CCA Review Team Manual:A Guide for Reviewers and Team

LeadersJune 2015 edition

Canadian Centre for Accreditation | Centre canadien de l’agrément500A – 970 Lawrence Avenue West, Toronto (ON) M6A 3B6

416-239-2448 1-844-239-2448 www.canadiancentreforaccreditation.ca | www.centrecanadiendelagrement.ca

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Table of Contents

Introduction .................................................................................. 1 The CCA Accreditation Program............................................................1CCA’s Approach to Accreditation...........................................................1About This Manual...............................................................................2For More Information...........................................................................2

The Reviewer Role ......................................................................... 3 Who Is Involved in a CCA Review?.........................................................3

The CCA Review Team..........................................................................................3CCA Staff...............................................................................................................3

A Reviewer’s Responsibilities...............................................................3A Team Leader’s Additional Responsibilities..........................................4Workload.............................................................................................4What We Expect from CCA Reviewers....................................................5What Reviewers Can Expect from CCA...................................................6

A Reviewer’s Guide to the Process ................................................. 7 Overview.............................................................................................7Planning and Preparation.....................................................................8

Things to Remember............................................................................................8Before the Site Visit: Divide the Work...................................................9

Things to Remember..........................................................................................10Before the Site Visit: Assess Pre-Site Evidence on One’s Own...............11

A Note on Strengths and Areas for Development...............................................11Things to Remember..........................................................................................11

Before the Site Visit: Make Team Decisions and Prepare the Visit.........13Team Decision Making........................................................................................13Site Visit Schedule Preparation...........................................................................13Things to Remember..........................................................................................14

The Site Visit.....................................................................................15Interviews...........................................................................................................15

A Word on the Chief Executive Interview/Meeting...........................................16On-Site File Review.............................................................................................16Client Journey.....................................................................................................16

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The Verbal Wrap Up............................................................................................17Things to Remember..........................................................................................17

The Preliminary Report and End of Review..........................................18The Preliminary Report.......................................................................................18Final Tasks..........................................................................................................18Things to Remember..........................................................................................18

Team Leader Guide ...................................................................... 20 Introduction.......................................................................................20Before the Site Visit: Team Work and Decision Making.........................20

Key Deliverables.................................................................................................20Checklist.............................................................................................................20

Before the Site Visit: Schedule and Prepare the Site Visit....................22Key Deliverables.................................................................................................22Checklist.............................................................................................................22

During the Site Visit...........................................................................24Key Deliverables.................................................................................................24Checklist.............................................................................................................24

After the Site Visit.............................................................................26Key Deliverables.................................................................................................26Checklist.............................................................................................................26

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Introduction

The CCA Accreditation ProgramThe Canadian Centre for Accreditation (CCA) is a national non-profit bilingual accreditation body serving a wide range of community-based health and social service organizations. CCA’s accreditation program supports organizations to continually improve the quality and efficiency of the programs and services they provide.

CCA’s Approach to Accreditation CCA offers a four-year accreditation that supports an organization’s quality management.

CCA looks at the whole organization, with an accreditation program that is modular. The accreditation program combines a set of Organizational Standards covering areas such as governance, organizational planning and performance, leadership and risk management, with program and service modules relevant to different services.

CCA standards reflect foundations of excellence at community-based health and social service organizations. These foundations include:

A focus on people and communities served, respecting their dignity and diversity

A strength-based approach to service delivery, recognizing the social and physical environments that impact people’s well-being and health

A commitment to equity and to actively addressing barriers to service A drive to improve outcomes for people and communities served Integration of continuous learning, improvement and innovation Decision making that is evidence-based Safe services and work settings Efficient use of resources to achieve outcomes Social and ethical responsibility Accountability and transparency

Evidence that the organization has met CCA standards is gathered through organizational documents and narratives presented ahead of time; responses to CCA surveys of community partners and other stakeholders; and review team observations, interviews, and document, file and/or process reviews as part of a site visit. Reviews are conducted by senior staff and board members recruited from partner organizations participating in CCA accreditation and trained as reviewers by CCA. Teams typically consist of a team leader and at least one other reviewer -- with

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some teams as large as five. The size and characteristics of the organization determines the size of the team and the length of the site visit.

