Planning, Organizing, and Conducting the Work
We’ve learned a lot over the past 30 years of working with our organizations, and we’d like to share the best of what we’ve learned about how to prepare for the work of getting accredited.
- Get Started Right Away
There is a lot of work to do and you are on a fairly strict time line...so don't wait!
- Prepare and Orient Staff to COA's Accreditation Process
Staff buy-in to your organization's decision to seek accreditation is a key factor in a positive accreditation outcome. Staff should know why the organization is seeking accreditation, what it hopes to achieve, what they can expect, how the process will effect their time and workload, etc.
Organization Accreditation Training Template
Summary of COA's Administration and Management Standards
Summary of COA's Service Delivery Administration Standards
- Review Your Accreditation Service Plan as Soon as you are Notified of Its Completion
This document will be placed on your MyCOA dashboard following your Intake Call. The Accreditation Service Plan is a comprehensive timetable that provides a schedule of key milestones in your organization's accreditation process. It also includes details about which Service Standards have been assigned to your programs. It is very important that there not be any errors so review this document to insure that information it contains is what you agreed to during the Intake Call.
- Appoint an Accreditation Coordinating Committee
COA recommends that the organization begin the self-study process by appointing a task force or coordinating committee that will work with your Point of Contact to assign tasks, keep staff on deadline, assess practices, help prepare, and generally work with the Point of Contact to mange the work of getting accredited. Typically the Accreditation Coordinating Committee includes senior administrative staff and program directors.
- Develop a Work Plan that Assigns Responsibility for Tasks and Incorporates Key Deadlines
Key deadlines can include deadlines established by COA as well as internal deadlines established to help you manage the work. A work plan can help you and your staff stay focused and ensures that you do not feel pressured as deadlines near.
Recommended Resource: COA has created an Accreditation Work Plan Template for you to use that incorporates the key activities and milestones in the accreditation process.
- Identify Staff Members who will be Responsible for Assessing your Current Practices with the Standards
Most organizations involve many of their staff in the review of standards. Depending on the size of the organization it may be useful and efficient to divide staff into committees and/or to use existing organizational committees to help review standards and prepare accreditation materials.
Examples of committees may include:
• Board Functioning / Fiscal Management
• Personnel / Training
• Buildings and Grounds
• Planning and Quality Improvement
• Service Delivery
• Committees addressing specific service sections or populations.
Task assignments should include clear expectations of the work that needs to be done and include time frames, and due dates. See "Track Progress" below.
- Train Staff Who Will Assess Practices on How to Read the Standards
It is especially important that they understand the relationship between the Standards and the Tables of Evidence so that as they are assessing practices they will understand how implementation of the standards will be evaluated.
How to Read the Standards and Tables of Evidence
Standards that May Be Not Applicable to Your Organization
- Establish a Record of Implementation
The Review Team will be looking for evidence that the standards have been implemented. In other words, they will be evaluating the extent to which the standards have been incorporated into the way that your organization does business and provides services on a day-to-day basis.
For example, it is not enough that your organization has a certain procedure–while that is important, the review team will also be seeking evidence that staff and/or stakeholders, as applicable, are aware of, and are applying that procedure.
For many standards that means that there is a record of implementation. For example, if the standard requires that an activity occur quarterly, then meeting minutes, a record of attendance, and an agenda may constitute a record of implementation.
Please be aware that documentary evidence is only one of several sources of evidence that may be assessed. Most standards will be assessed based on multiple types of evidence. In fact, there are many standards for which the primary source of evidence is interviews with staff and/or other stakeholders, and for which COA will not be looking at any documents at all!
Types of evidence include:
– Documents (e.g., meeting minutes, fire drill logs, copies of driver's licenses, monthly financial reports)
– Records (case records, personnel files)
– Interviews with staff, management, the Board, and clients
– Data and data reports
– Results from COA's Stakeholder Survey process
Evidence of Implementation Worksheet
- Assess Your Practices Against the Standards
A self-assessment of your organization's practices against COA's standards is at the heart of the accreditation process. The results of this assessment will form the core of your “game plan” for meeting and demonstrating implementation of the standards.
