Standards Q & A: Policy and Procedures

Q: I am a new HSA and am trying to find where the NCCHC standards are addressed in my policies and procedures. Is there an easy way to keep track of this? Is it OK that my policies are not numbered the same as the NCCHC standards manual?

A: Yes and yes. This is actually a very common situation. Your health services policies and procedures are not required to mirror the numbering system used in the NCCHC standards manuals, although each NCCHC standard must be addressed in your policies and procedures.

If your policies do not mirror the NCCHC standards numbers, we highly recommended creating a policy and procedure crosswalk document to quickly identify the NCCHC standard that corresponds to each health services policy.

Make a spreadsheet that has all the NCCHC standards in one column. In the next column put the corresponding health services policies and procedures that address the compliance indicators within that standard. This document is a great resource when you are revising policies and an invaluable tool during your NCCHC accreditation surveys.  

Wendy Habert, MBA, CCHP, is NCCHC’s director of accreditation. Send your standards-related questions to [email protected].

From CorrectCare Volume 36, Issue 2, Fall 2022