WHAT IS THE TABLE OF EVIDENCE?

The Table of Evidence is organized into a chart that outlines the necessary evidence your organization needs to provide in order to demonstrate implementation of the standards. This includes a written Administration and Management, Service Delivery Administration, or Service Narrative, relevant attachments to support the narrative, applicable forms and charts, Self-Study documents, on-site documents, and on-site activities.

Your organization will use the Table of Evidence and the Narrative templates in the Related Files as a guide to assemble your Self-Study and prepare your organization for the on-site visit.

The Administration and Management and Service Delivery Administration Narratives provide an opportunity for your organization to discuss key practices that contribute to performance and productivity. It also provides the Peer Review Team with a clear understanding of how your organization is utilizing the standards to advance and sustain your mission and goals (see example 1).

The Service Narrative is divided into two sections - Program Information and Program Outputs and Outcomes - and provides an opportunity for your organization to describe the unique characteristics of your program(s) covered under a specific service (see example 2).

Program Information includes basic demographic information that helps the Peer Team become familiar with the unique characteristics of the program(s) and the population(s) being served.

Program Outputs and Outcomes includes information that helps the Peer Team understand how your organization is aggregating data, and measuring quality and outcomes in the program(s) being accredited.

The Self-Study Documents column includes evidence that should be provided in your organization's Self-Study, which is submitted to COA and the Peer Team prior to the site visit. These documents demonstrate how your organization is implementing the standards for that section.

The On-Site Documents column includes evidence that your organization should have readily available for the Peer Team when they arrive for the site visit. The Peer Team may review these documents if they need further information to evaluate your implementation of the standards. The Peer Team has the discretion to request additional documentation if they need further information to properly rate a standard.

The On-Site Activities column identifies the individuals who may be interviewed by the Peer Team during the site visit, as well as any necessary case record reviews or facility observations. The Peer Team has the discretion to interview additional individuals within your organization if they need further information to properly rate a standard (see example 3).