The Development of an Accreditation Toolkit: A Quality Improvement Initiative

Abstract

Urgent care centers (UCCs) are not required to be certified or accredited in any state, however, accreditation is an essential measure of healthcare quality and shows outside endorsement of meeting set quality and safety standards. Through accreditation, UCCs gain a market and financial advantage in showing a commitment to quality and safety in meeting set standards established by an accrediting body. Currently, few UCCs in Michigan are accredited, creating great variations in the quality and safety of care from one center to another. Emcura Immediate Care (Emcura) is one such UCC in Michigan that is currently not accredited but seeks accreditation to show this commitment to their patients and to stand out from other UCCs in the area as maintaining this higher standard. Purpose: Emcura located in Bloomfield Hills and Novi, Michigan, sought to become an accredited UCC through the Urgent Care Association (UCA) and required leadership in this endeavor. The advance practice registered nurse (APRN) and Doctor of Nursing Practice (DNP) candidate acted as project facilitator to perform a quality improvement project at Emcura. The project intent was to lead a multidisciplinary team through the beginning phases of the accreditation process through the UCA and create an accreditation toolkit to guide Emcura in the accreditation process when prepared. Methods: The Institute for Healthcare Improvement (IHI) Model for Improvement (MFI) and Lewin’s Change Theory (LCT) were used to lead a multidisciplinary team at Emcura through the self-assessment and gap analysis phase of accreditation. The self-assessment and gap analysis were guided by the accreditation standards of the UCA. Emcura was then asked to decide whether to pursue accreditation immediately or to wait for application. An accreditation toolkit was created by the project facilitator to act as a guide for Emcura when ready to apply for accreditation. Analysis: Plan-Do-Study-Act (PDSA) cycles, consistent with IHI MFI were used during the self-assessment and gap analysis to ensure the project stayed organized and that all components of the UCA accreditation standards were evaluated against current clinical practices, policies, procedures, and environment. The accreditation toolkit was then be created and evaluated by the DNP committee and Emcura for usefulness to the organization as a guide for future accreditation. Significance: Through accreditation, standards for quality and safety must be met and contribute to increased quality of care for patients of UCCs like Emcura. However, accreditation takes time, commitment, and leadership expertise that UCCs may lack. The DNP prepared APRN possess the leadership skills needed to help guide UCCs through the accreditation process and is skilled at identifying gaps and seeking solutions to fill them. Leading Emcura through the early stages of the accreditation process of organizational self-assessment and gap analysis, with creation of an accreditation toolkit, provides the perfect symbiotic format for Emcura and the project facilitator of this DNP project. Emcura learned more about their organization and the accreditation process and was left with a toolkit as a guide for future accreditation. The project facilitator was able to utilize DNP prepared APRN experiential skills to lead Emcura in this endeavor and in creation of the accreditation toolkit. This project provided the project facilitator with an opportunity to function in a consultant role and opens the door for further advancement on policy in the regulation of UCCs to influence changes in current practice.