About This ManualThis manual is designed to be the central reference for CCA reviewers.

The term “reviewers” includes team leaders and youth reviewers. Where something pertains only to these specialized roles, the manual specifies it.

This manual provides:

An introduction to a CCA reviewer’s role and responsibilities A reviewer’s guide to the process, organized chronologically according to a

reviewer’s tasks at each stage of the review A team leader’s guide to the additional deliverables and tasks that are part of

leading a team

The manual references additional essential tools and resources made available to reviewers in the Reviewer’s Corner of GoCCA, the password-protected section of the CCA Web site at www.canadiancentreforaccreditation.ca.

For More Information Canadian Centre for Accreditation | Centre canadien de l’agrément500A – 970 Lawrence Avenue West, Toronto (ON) M6A 3B6416-239-2448 1-844-239-2448 info@canadiancentreforaccreditation.ca

www.canadiancentreforaccreditation.ca | www.centrecanadiendelagrement.ca

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The Reviewer Role

Who Is Involved in a CCA Review?The CCA Review Team

CCA reviews are conducted by reviewers recruited from organizations that participate in CCA accreditation. They are either staff, members of the board or governing body, or volunteers that are trained by CCA.

Review teams consist of a team leader and at least one other reviewer -- with some teams as large as five. The team is adjusted based on the size and characteristics of the organization. Review teams are made up of individuals from a mix of community-based sectors, with the team leader generally having direct experience in the sector of the organization being reviewed.

Team leaders are reviewers that have had experience participating in several reviews, and have been selected and trained by CCA to lead teams.

CCA Staff

A CCA Accreditation Manager is assigned to each review. The manager, the CCA Accreditations Coordinator and CCA’s Office Manager provide support to the review team and the organization during the review process.

A Reviewer’s ResponsibilitiesA reviewer is expected to:

Participate actively throughout the process Assess pre-site evidence (documents, narratives, surveys) before the site

visit Make individual assessments of whether the organization meets indicators

using the GoCCA Web Tool Participate in making team decisions on all indicators Lead interviews and other site visit activities Prepare and deliver the Verbal Wrap Up on site Debrief with team members and support team decision making throughout

See A Reviewer’s Guide to the Process below for more on the tasks at each stage of a review.

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A Team Leader’s Additional ResponsibilitiesThe team leader assumes responsibility for leading the team’s work between two and three months before the site visit. This responsibility ends on delivery of the draft Preliminary Report to the CCA Accreditation Manager. In addition to carrying the same responsibilities as other reviewers, the team leader manages the work of the review. This involves scheduling meetings to keep track of the work of the team, helping to orient team members to their roles, and mentoring less experienced team members.

More specifically, a team leader is expected to:

Provide leadership to the review team throughout the process Liaise with the CCA Accreditation Manager Lead the assignment of standards/indicators to team members for their

individual assessments prior to the site visit (team members should expect to take responsibility for specific on-site interviews and observations linked to these standards/indicators, and these aspects of the Verbal Wrap Up)

Facilitate the reaching of a team decision on all indicators in the review Help to orient team members to their roles and mentor less experienced

reviewers as required Plan for the site visit in consultation with the organization and according

to CCA requirements, and in particular to develop a detailed site visit schedule

Oversee the successful preparation of the team and completion of all site visit activities – including the Verbal Wrap Up

Complete tasks and writing up of findings for production of the written Preliminary Report

WorkloadA CCA review represents a substantial workload.

The team leader spends between 25 and 30 hours pre-site visit coordinating various aspects of the review in consultation with the CCA Accreditation Manager, the organization, and the other reviewers. This includes time reviewing pre-site evidence.

