and use the Tables of Evidence and other charts and tools within each section, advice and suggestions on how to write administration and management, service delivery administration, or service narratives. Training should also include how to read, assess, and assign an internal "rating," using the COA rating system and COA rating guidelines.
• Assign a timeframe for each team to conduct a "self-assessment" of their assigned sections. The self-assessment should include reviewing all standards and assigning a "preliminary rating" for each. The self-assessment also should include looking at the section's Table of Evidence to ensure that the required documentation is available and up-to-date and that the organization feels prepared to engage in the on-site activities that will occur. Teams should also begin writing the administration and management, service delivery administration, or service narratives.
• Use tools provided by COA to help in the self-assessment. COA has several tools that can be helpful, including various checklists (see Related Files and Tools Index). Note: The tools should be used in conjunction with the standards and should not replace reviewing the details of each standard and assessing current operations with regards to the standards.
• Review the HIPAA Fact Sheet listed under the related files on this page. After reviewing the Fact Sheet, and if applicable, complete the HIPAA Business Associate Addendum, which is also listed under related files on this page.
• Review the applicable Tip Sheets (see Tools Index) to gain a better understanding of how to implement the standards based on your unique organizational structure and model.
• Of special note: Remember that achieving COA accreditation is only possible when you have demonstrated clear evidence of having implemented the standards. Interviews conducted by the COA on-site review team are extremely important as they reveal the extent to which a policy and procedure has been operationalized within the organization. Use the interviewing process extensively and build in interview questions on the agenda for regular program/departmental staff meetings.
• Develop improvement/action plans for standards identified as "not implemented." Feedback from organizations suggests that formalizing action plans, including the assignment of a responsible individual with timeframes and clear expectations of the work to be done, can help ensure the accreditation timeline is met.
• Re-evaluate. At some point after the development and implementation of the action plans, go back and have your assigned individuals or teams re-evaluate evidence of implementation of the standards. See if the areas identified as challenges have been addressed.
• Start pulling it all together. All of the pre- and on-site documentation from the tables of evidence must be organized and prepared for either submission in the organization's Self-Study or to have available on-site for the peer review team. The main components that you need to ensure are included are: administration and management, service delivery administration, or service narratives, all pieces of evidence, all NA requests and any chart or tool that is required in each section of the standards.
• Consider conducting a "mock site visit." Mock site visits are extremely effective in helping to assess organizational readiness for accreditation/ reaccreditation. In fact, they are such powerful tools, you may want to consider conducting one at the beginning of this process along with another mock review as you near the site visit. Mock site visits can include a facilities review, case record review, and extensive interviews with staff to ascertain implementation of the standards. Used at the beginning of the process, a mock site visit can help assess where your most significant gaps are and help triage and define where you will need to invest the most amount of resources and staff time.
  
  Many of the checklists in the Related Files and Tools Index can be used to conduct a mock site visit. Give COA a call if you have any questions.
• Develop and stick to your timeline! By developing a timeline that incorporates key deadlines as delineated in your accreditation agreement, you can help your staff stay focused and ensure that you do not feel pressured as deadlines near.