The best way to map policies to standards and get accredited

Discover what it takes to get accredited, and how four organizations transformed their accreditation process to save time and money.

December 21, 2020

The accreditation process looks different in every industry. CALEA accreditation looks different for law enforcement than TJC accreditation does for healthcare.

The reason is clear. Police officers and nurses have different jobs, and they need to be accountable to different standards.

Despite all the differences, there is one commonality: the need to prove compliance by mapping your policies to standards. The only question is how you do it, and how well.

In this article, we’ll explore accreditation processes across four industries, how to map policies to standards, and the difference between a policy and a standard.

Policy vs. Standards

What is a policy?

Policies are a set of guidelines outlining an organization’s plan for addressing a wide array of issues. Policies (and all important documents) influence culture, communicate expectations to employees, and guide operations. As such, they need to be easily accessible by staff at all times and periodically updated.

What is a standard?

A standard is a level of performance that needs to be achieved to receive accreditation, based on industry best practices and regulations. Accrediting bodies create the standards and hold member organizations accountable to them through a stringent accreditation process. Performance is usually measured during an onsite assessment, when an organization’s policies and procedures are compared to the accrediting standards.


How to get accredited

We looked at the accreditation process for accrediting bodies within four distinct industries:

  • Law Enforcement: CALEA (Commission on Accreditation for Law Enforcement Agencies)
  • Healthcare: TJC (The Joint Commission)
  • Fire/EMS: CPSE (Center for Public Safety Excellence)
  • Parks and Recreation: CAPRA (Commission for Accreditation of Park and Recreation Agencies)

Each of their accreditation processes vary slightly, but they all involve some combination of the following 5 steps:

Step 1: Enrollment

For each accrediting body, there is some form of enrollment process where you (the applicant) have to choose an accreditation program, review requirements, pay a fee, and/or submit an application.

Step 2: Training

Sometimes training is required as well. These training sessions help you understand the specific accreditation process and everything that will be required. In this phase, an accreditation manager needs to be assigned, someone who can complete the required training and own the process for your organization.

Step 3: Self Assessment

Each accreditor has a self-assessment phase, where you have to compare your performance against the accrediting standards and/or complete a number of accreditation documents.

For example, once an organization has registered or enrolled, the CPSE gives applicants 18 months to complete three documents: community risk assessment, community-driven strategic plan, and self-assessment manual.

Step 4: Assessment or Survey

Once the self-assessment is completed, it’s time for the onsite assessment or survey conducted by trained representatives from the accrediting body. In healthcare, these surveys are unannounced, so organizations always need to be prepared.

The end result is an accreditation report and final verdict. CAPRA and CPSE require an official hearing, which you or your accrediting manager need to attend to receive approval or denial.

Step 5: Accreditation Maintenance

Maintenance is required for all accreditations. With industry best practices and regulations frequently evolving, it’s easy to understand why.

The best way to get reaccredited is to maintain it year-round: assessing organizational performance, staying abreast of new or updated standards, tracking document updates, and clearly mapping your policies to those standards.

With most review cycles occurring on an annual basis, some organizations view accreditation as a one-time event. Preparing for an onsite assessment will always take time, but accreditation should be viewed as an ongoing performance improvement process.

How to map your policies to accreditation standards

Clearly, receiving and maintaining accreditation takes a lot of work. Since compliance is often determined by measuring alignment between standards and policies, it’s important to have a system in place for showing and demonstrating compliance. Like most things, there’s an easy way and a hard way.

The hard way

The hard way is also one of the most common ways. It’s using paper, or some combination of paper and digital (email, shared drives, Dropbox, etc.), to manage the process. Let’s explore how organizations across a couple industries used to do it.

Lacey, WA Police Department

Lacey PD had a system for maintaining WASPC (Washington Association of Sheriffs and Police Chiefs) accreditation, but it was complex and paper-based. To prepare for re-accreditation, they recruited three staff members to sort through the paperwork, who spent weeks digging up documents, highlighting policies and standards, labeling papers with tabs and sticky notes, and organizing files in cardboard boxes.

War Memorial Hospital

War Memorial Hospital, a 28-site healthcare network, struggled with one of DNV’s key accreditation standards—regularly reviewing and updating policies. With all the files to sort through, they often couldn’t complete it on time, which put them at risk of noncompliance and created a safety risk for nurses using outdated treatment information. The accreditation team had no system for tracking employee signatures on key documents, and even if they could, they wouldn’t know if the signed version was the most current one.