The other reviewers on the team need between 20 and 25 hours before the site visit to review pre-site documentation, assess indicators and record assessments and comments in the GoCCA Web Tool.

During the site visit, the team should expect busy, full days taken up with interviewing individuals and groups, making observations, reviewing files, checking on-site documents and visiting the organization’s site or sites. Throughout the process reviewers are expected to use the GoCCA Web Tool to continue to

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document their individual decisions and keep notes that will facilitate team decision making. Time between interviews and other activities as well as late afternoon and early evening hours are set aside for team debriefings, team decision making and preparation of the Verbal Wrap Up.

During the site visit or immediately after, the team leader may need between two and five hours to review assessment and edit findings so the CCA manager can prepare the written Preliminary Report.

What We Expect from CCA ReviewersCCA expects reviewers to demonstrate:

Respect for the confidentiality and privacy of the organization and its clients

Experience and knowledge that is well-grounded in the realities of organization being reviewed

Curiosity and willingness to learn Understanding of not-for-profit governance and a client-centred

community-based approach to program delivery Good written and verbal communication skills Interviewing skills Familiarity and ease with using computers and the Internet The ability to analyze and synthesize information The capacity for making sound judgments Teamwork skills Good time management, flexibility, and problem-solving skills Integrity and trustworthiness Support for CCA including a willingness to share with CCA insights and

observations to contribute to the ongoing improvement of the CCA program

CCA issues each reviewer with a username and password that provide access to the the password-protected GoCCA section of the CCA Web site and to the GoCCA Online Accreditation Tool to complete their tasks on the review to which they are assigned.

Reviewers must have access to their own or their organization’s portable computer (PC or Mac) throughout the review period, beginning two months before the site visit. The computer must have:

Capability to connect to the Internet A Web browser updated to a recent version Microsoft Word, Excel and PowerPoint (version 2003 or later) Adobe Acrobat Reader Capability to download and install software (for example, GoToMeeting

and GoToWebinar for trainings and online meetings)

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What Reviewers Can Expect from CCA CCA is committed to providing reviewers with:

Orientation to the structure and content of the CCA accreditation program Training to carry out duties as a reviewer Logistical assistance in preparing for the review Support at all phases of the review, including consultation on interpreting

CCA’s standards and requirements A readiness to accept reviewers’ feedback and to use it to improve the

process Appreciation and recognition for their participation in the CCA accreditation

program

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A Reviewer’s Guide to the Process

OverviewThis is the timeline of a review from the perspective of a reviewer.

Planning and preparation starts about six months before the organization’s site visit, when we recruit the team. Between two and three months before the site visit is when the work of the team really begins in earnest. By the end of the site visit, the level of involvement tapers off.

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Timing in Relation to the Site Visit-6 months -4 months -2 months -1 month -2 weeks +1 week

Planning and PreparationPlanning and preparation for a review starts about six months before the organization’s site visit, when we recruit reviewers onto a team. CCA builds the review team (including a designated team leader) based on factors such as sector-related experience and knowledge, CCA-related experience, availability, and the mix of skills and backgrounds needed on the team.

By email, we then do a conflict of interest check with team members and with the organization. CCA defines a conflict of interest as “any obligation or interest that materially affects or interferes with the judgment and/or objectivity of a review team member in the performance of his/her duties for the organization being reviewed.” A past or current working relationship in and of itself does not necessarily constitute a conflict. Reviewers are encouraged to ask CCA if in doubt. If there is a conflict of interest declared either by the organization or a team member, the CCA selects and assigns another reviewer.

Once conflict of interest clears, we connect team members with one another and with the review’s designated CCA Accreditation Manager, and send instructions on booking travel and accommodations.

Things to Remember

If you have not logged in to GoCCA in a while, test your username and password now to make sure you can get in.