Organizations typically find that they already meet most of COA's Standards, once they begin the work of assessing their practices. Others find that while their day-to-day practices generally conform with the Standards, they need to formalize much of what they do into written policies and procedures.
Nevertheless, almost every organization will discover that there will need to modify at least some of its practices or implement new practices. Depending on the area of practice or standard, this can take time and may involve multiple staff at different levels of the organization all the up to the Board. So it is important not to let this work pile up, or wait until the last minute to begin making changes.
Steps in Assessing Implementation
1. Go through each applicable section of standards, and, for each standard within these sections, evaluate the extent to which your organization has already implemented the standard and can demonstrate that it has been implemented.
2. Check the documents listed in the Tables of Evidence. Do these documents already exist? If so, to what extent do they meet the requirements of the standard? If not, its time to start working on a draft.
3. Check the rating indicators. If your organization is confident that it is meets the standards, at least at a level of rating indicator 2, then move on to the next standard.
Remember, ratings of 1 and 2 are considered "passing," while ratings of 3 and 4 are not. While more ratings of 1 within a section will help offset scores of 3 or 4, a score of 2 is as good as a score of 1 on any individual standard.
- Disseminate Stakeholder Surveys
COA requires organizations to survey key stakeholders as part of the accreditation process. Survey results are a source of evidence for many of the standards, and in some cases may be one of the primary sources of evidence for a given standard. The resources listed below explain the Stakeholder Survey process in greater depth and provide specific instructions.
Generally, the Stakeholder Surveys process should begin approximately six months before your Site Visit date. If you have any questions about this process please contact your COA Accreditation Coordinator.
Stakeholder Survey Instructions
Stakeholder Surveys / Standards Crosswalk
Engaging Clients in the Stakeholder Survey Process
How to Complete the Stakeholder Surveys - Self-Paced Training
- Track Progress
COA recommends that you take a systematic approach to tracking the various tasks that will be conducted in order to stay within the time frames and meet the deadlines outlined in your Accreditation Service Plan. A number of different staff or teams of staff might be in various stages of assessing practices, updating or creating new policies or procedures, initiating entirely new practices, undergoing training etc. At any given moment you should know what has been finished, what is still being worked on, and what work still needs to be started.
There are several ways to track progress:
• Take notes on hard copies of the standards
• Create a spreadsheet or Word document to track progress
• Use one of the tools created by COA to track progress
Standards Assessment and Tracking Worksheet
Evidence of Implementation Worksheet
- Regularly Check for Standards Updates
Don't forget to check COA’s website for relevant Standards Updates! While you will not be held responsible for any Standards Update issued after you formally start the accreditation process, the vast majority of Updates will provide relief and you are free to take advantage of them up until your site visit.
How to the Read the Standards and Tables of Evidence
- Take Advantage of the Many Training and Technical Assistance Resources COA Makes Available
A wide range of training and technical assistance resources are available to facilitate your journey toward achieving COA accreditation. These resources include many tools specifically designed to help you organize your work and track your progress. These can be accessed through the Training and Resources section of the website.
For more information see:
Trainings and Resources
- Accreditation Guidelines
- Policies and Procedures
- Training and Resources
- Solutions to FAQs
- Post Accreditation Outreach
Private Organization Accreditation
CSS Healthcare Services provides Community based health services to the young, the elderly and to Individuals with Developmental Disability. Founded in 1997, we have the ability to offer a variety of quality community-based services to our clients, which has greatly contributed to our growth and success.
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Carolina Adoption Services, Inc.
Susan A. Fox, Assistant Director
Being accredited by COA has offered Carolina Adoption Services many benefits. First, COA offers our families confidence in the services we provide. Second, we have been accredited by COA for over 10 years, which reinforces our integrity as an agency and service provider.