Accreditation and certification processes offer benefits for service providers as well as funders. However, these processes can create a high level of stress, involve large amounts of effort and disrupt the focus of organisations on their other goals. Are there ways to reduce the level of stress and streamline the process? Here are the top ten tips from our staff to help make accreditation a more efficient and less painful experience.

This article reflects the views of Lirata staff and draws on our experience in accreditation, consulting and internal quality management roles. The strategies that will work best in individual organisations or accreditation processes may vary and this article does not constitute professional advice about your specific circumstances.

Note on terminology: a range of terms are used to describe formal processes of assessment against specified quality and safety frameworks or standards. In this article, the word 'accreditation' is used as an overarching term to refer both to accreditation and certification processes. The term 'assessment' is used to refer to the process of independent third party examination of an organisation's performance against a specified safety or quality framework or standards, to determine whether accreditation should be granted. We recognise that other terms including 'survey', 'audit' and 'review' are used to refer to this process under other frameworks.

 
 

Finding ways to reduce accreditation stress

Accreditation has a range of benefits. It carries a level of kudos that can boost an organisation's credibility. It's an important lever for funders to use in achieving compliance with certain policy or practice frameworks. And accreditation agencies are able to see a clear difference in the level of sophistication and professionalism of organisations that have been involved in accreditation programs over time, compared to those that have not.

However, undergoing accreditation is a stressful process for organisations. If your organisation is participating for the first time, there will be many unknowns, which add to the stress. If you have been through multiple cycles already, you will know the process better, but there is always the worry that performance may have dropped, that new issues may come to light that were not identified previously, or that the organisation will struggle to demonstrate the quality of its work and systems. The pressure is greater when accreditation results could influence funding.

Accreditation tends to impact most heavily on a small group of staff who carry the main responsibility for preparation. However, other staff and managers are often concerned about their involvement in assessment processes, as well as the potential results.

There are many factors that influence the level of stress and disruption experienced by organisations undergoing accreditation. The way that assessment processes are structured is an important aspect. There is emerging evidence through projects such as the Short Notice Accreditation Assessment Pilot, overseen by Queensland Health and the Australian Commission on Safety and Quality in Health Care, that giving organisations less notice of impending assessments and encouraging them to adopt an 'accreditation ready every day' philosophy can reduce accreditation burden and stress.

Putting aside the accreditation model itself, the way that organisations understand and prepare for assessment can play a significant role in both stakeholder experience of the process, and the outcome.

We've never worked with an organisation who found accreditation a breeze. But with the right preparation, the process can be more efficient and less stressful. Here are our top ten tips that may assist.

1. Identify how your organisation can get the most out of accreditation

Usually, the first goal that comes to mind when approaching accreditation is "passing the test". But it's worth considering what else your organisation can gain from the process, beyond the certificate.

Accreditation is an opportunity for learning and quality improvement. It's a chance to gain external thinking and feedback about your systems and your work. Look to gain the greatest value you can from that external input. It can also be a lever for internal change – engaging multiple levels of stakeholders, from Board to frontline staff, in thinking about what is needed to move the organisation forwards.

Because accreditation looks across many aspects of the organisation, it provides an opportunity for noticing and beginning to address a broad range of systemic problems. It can place an organisation on the path to clearly defined improvements in many areas. Accreditation can provide organisational leaders with a useful tool for placing important but non-urgent issues in the spotlight, strengthening the effectiveness and strategic positioning of the organisation.

2. Start early – but don't overdo it

Leaving accreditation preparation to the last minute usually doesn't lead to good outcomes! It means you have less opportunity to present yourself in a positive light to the assessors, as well as less opportunity to fix any gaps or problems before the assessment date.

For preparation to be efficient and effective, you will need to be organised. Rather than waiting for the accreditation provider to provide information, be proactive and seek out the information you need.

We recommend that you start planning at least 6 months ahead. Contact your accreditation provider to confirm the assessment dates, Standards, and when you will need to submit any documentation required. Then develop a plan to ensure that you will be ready in time. This also helps to avoid last minute panics.

If you are participating in short-notice or unannounced assessments, then preparation will be even more important. Rather than preparing for an event though, your goal will need to be to establish high-performing quality and safety systems as part of business as usual, so that your organisation is ready for an assessment at any time.

On the flip side - it sounds counter-intuitive, but sometimes over-preparation can be as problematic as under-preparation. Organisations sometimes invest so heavily in accreditation preparation that it impacts on their ability to pursue other priorities, including quality improvement initiatives. Overwhelming assessors with large volumes of self-assessment and evidence is usually not helpful – assessors have very limited time and there's no point turning your key evidence into a needle within a haystack of documentation. It's preferable to provide five documents with clear, applicable evidence on a specific criterion than 50 documents of marginal relevance.

We recommend keeping your self-assessment brief and to-the-point. Avoid statements about what your organisation thinks and values ("We have a strong commitment to respecting clients' privacy …") and focus more on the concrete elements of organisational systems and processes ("We provide clients with a privacy brochure at point of intake …").