Look at the calendar. Plan to book off at least 20 hours to complete your pre-site tasks starting two months before the site visit.

Make sure the information CCA has on file for you is up to date. Check preferred contact information, biography, and dietary and other special requirements.

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Consult the Travel and Expense Policy for Site Visits located in the Reviewer’s Corner section of GoCCA for instructions on booking travel and accommodations, and claiming expenses.

Before the Site Visit: Divide the WorkAn organization’s pre-site evidence in the GoCCA Web Tool is ready for the review team between two and three months before the site visit.

The immediate focus of the review team’s work is in assessing all the indicators that are dependent on pre-site documents, narratives and CCA’s surveys of the organization’s stakeholders. A reviewer first works on his/her own in the GoCCA Web Tool to assess a set of assigned pre-site indicators.

The indicators are assigned during a team kickoff phone or Web meeting called by the team leader before or around that two-month point. Each member of the team (including the team leader) is assigned indicators based on factors including experience, workload balance and the goal of having two sets of eyes on the indicators. A reviewer’s assigned indicators become areas on which the reviewer will focus throughout the review. For example, if a reviewer was responsible for assessing human resource indicators, s/he should also expect to take the lead on those questions in on-site staff interviews and in the Verbal Wrap Up.

During the meeting, the team also reviews travel plans and other practical arrangements, goes through a refresher on how to enter decisions and comments in the GoCCA Web Tool, divides up the work, and sets dates for follow-up check ins and meetings.

It is also at the two-month point that the team leader begins working with the first draft of the site visit schedule provided by the CCA Accreditation Manager.

See the Team Leader Guide below for details.

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Consult the Team Kickoff Meeting Agenda located in the Reviewer’s Corner section of GoCCA.

Things to Remember

What you do now and how you do it contributes to the final product and will make the process easier. So, let’s understand the end game.

By the end of the site visit, there must be a team assessment of Met or Not Met on each and every indicator.

The site visit closes with a Verbal Wrap Up in which all team members participate to present the preliminary results of the review. It has a set format that includes highlighting for each module particular strengths, any areas where there are unmet standards that will have to be addressed for accreditation, and other areas that are opportunities for further quality improvement.

After the site visit, a Preliminary Accreditation Report is prepared. It has a module-by-module structure consistent with the Verbal Wrap Up.

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Before the Site Visit: Assess Pre-Site Evidence on One’s OwnAt this stage, a reviewer’s job is to make an individual assessment on all his/her assigned indicators that are dependent on pre-site documents, narratives and CCA’s surveys of the organization’s stakeholders.

The reviewer logs a decision of Met, Not Met or Don’t Know for each of these indicators in the GoCCA Web Tool, adding comments and questions on each in the text box provided. (The default is No Decision; leave No Decision only if no assessment of the indicator has taken place at all yet.) A brief note on why the indicator is assessed as Met, Not Met or Don’t Know is essential to the team debriefing and decision-making process. Each reviewer’s decisions and notes on an indicator are visible to the rest of the team in the GoCCA Web Tool.

All members of the team must complete their assessments by the deadline agreed in the team’s kickoff meeting, in order to provide enough time for the team leader to roll up the results and facilitate the making of team decisions no later than two weeks before the site visit.

A Note on Strengths and Areas for Development

Along with recording a Met/Not Met/Don’t Know decision, reviewers have the opportunity to flag an indicator as “Strength” or “Area for Development.” At this early stage, your assessment work is starting to create a picture of the organization. Start to flag areas/indicators that you think may be emerging as particular strengths of the organization. While these may change later, ticking the possible ones early will help you and the team eventually make note of areas where the organization particularly shines. Leave aside Areas for Development for now.

Things to Remember

Be intentional Review information about the organization in the Organizational Profile

before starting documents review and assessment of indicators. Filter indicators by evidence type (for example, filter indicators that call for

the staff survey and assess those in a set). Organize reading time around a logical cluster of documents (for example,

filter documents to show only board minutes and read/assess linked indicators in a set).

