Creating Documents
No area of CARF® accreditation preparation instills more anxiety than the creation of required documents. Organizations preparing for their initial survey often develop tunnel vision; focusing on policy and procedure preparation, to the exclusion of other processes. The goal, of this article, is to provide a greater understanding of what CARF® compliant documentation entails to help alleviate that anxiety and create a process for documentation, which will allow you to expand your focus to other areas. I’ll also provide tips and suggestions for organizing your preparations
Written documentation can be broken down into several categories.
Policies and procedures…
…include leadership, financial management, human resources, health and safety, persons served, etc.
Generally, a policy sets a specific rule while the procedure sets the process to follow with regard to the rule. Your policies and procedures provide the blueprint for your business operations. They are vitally important to provide clarity and resolve conflicts, as well as, protect against liability issues. They must take into account, not only national accreditation standards, but also, federal, state and local laws and regulations. In addition, they must mirror your organization in practice. In other words, that which you say you are doing in writing, you must actually be doing in practice.
Written plans…
…will include strategic planning, budgets, risk management, performance improvement, etc.
Written plans bridge the gap between where you are, as an organization, and where you want to go. An assessment is created and compared to the policies and goals of the organization to prepare the plan.
Assessments…
…are completed by collecting data. Critical incidents, grievances and surveys are all means of data collection that assist in assessing various areas of your organization. These assessments are used to provide written reports, analysis and evaluation
Evidence based documentation…
…refers to training reports, job description reviews, personnel attestations (acknowledgements), etc.
There are many areas that require a combination of documentation from these categories. It’s important to understand the symbiotic relationship between various documents and processes. For example, Risk Management documentation will include a Policy/Procedure document, an assessment and a plan for preventing and/or reducing loss. There will also be many supporting policies, procedures and activities geared toward managing risk.
Working with Templates
Don’t reinvent the wheel, just realign it. – Anthony J. D’Angelo
By far, the most cost effective means of creating your policies and procedures is to utilize document templates. When seeking CARF® accreditation, it is important that templates are written specifically to meet those standards. Templates can help insure that all areas of the standards are covered and save thousands of hours in the creation process. When used correctly, they provide a solid basis for document creation.
Document templates should not be used as a fill in the blank, cookie cutter, policy. Instead, consider templates to be the starting point for creating your custom documents. Every word in the template should be read, and statements considered, for applicability and truth, as it applies to your organization. As an example, among the provisions of the Accreditation Now, Code of Ethics and Conduct, remedy for government Investigations is the following:
- When a representative from a federal or state agency contacts a (Insert organization’s name here) employee at home or at their office for information regarding the organization or any other entity with which the organization does business, the individual will contact the CEO immediately. If the CEO is not available, the individual will contact the Operations Officer.
This statement may be true as written, by inserting the name of the organization, or it may need to be altered.
Example 1
- When a representative from a federal or state agency contacts a (ABC Company) employee at home or at their office for information regarding the organization or any other entity with which the organization does business, the individual will contact (Administrator for their location) immediately. If (Administrator for their location) is not available, the individual will contact the Operations Officer. Site Administrators will then report directly to the Operations Officer.
Example 2
- When a representative from a federal or state agency contacts a (ABC Company) employee at home or at their office for information regarding the organization or any other entity with which the organization does business, the individual will contact the Legal Department immediately. Reports to the legal department are to be made in person or through the official corporate email account.
Working with templates provides continuity in terms of format, theme and style. This allows multiple team members to work on various documents while maintaining the integrity of cohesion. Similar formatting of documents also eases the burden of collaborating team members and approval committees.
Document Management
An ounce of prevention is worth a pound of cure. – Benjamin Franklin
A good document management system will address the following:
- Reduce risks and legal fees
- Reduce time spent on phone and email clarifications
- Improve accountability
- Improve employee knowledge, access, and attestation
- Improve collaboration across departments and locations
- Ensure correct versions are available to relevant personnel
- Ease updating and approval functions
- Ensure timely reviews
- Quickly revise and distribute changes
- Protect against catastrophic loss
With the time and expense involved in preparing your organizations documents, it is imperative that a catastrophic event plan be put in place to protect those documents. Storing documents, electronically, offsite, can protect your assets from a natural disaster, cyber-attack or network crash.
CARF® standards require that most documents be reviewed on a regular basis. The review term can be monthly, quarterly, annually or as needed, depending on the document. When managing hundreds of documents, it’s important that your Document Management System (DMS), include a reminder function that can be directed to the appropriate staff member(s). Accreditation Now’s DMS takes this concept a step further in allowing notification of key personnel should the review not be completed on time.
If many members of an organization are working on document creation, a DMS allows members to collaborate across departments and locations to final creation. Board members or administrators can easily access the documents for final approval. If only one or two individuals are working on document creation, having an organized, online file, to refer to, can help ensure that specific documents are not overlooked.
An organized document management system eases the survey process. The documents are easily located and review dates readily available. In fact, the Accreditation Now system provides a single document providing current review dates for all documents in the system. This can save a tremendous amount of time and effort during the survey.
This content provided by: Accreditation Now, Inc.