Newton, MA Police Department

While preparing for re-accreditation, Newton PD would print out physical copies of new policies and accreditation documents, send them to every bureau, and wait for the signed copies to return. If documents needed edits based on bureau feedback, the whole process restarted. This method required an overwhelming amount of paper, manpower, and time—it took a five-person team multiple 60-hour weeks to complete everything. Not only were they paying for printing, shipping, and storage of accreditation files, overtime pay was through the roof.

Georgia Southern University Health Services

GSU’s accreditation manager, Kim, was working hard but lacked the tools to work efficiently. She spent months hand typing AAAHC standards and checking them against GSU’s policies and training. Though she kept some paperwork on the university’s shared drive, maintaining it all was tedious and time-consuming.

When it was time to distribute AAAHC compliance training or continuing education material, Kim would send out emails constantly to remind staff to attend training and complete the required tests. Adding to the challenge, she didn’t have an easy way to track if everyone’s AAAHC compliance training was up-to-date or not.


The easier way

Can you relate to any of their challenges? What does your accreditation process look like? Despite being in different industries, each of these organizations have something in common. Yes, they all faced similar accreditation challenges. But more importantly, they all found a solution—a policy management platform with the ability to automatically map policies to accreditation standards.

They found PowerDMS.

“In a healthcare situation, not following the correct protocol could be the difference between life and death. With PowerDMS, the most relevant policies are up-to-date and available in all of our facilities. We did away with the three-ring binders and the old paper copies. It makes things so much easier.”

- Stephanie Pins, Accreditation Manager at War Memorial Hospital

The PowerDMS platform has policy, accreditation, and training tools, but unlike many solutions on the market today, these tools automatically connect and inform one another to save you time and money. 

PowerDMS’ powerful software has helped Lacey PD, War Memorial Hospital, Newton PD, GSU Health Services, and many others attain and maintain accreditation. Could the following features and benefits help your accreditation process as well?

  • Electronically attach policies and proofs of compliance to standards

  • Highlight standards that need additional proofs of compliance

  • Collaborate with accreditation team members via automated workflows

  • Give assessors access to your proofs of compliance prior to an onsite visit

  • Conduct mock assessments and remote assessments

  • Receive alerts when standards need updating

  • Be notified of every policy impacted by an updated standard

  • Easily distribute updated policies and standards to employees

  • Track read receipts and E-signatures on disseminated policies

Lacey, WA Police Department

After implementing PowerDMS, Lacey PD saved about $2,000 on administrative costs related to accreditation. They also saved two months in accreditation prep time.

War Memorial Hospital

PowerDMS helped War Memorial Hospital eliminate an estimated 40 hours in both meetings and collaboration during accreditation. Not to mention the paper, printing, and storage costs saved by securely storing their content in PowerDMS. The team at War Memorial can now rest assured that the latest version of any policy is on every computer in all of their 28 locations.

Newton, MA Police Department

Newton PD saved time and thousands of dollars thanks to PowerDMS’ training module, automatic notifications, file management, secure storage, easy accessibility, dissemination system, archiving capabilities, simple search, and more.

Georgia Southern University Health Services

When GSU Health Services first applied for AAAHC accreditation, it took Kim about two years to prepare for the self-assessment. Using the same outdated system, it would take her months to update the self-assessment each time AAAHC published standards changes. Now with PowerDMS, Kim is able to update the self-assessment within a couple weeks.

“Leadership and administrators [at ASC’s] wear so many different hats and do so many different things. PowerDMS is like a personal assistant. I wouldn't even consider taking a position in another center if they didn’t agree to get PowerDMS. It’s seriously life-changing from an administrator standpoint.”

- Chris Washick, RN, CASC, Administrator at Triangle Orthopaedic Surgery Center

Everything you need in one place

PowerDMS publishes state, national, and international standards, including many of the ones listed in this article: CALEA, TJC, AAAHC, CPSE, and CAPRA (view the full list of published standards).

What does this mean for you? When combined with our interconnected policy and accreditation modules, these published standards simplify the accreditation process, giving you everything you need to prove compliance and maintain accreditation in one convenient location.

Interested in time and cost savings similar to War Memorial Hospital and Lacey PD? Schedule a free demo today to learn how PowerDMS can help your organization.

Mapping policies to accreditation standards is but one of the most common problems organizations like yours encounter. Learn about the others here (and their solutions).

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