3. Know the requirements

Each accreditation framework, and each accreditation provider, will have a different set of requirements and expectations about the accreditation process. These could relate to the items you need to provide to the assessors, the types of activities that will occur during the assessment (e.g. document review, interviews, site audits, file audits, observation), which of these occur on-site, how long the assessment will take, the types of questions the assessors will ask, and how you should present your evidence or self-assessment.

Get clear on these requirements as early as possible. Ask the accreditation provider, or the lead assessor, for a detailed list of the activities that will occur as part of the assessment. And find out exactly what paperwork will need to be submitted when, in what format.

You will also need to be clear on additional regulatory requirements that may be connected with accreditation, but not part of the accreditation process itself. For example, some funders may require registration of organisations within a specific regulatory regime. Accreditation is often a necessary precursor to achieving registration, but there will be extra administrative steps involved in finalising registration. Your accreditation provider and/or funder will be able to advise further.

One of the best ways to gain a clear understanding of accreditation processes is to have an assessor on staff. If you don't already have someone with that knowledge on your team, then consider encouraging one of your staff to undertake training in quality assessment. (Some accreditation providers utilise a peer assessor model and welcome assessors who are currently working in organisations within the health and community services sectors.) These people will prove an invaluable resource in guiding you through your own accreditation processes.

4. Coordinate responsibility and brief your stakeholders

Someone within your organisation will need to take leadership of the process from your end. If you have a Quality Manager or equivalent role, then driving the accreditation preparation process will normally be part of their role. If not, a manager will need to take responsibility.

Regardless of who is leading the process, for preparation to be effective it will need to be a team effort. Relying on one person to do it all is risky. It's much better if accreditation – and organisational quality in general – is seen as a shared responsibility across all areas, rather than the concern solely of the Quality Manager.

Get your key internal stakeholders together to discuss who will do what:

  • Organising the logistics of the assessment.
  • Completing or updating your self-assessment (if applicable).
  • Identifying, prioritising and addressing outstanding organisational issues or gaps that could jeopardise your accreditation.
  • Collating evidence documents.

Where possible, delegate responsibility for parts of the work to the different departments or teams who will be accredited. You will need to meet or at least communicate regularly to check progress and ensure that the process remains on track.

Don't forget that where materials are prepared by multiple people, someone will need to do a final consolidation and edit to ensure that the overall picture makes sense. Presenting an inconsistent and jumbled story will not provide the assessors with a positive view of your work.

A range of stakeholders will usually be involved in the assessment process itself – management, frontline staff, perhaps patients or clients, Board members, or sometimes external stakeholders such as representatives of partner organisations. In the lead up to the assessment, confirm with the lead assessor exactly who will need to be involved in interviews.

Ensure that you brief these stakeholders on what their involvement will be and what is expected of them. Staff can sometimes feel nervous about participating in assessment interviews. It is useful to let them know the purpose of the interviews and the types of questions they are likely to be asked. You can find out more about the interview process from your accreditation provider and/or lead assessor.

5. Schedule assessment processes for manageable impact

It is becoming increasingly common that organisations are subject to multiple accreditation requirements. This is particularly the case for organisations that have diverse state and federal funding streams, each with their own accreditation requirements attached. Compliance burden is a significant issue for service providers, and there is a need for regulator attention to the issue. However, given the current reality of multiple accreditation requirements, there are still steps that organisations can take to keep the impact manageable.

There are two scheduling strategies that organisations tend to adopt: either to try to align accreditation assessments to occur at the same time – to "get it over with in one big hit" – or to distribute them over time to spread the impact. Some organisations we have worked with have found that having to respond to multiple external assessments one after another can interfere with their ability to implement substantive programs of quality improvement in between, as effort is repeatedly directed into assessment preparation. Others struggle with the resourcing required to successfully prepare for simultaneous assessment processes, and try to space them out. If unsure which strategy may work best for your organisation, it may be worth talking with colleagues in other organisations to see what has worked for them.

There may be external drivers for the scheduling of assessments – for example, funders' requirements for compliance by a certain date. Even within these constraints, there may be opportunity to adjust the assessment timing to fit with your organisation's other priorities. Talk to your accreditation provider(s) about possibilities to bring forward or delay assessments to fit with your needs. (If the accreditation scheme involves short notice or unannounced assessments, you may not be able to influence timing in this way.)

If you currently have multiple accreditation providers, there may be potential to consolidate these to limit the number of different sets of requirements and processes that you need to work within. Many accreditation providers offer accreditation across a range of standards.

6. Understand your organisation and your accreditation risk areas

In all accreditation frameworks, there is the possibility that your organisation will be found not to have met the required standards. Although you will often be provided with the opportunity to address these issues after the assessment (for example, through a Corrective Action period), it is preferable where possible to identify them beforehand.

This can be helpful in several ways.

  • It can provide the chance to fill gaps prior to external assessment, for example by creating additional policies, updating records, introducing new practice frameworks or training mechanisms, and so forth.
  • It can mean these areas don't come as a surprise when they are identified by the assessors, giving you time to prepare a reasoned response.
  • Assessment findings may be less negative if you can demonstrate that you are aware of gaps and have plans in place to address them.

