Prepare your organization for CHAP accreditation

The Community Health Accreditation Program (CHAP) in New York City offers a comprehensive self-study guide that walks the organization through the four chapters of standards, says Terri Ayer, RN, MS, CNAA, interim president and chief executive officer.

While some organizations approach completion of the guide differently, Ayer suggests that it be used as a self-evaluation tool. A consultant can help you go through the process, but it should be people from the agency actually answering the questions, she adds.

Once completed, the guide is sent to CHAP to be evaluated prior to the site visit.

"When our site visitors arrived, they were already familiar with our agency and had specific issues to discuss," says Doris Mosocco, RN, CHCE, director of quality management for Riverside Hospital Home Care Division in Newport News, VA. This resulted in a very efficient, very focused survey, she adds.

While there are no single areas that show a preponderance of recommendations over other areas, Ayer and other CHAP-accredited agency managers suggest that the following areas receive attention:

  • Proof of diploma and license

Every personnel file for a professional staff member not only should include verification of a valid license but also a copy of the employee’s diploma or transcript. "This differs from Joint Commission on Accreditation of Healthcare Organizations (JCAHO) standards that only require verification of license," says Cober. "We require the diploma or transcript as an extra measure to ensure that the employees are who they say they are," Ayer adds.

  • Employee self-evaluation

CHAP also requires that employees complete an annual self-evaluation in addition to the supervisor’s annual evaluation, says Karen Cober, RN, MSN, administrator of Medical Center Home Care & Hospice in Johnson City, TN. Copies of the self-evaluation must be in the personnel file, she adds.

  • Financial information

Unlike JCAHO, CHAP evaluates the financial viability of the organization. "We want to make sure that agencies have not only the clinical and human resources to provide quality care but also the financial resources to assure patients that they will be around to continue providing care," Ayer says. Documentation for financial resources includes budgets, audited financial statements, and proof of cash reserves or credit lines to support the agency in difficult times, she explains.

  • Performance improvement

CHAP does not require presentation of one major performance improvement project but does look for evidence that performance improvement is ongoing in all aspects of the agency, Mosocco says. You can meet this standard by showing simple things, such as changing a form to make it easier to use and clearer in meaning, she adds. Another item that Cober points out is accessibility. "We regularly check the response time of our answering service, but every agency needs to know that a site visitor will make a call after hours to see how much time passes before a response is received. Make sure you’ve remembered to check out your answering service as well as all your other areas."