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Refer to the Preliminary Report Template and the Verbal Wrap Up Template located in the Reviewer’s Corner section of GoCCA.

Be thorough and decisive If an indicator only requires pre-site evidence (for example, dependent only

on a pre-site document), push yourself to respond Met or Not Met. If you assess Don’t Know, establish why and what follow up will get you the evidence you need.

Rely on and support other team members Raise questions with your team leader as they come up. Set aside adequate time, don’t leave work until the last minute and adhere to

deadlines.Make notes in the GoCCA Web Tool

To remind yourself why you decided Met, Not Met or Don’t Know To help to determine what would need to be done to meet indicator To prompt yourself to ask a specific question on site To use in the development of the Verbal Wrap Up and the Preliminary Reprt

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Before the Site Visit: Make Team Decisions and Prepare the VisitAfter team members have assessed indicators on their own, the team works to come to consensus on team decisions and plans for the site visit.

Team Decision Making

The team leader is responsible for making sure that the team gets to a team decision on each indicator, and for entering and maintaining team decisions in the GoCCA Web Tool as they evolve. By the end of the site visit, the team must have made a team decision of Met or Not Met on each and every indicator.

The goal at this pre-visit point, is to have a team decision entered on all indicators dependent on pre-site evidence and to have identified follow-up tasks for the site visit.

The team leader hosts a phone or Web meeting for this purpose no later than two weeks before the site visit. Prior to the meeting, the team leader goes through the results, makes team decisions where there is consensus, identifies areas of disagreement or points needing discussion, and circulates an agenda and reports of indicators to discuss during the session. Team members should review the materials in advance of the meeting and identify questions to bring up and any changes that they might want to make in their own decisions that will bring the group closer to a unanimous team decision.

During the meeting, the team also reviews travel plans and other practical arrangements, set dates for follow-up check ins, and review the site visit schedule.

Site Visit Schedule Preparation

The site visit schedule is developed by the team leader with the input of the organization. About two months prior to the site visit, the team and organization are provided with a first draft from the CCA Accreditation Manager. The team leader begins working with the organization’s accreditation leads to take this draft forward.

By one month before the site visit, the team leader circulates a second draft to the team, to the CCA Accreditation Manager and to the organization for feedback in advance of the Team Consensus Decisions Meeting. A final version of the schedule is due to CCA and to the organization no later than two weeks before the site visit.

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For instructions on what to cover in the meeting, consult the Team Consensus Decision Meeting Agenda located in the Reviewer’s Corner section of GoCCA.

Things to Remember

Be prepared Set at least 1.5 hours aside for the Team Consensus Decisions Meeting. Review the materials and your notes before the meeting.

Stay on track Focus on areas where team members “disagree.” Do not delay making a decision if the on-site review cannot reasonably

provide further evidence.Look ahead

Come out of the meeting with a clear to-do list (for example, questions for the CCA Accreditation Manager, items for the organization to prepare, documents that are missing and to request from the organization for delivery when the team is on site or prior, adjustments to be made to the site visit schedule).

Start to identify and note areas emerging as organizational strengths.

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Consult the Site Visit Schedule Builder located in the Reviewer’s Corner section of GoCCA.

The Site VisitSite visits range from between two and five days. Most occur over three days.

While the site visit schedule will look different for different organizations, the types of activities and requirements are more or less the same. The team is oriented to the organization; conducts a number of interviews; observes the facilities and sometimes programs in action; reviews some files and documents on site and traces processes as they occur; and, finally, ties off the site visit with a Verbal Wrap Up presenting an overview of the preliminary results.

Reviewers participate in all aspects of the site visit. Team members work together and individually throughout, and debrief and make decisions and comments as they go in order to arrive at final team decisions for every indicator.

Throughout the site visit, reviewers continue to log their decisions and comments using the GoCCA Web Tool, while the team leader logs team decisions at team debriefings.

