Guide to CCA Site Visit Activities Last updated: January 31, 2016 The site visit schedule is developed by a CCA Accreditation Manager with the input of the organization.This table contains the elements that are part of a CCA site visit. Activity Purpose Organization Participants Suggested Duration of Activity CCA Team Applies to which reviews? Worksheet: My Notes About This Review Orientation to the organization Orient review team to the facility and any additional sites and their workspace executive and others as specified by the agency 1.5 hour All All Orientation to files/ documents Orient reviewer to file/ documents system for file review or client journey Accreditation lead or other as appropriate (for example, Client Journey Navigator) 30 - 60 minutes One team member All Touch base with chief executive Share any important logistical or contextual information impacting the review Chief executive 15 minutes Team leader All On-Site Document Review Review limited number of documents not uploaded into tool or documents requested by review team Accreditation Lead or other as appropriate 15 minutes One team member All Board or Governing Body Interview Gather information from the governing body At least 2/3 of the governing body’s members Recommend including chair and treasurer No staff (including chief executive) 1.5 hour (usually on day one) All. Must include Youth Reviewer if applicable. All Staff Interviews Group Cross-Section Gather information from cross-section of staff Org with 20 staff or fewer: 4-7 staff Org with 21-75 staff: 5-10 staff Org with 76-150 staff: 7-12 staff Org with more than 150 staff: 12 staff Non-management staff 1.5 hour on in the site visit) At least two team members All
No supervisors with direct reports in same interview Representation across programs, services and administration, and representing a range of roles Staff Gather information from groupings of staff No more than 8 staff per interview Group approach encouraged If indicators are specific to one program/service, group staff according to that program/service (for example, day treatment staff, EAP staff) If indicators span more than one program/service, staff by type of program/service or role (for example, cross-section of clinical/direct-service staff) Up to 1 hour each Number of interviews dependent on size and structure of organization One or two team members All Managers Gather information from program-/and managers Sometimes individually, often grouped with program-specific staff Up to 1 hour One or two team members Optional - pending whether indicators covered in other interviews Staff/ Managers Gather information from staff and manager in administrative areas Individually or in group as appropriate 30 min to one hour One team member Optional - pending whether indicators covered in other interviews IT Staff Gather information from IT staff (if different from admin staff) Individually or in group as appropriate 30 min to one hour One team member Optional - pending whether indicators covered in interviews
Managers Group Interview Gather information from a group of the organization's managers Maximum of 8 individual managers, per organization structure Replace with individual interview if no senior management team No executive 1.5 hour (usually middle to late in site visit) Majority of team members (all if possible) All CE Interview and Initial Verbal Wrap Up Gather information from chief executive and present advance view of preliminary results to date prior to verbal wrap up executive only 1 hour (late in the site visit after most activities completed) All All Stakeholder Interviews Clients Clients – Children/ Clients – Parents/ Family Gather information from groups of clients as appropriate depending on the organization No organizational staff are present 1 hour to middle of site visit) One team member CYMH CW Caregivers Children in Care Foster Parents Gather information from the indicated groups if appropriate to the organization being reviewed No organizational staff are present (unless the children in care group requests that a support person be present) 30 minutes to one hour One team member CW Youth Gather information from a group of young people who are members of the Youth Engagement Program Youth in Youth Engagement Program 30 minutes to one hour Youth Reviewer CYMH On-Site File Review Employee File Audit (in orgs where 20 or fewer staff) Review samples of files using CCA Employee File Audit Checklist provided in Go CCA (Note: Done by the CCA team only where organization has 20 staff person may be present to facilitate reviewer’s pulling of sample of files 30 min hours One team member All where 20 staff or fewer
Observation - General Observe physical facilities, systems, infrastructure Participants in the case conference or program/service demonstration No more than one hour One team member All Observation - Case Conference Observe a case conference Participants in the case conference No more than one hour One team member CYMH Observation - Program Observe a program in action Participants in the program/service No more than one hour One team member CYMH Verbal Wrap Up Verbal Wrap Up Provide a high level verbal report to the organization of the preliminary results of the review. Follows prescribed CCA template and includes strengths, areas for further quality improvement, and any requirements still to address for accreditation. At the discretion of the Chief Executive Recommended for all members of staff and governing body No more than 30 minutes All All Meals Lunches Org provides food; working lunches for team. Breakfast and Supper on your own N/A All All Team Debriefing Team Debriefing Allow the team time to make team decisions and discuss aspects of the review as needed; the TL should also build in some private time to update team decisions in tool and to manage details of the review N/A At least twice a day for at least an hour each. All All Legend: CBPHC = community-based primary health care