Initial Scope Review
When a hyperbaric treatment center considers seeking UHMS Accreditation the first order of business is to assess the extent to which its current facilities and practices conform to the standards required for accreditation. During the course of an initial two- to three-day site visit our consultant will help the center’s staff understand how completely the center conforms to the requirements.
As we identify tasks required for accreditation, we can also provide insight into the scope of effort, time, and resources required to make up any difference between the center’s current operation and one that will satisfy the survey requirements. This initial perspective will provide the center’s management with insight into critical path dependencies between tasks and the time required before a site visit by UHMS surveyors.
Benchmark Report
We will prepare a written report based on the initial scope review, identifying the tasks necessary to achieve conformance with the accreditation standards and the estimated resources required to perform them. We will highlight any dependencies between tasks so they can be performed in the best order. The benchmark report can be used during the course of preparation for the survey and adjusted as necessary as the work progresses.
SURVEY COMPONENT REVIEWS
As the center works to prepare, our consultants can work with the center’s staff make detailed assessments of the progress in specific areas. Some of this work may require site visits. Documentation can be reviewed off-site.
SURVEY SITE VISIT PLANNING
As the date of the survey visit approaches we can help the center’s staff ensure everything is in order. Having the correct documentation readily at hand and anticipating potential questions will help the UHMS surveyors use their time to best effect.
Areas to Consider
The UHMS Accreditation survey includes the following areas of hyperbaric oxygen therapy practice and facility administration. The treatment center management and staff should evaluate their current performance in each of the survey areas relative to the standards established for accreditation.
The evaluation should also consider the resources required to close any gaps between the center’s current operation and the standards. Time, human and capital resources, and other constraints affect the scope and duration of an accreditation preparation project.
Survey Areas:
- Governance
- Administration
- Operations
- Maintenance
- Facility construction
- Chamber fabrication
- Chamber ventilation
- Chamber electrical systems
- Chamber fire protection system
- Medical gas system
- Patient rights
- Patient assessment
- Patient care
- Environmental care
- Patient education
- Quality improvement
- Professional improvement
- Leadership
- Human resources
- Information management
- Infection control
- Medical staff
- Teaching and publication
- Clinical research