Interviews

The CCA review team conducts a number of mostly group interviews while on site, including with the board or governing body, with groups of staff including a staff cross-section interview, with program-specific staff, with managers and with the chief executive.

Each interview must be opened and closed using the format set by CCA.

Interviews are tied directly to indicators. The list of indicators for each interview is generated using the GoCCA Web Tool’s filters and/or reporting function.

There are no pre-set questions. Review team members, using the decisions and comments logged in the tool, work the indicators into a question format with which they are comfortable and that will hone in on what is specifically needed as evidence to satisfy the indicator.

Each reviewer is responsible for crafting his/her own questions. Where possible, interview questions are developed and asked by review team members who were assigned as a lead on the pertinent indicators.

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For instructions and requirements for activities on site, consult CCA’s Site Visit Schedule Builder located in the Reviewer’s Corner section of GoCCA.

Refer to the Interview Opening and Closing Comments located in the Reviewer’s Corner section of GoCCA.

A Word on the Chief Executive Interview/Meeting

The interview with the organization’s chief executive is unique. It serves two purposes: to ask questions based on the list of indicators for the chief executive interview and to present an initial version of the Verbal Wrap Up (see below).

On-Site File Review

Some CCA reviews require the review of a sample of client and/or program files during the site visit. The contents of each file in the sample is reviewed against a CCA checklist of elements one would expect to find or see in evidence.

As a rule, at least one review team member is assigned the review of files as part of the site visit schedule. An orientation to the files or filing system is provided by the organization near the beginning of the site visit.

There are sampling guidelines, file-review checklists and instructions for completing file reviews specific to each sector.

Client Journey

Some CCA reviews include a client journey, the tracing of a small number of clients’ movement through service by way of client interview, file review and provider interviews.

As a rule, one review team member is assigned the client journey as part of the site visit schedule. The organization assigns a “navigator” to facilitate the setting of interviews and pulling of files.There are guidelines, checklists and instructions for completing the client journey specific to each sector in which it is used.

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For guidelines on the content, duration and timing of the chief executive interview, consult CCA’s Site Visit Schedule Builder located in the Reviewer’s Corner section of GoCCA.

Refer to the file review checklists located in the Tools for CCA Reviews section of GoCCA.

Refer to the Guide to the Client Journey located in the Tools for CCA Reviews section of GoCCA.

The Verbal Wrap Up

The site visit closes with a Verbal Wrap Up in which all team members participate to present the preliminary results of the review.

The 20-minute presentation has a set format that includes highlighting for each module particular strengths, any areas where there are unmet standards that will have to be addressed for accreditation, and other areas that are opportunities for further quality improvement. It is a “heads up” of the coming written Preliminary Report.

All team members participate in preparing and delivering the wrap–up presentation, using one of three template scripts chosen according to the number of unmet standards required for accreditation. The team leader is expected to submit the team’s written Verbal Wrap Up speaking notes to the CCA Accreditation Manager by email along with the Preliminary Report.

Things to Remember

Continually debrief, synthesize information, and narrow down the work and indicators to only the ones still requiring follow up.

Use the reports and filters in the GoCCA Web Tool to check which indicators are still Don’t Knows or require follow up.

Use the GoCCA Web Tool to output interview guides which you can print or call up on your laptop screen. It is easier to conduct the interview and make notes on the interview guide. Then, debrief as a team later, and update team decisions and comments in the GoCCA Web Tool.

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Refer to the Guidelines for the Verbal Wrap Up located in the Tools for CCA Reviews section of GoCCA.

The Preliminary Report and End of ReviewThe Preliminary Report

To close off the review, the team leader reviews assessments and ensures team findings (comments on indicators) are written up clearly and concisely. The team leader provides to the CCA Accreditation Manager:

The Verbal Wrap Up notes A final version of the site visit schedule that reflects activities completed and

people seen Any additional notes

The CCA Accreditation Manager drafts the written Preliminary Accreditation Report based on information generated from the GoCCA Web Tool. The manager may ask the team leader for clarification and additional input as the report is developed.