The best way to identify your accreditation risk areas is to undertake a gap analysis well ahead of the external assessment. This means undertaking your own internal self-assessment of your organisation using the Standards or Criteria for the assessment. This will need input from content experts in specific areas – for example, self-assessing your organisation's HR system will require input from staff responsible for HR management and HR administration. These staff will often have clear ideas about how their areas of operation could be improved. However, they may also be quite accustomed to the current way that things are done. Having someone outside of that area who can ask prompting questions about systems can be very useful in uncovering gaps.

Your gap analysis will identify strengths and weaknesses in relation to the assessment requirements and standards. Assess these to determine which are most likely to have major consequences for your accreditation. Prioritise action to address these. There may be others which are still important – these can be added to your ongoing quality work plan.

In some accreditation frameworks, there are certain events or findings that can have additional negative consequences. For example, certain types of non-compliance may be reportable to regulatory bodies. At a minimum, this presents a reputational risk; at worst, it can result in loss of funding. Find out from your accreditation provider whether the accreditation frameworks you are subject to involve reportable circumstances of this type. If they do, then thoroughly review your systems and practice in those areas prior to assessment.

7. Don't try to fake it

If gaps emerge before or during assessment, it can be tempting to try to "paper these over" in the hope that the assessment team will not notice the issue. Assessors often have stories about documents that were missing at the beginning of the assessment, then mysteriously appeared later in the process, with content remarkably similarly to another document found on the internet… or sometimes even have another organisation's logo still at the top. In other cases, organisations coach staff to give particular responses at interview, which may be at variance with actual practice in the service.

Although "fake it till you make it" is a useful motto in some fields, it is usually counter-productive in accreditation processes.

The cover-up approach often doesn't work – assessors are trained to triangulate multiple sources of evidence, and quickly pick up on inconsistencies. It's stressful for staff, feeding into the perception that they have to "put on an act" rather than simply talking from their experience. And perhaps more importantly, "faking it" means that you are losing genuine opportunities to improve your systems and practice. Remember that if serious gaps are identified, you will generally have an opportunity to address these following the assessment. Having the assessor's input into what the gaps are, and how you should address them, can help your organisation to respond more effectively and efficiently to these matters.

A transparent and collaborative approach with the assessment team usually works best.

8. Organise your evidence

Accreditation processes normally require you to provide a range of documentary evidence: policies, procedures, plans, meeting minutes, and so forth. The assessors will use these documents as a key source of evidence in relation to the standards. If insufficient evidence is available, you will not be able to demonstrate that your organisation meets the standards. It's in your interests to organise your documents in ways that help assessors find the relevant evidence, quickly.

Check with your accreditation provider and/or lead assessor to see whether they have specific requirements for how evidence is presented. For example, some providers require evidence documents to be uploaded to an online tool and linked to the specific standards to which they are relevant.

If your provider has not given specific directions about organising evidence documents, one option is to provide electronic evidence in folders as follows:

  • A folder which contains current versions of all policies and procedures. This will let the assessors quickly gain an overview of your policy system.
  • A set of folders which contains Terms of Reference, recent minutes and work plans (where applicable) from key organisational structures – for example, Board, management team meeting, staff meeting, OHS Committee, etc. This will let the assessors quickly see what issues are considered in each of these forums.
  • A set of folders organised in accordance with the structure of the accreditation standards and criteria. For example, if you are being accredited against a set of 4 standards, each with several criteria, then provide four standards folders, with subfolders for criteria. Place key evidence relevant to each standard or criteria in these folders.

Over time you will build up a bank of documentary evidence which is relevant to accreditation. This will need to be updated regularly, with the latest versions of minutes, procedures and so forth. Maintaining this evidence bank will make the process of providing evidence for specific assessments much quicker than if you start from scratch each time.

9. Set moderate expectations

Remember that any accreditation assessment is just one step on a longer journey of quality improvement. Each assessment will show areas of strength and areas for improvement, so it's wise to have an expectation of mixed results, and to understand that there will be further work to do based on the outcomes. Communicate these expectations to stakeholders and don't let expectations build too high!

It's often particularly important to set this expectation at senior management and Board level. Prepare the ground for the probability that there will be areas where performance is found to be lacking, and reinforce the view that it's better to know about these areas and be able to deal with them, than to let them go unattended. It's also useful for stakeholders to understand that while some issues may need to be addressed quickly to achieve accreditation, others may involve a longer-term process of reflection and action as part of an ongoing quality improvement plan.

It can be interesting to compare your organisation's accreditation results with those of other like organisations, however be wary of the expectations that this can set up. Each organisation and each assessment has a unique context and there are many factors that influence organisational performance and assessment findings. If your goal is to continue improving your own organisation, it is generally more useful to focus on what you can learn from the qualitative findings about your organisation, than to view accreditation results as a numerical score.

10. Access external advice in preparation if required

If you are struggling with preparing for accreditation, or just want to check you are on the right track, it can be helpful to obtain external advice. One option is to speak to colleagues in other organisations who are involved in the same accreditation processes that you are. Look to build a network of support around yourself and your organisation. There are also many consultants who understand accreditation processes and can provide advice, or assist you with processes such as self-assessment and preparation of evidence.