The organization’s response will be reviewed by CCA staff when it comes in six weeks later.

Final Tasks

The reviewer’s work is almost done! As soon as the Preliminary Report is sent, reviewers are asked to submit review-related expenses to CCA, shred papers related to the affairs of the organization under review, and permanently delete electronic files downloaded on their computers.

Each reviewer on the team receives a confidential online survey from CCA. Reviewers’ feedback on their experience with the accreditation is invaluable to the quality and development of the CCA program.

Things to Remember

Documents accessed in the GoCCA Web Tool have ended up in the Downloads on your computer and will need to be deleted. The filenames all start with the same few words identifying the review.

o Sort the folder containing downloads by name. o Select and delete all the files pertaining to the review.o Empty the trash/Recycling Bin.

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Refer to the Sample Preliminary Report located in the Tools for CCA Reviews section of GoCCA.

Consult the Travel and Expense Policy for Site Visits located in the Reviewer’s Corner section of GoCCA.

Team Leader Guide

IntroductionBeyond his/her duties as a reviewer, there are some key deliverables for which the team leader is responsible. This section gives the team leader a quick run down and checklist for each stage.

Before the Site Visit: Team Work and Decision MakingKey Deliverables

Team members ready Work divided Team decisions made on indicators that call for pre-site documents, surveys

and narratives Travel, accommodations and any practical arrangements booked

Checklist

Key Deliverables Team Leader’s Tasks

Team members ready

Orient team members to timelinesOrient team members to main tasks in GoCCA Web Tool (logging in on portable computer will be bringing to review, reviewing Org Profile, entering assessments and comments, filtering standards)Set up and schedule Team Kickoff MeetingReview Organization’s Profile, contact information and other basics in GoCCA Web ToolNotify CCA Accreditation Manager of changes in contact information, dietary restrictions or special requirements

Work divided Hold Team Kickoff MeetingSee Reviewer’s Corner – Agenda for Team Kickoff Meeting

Divide assessment of indicators (two sets of eyes on each indicator, see tips)

Review instructions for making individual assessments

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Set and agree on three deadlines:o Team members to complete individual

assessment of indicators in GoCCA Web Tool

o Team leader to consolidate into team decisions in GoCCA tool; produce and send team/consensus decisions reports to team members

o Team Consensus Decisions Meeting to review team/consensus decisions and identify follow up

Email notes from kickoff meeting / division of indicators

Team decisions made on indicators that call for pre-site documents, surveys and narratives

Make individual assessments in GoCCA Web Tool on your assigned indicatorsCheck in with team members on progress making individual assessments by deadline; support/mentor team members as neededReview individual assessments on indicators that call for pre-site documents, surveys and narratives.Make team decision and comments on each (marking Don’t Know where consensus still needed)Produce and review reports:

Generate reports of Not Mets and Don’t Knows Review reports; flag points of disagreement and

other items requiring team discussion, and items for follow up

Send team/consensus decisions reports to team membersHold Team Consensus Decisions MeetingSee Reviewer’s Corner – Agenda for Team Consensus Decisions Meeting

Enter/edit team decisions and comments in GoCCA Web Tool on indicators that call for pre-site documents, surveys and narratives

Travel, accommodations and any practical arrangements booked

Contact CCA travel agent for hotel options and own travel arrangementsSee Reviewer’s Corner – Travel Booking and Expense Claim Policy and Procedures for Site Visits

Choose hotel for teamMake own travel arrangementsCheck in with team members to ensure they have made own bookings

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Before the Site Visit: Schedule and Prepare the Site VisitKey Deliverables

Site visit schedule completed Team members prepared for site visit tasks assigned Site visit logistics arranged/confirmed

Checklist

Key Deliverables Team Leader’s Tasks

Site visit schedule completed

Contact chief executive and/or accreditation lead to introduce yourself and book meetingReview initial draft of Site Visit Schedule Builder and day-by-day schedule from the CCA Accreditation Manager (worksheet column).Set and hold meeting to get organization’s input and recommendations on site visit schedulePrepare second draft Site Visit Schedule; post to GoCCA Review Dashboard’s Key Files; send to organization, team members and CCA Accreditation Manager for feedbackPrepare final Site Visit Schedule; post to GoCCA Review Dashboard’s Key Files; send to organization, team members and CCA Accreditation Manager

Site visit logistics arranged/confirmed

Contact organization to ensure on-site arrangements made for:

A private, lockable work room Food for working lunches (please note

dietary restrictions and allergies on the Team Info Memo sent)

A room or rooms in which interviews can be conducted

Internet access (preferably wireless) Access to a printer (printer in the team’s

work room preferred) Access to a telephone, if possible

Team members prepared for site visit tasks assigned

Prompt team members to review site visit activities and to access resources they will require (for example, on-site file review checklist, client journey guidelines)See various in Reviewer’s Corner and Tools for CCA Reviews

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Generate interview guides in GoCCA Web Tool; distribute to team members with Interview Opening and Closing Comments scriptSee Reviewer’s Corner – Interview Opening and Closing Comments

Delegate preparation of interview questions (team members should have at least prepared day one interviews before arriving on site)Remind team members to test portable computers they will bring on siteConfirm team’s meeting arrangements on site before start of site visit at organizationSee Reviewer’s Corner – Agenda for Team On-Site Meeting

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During the Site VisitKey Deliverables

Site visit activities completed successfully Team decisions final on all indicators Verbal Wrap Up speaking notes drafted; Verbal Wrap Up rehearsed.

Checklist

The team leader is responsible for ensuring the team completes all aspects of the site visit culminating in the Verbal Wrap Up on the last day of the visit. In addition, the team leader is a liaison, where needed, between the team and organization’s representatives and between the team and CCA.

The site visit schedule becomes, in itself, a checklist of day-by-day activities in addition to these tasks.

Key Deliverables Team Leader’s Tasks

Site visit activities completed successfully

Liaise with organization representatives as needed regarding on-site arrangements, questions, etc.Manage the site visit ensuring interviews, observations, file reviews and other activities are completed as requiredGenerate up-to-date interview guides and tools in GoCCA Web Tool as needed; distribute to team membersGuide the development of the Verbal Wrap Up, ensuring that written speaking notes are prepared according to the CCA template.See Reviewer’s Corner – Review Team Script: Verbal Wrap Up

Lead the team in a rehearsal of the Verbal Wrap UpUpdate site visit schedule as you go if any changes

Team decisions final on all indicators

Guide regular team debriefings throughoutEnter/update team decisions in the GoCCA Web Tool throughoutProduce and review reports/interim results at regular points (reword); flag items still requiring decision, team discussion, follow up, inquiry with CCA Accreditation Manager, etc.

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After the Site VisitKey Deliverables

Decisions reviewed, comments finalized Verbal Wrap Up speaking notes, final site visit schedule and client journey

and/or file review checklists submitted to CCA Accreditation Manager. Final administrative tasks completed

Checklist

Key Deliverables Team Leader’s TasksDecisions reviewed, comments finalized

Filter for all Not Met indicators and edit through team comments for completeness and clarity

For Preliminary Report

Submit to CCA Accreditation Manager: Verbal Wrap Up speaking notes Final site visit schedule Client journey and/or file review checklists

(completed)Respond to questions from CCA Accreditation Manager as needed

Administrative close-off tasks completed

Shred/delete documents as directedSubmit expense claimSee Reviewer’s Corner – Travel Booking and Expense Claim Policy and Procedures for Site Visits

Complete online evaluation when received from CCA

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