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Emily Mayes, RN, BSN
Quality Assurance Coodinator, Agency Accreditation Coordinator, Privacy and Safety Officer
Surry County Health & Nutrition Center

The Surry County Health & Nutrition Center implemented their Red Folder Project in 2016. According to Emily Mayes, the AAC, the goal was to involve each member of the accreditation team in a way that they had not been involved before. They took the following steps to implement the project:

• Assigned each team members the activities they are responsible for
• Made copies of the completed 2015 HDSAI
• Each accreditation team member received a red folder with a copy of the completed activities from the 2015 HDSAI for the activities they had been assigned. They chose red folders because it is an easy color to see on the desk and is a reminder of accreditation responsibilities

The red folders are separated into six sections:

Section 1 – Activities assigned to the team member
Section 2 – Activities due in 2016
Section 3 – Activities due in 2017
Section 4 – Activities due in 2018
Section 5 – Activities due in 2019
Section 6 – Activities due anytime

Separating the sections by year allows team members to focus on one year at time, which helps keep team members from getting overwhelmed collecting evidence. Emily scheduled quarterly face-to-face meetings between 2016 – 2019 with all team members using the red folders to discuss/collect evidence along with way. Team members make notes in their red folders as needed.

Each accreditation team member has an Accreditation Team Assigned Activities form that is kept in their personnel file. After each quarterly meeting, the signature page of this form is signed.

According to Emily, “We are very happy with our red folders! Evidence is collected at a nice, steady rate – even between meetings!” Seeing the red folders on their desks prompts team members to stay focused on collecting evidence between meetings. In addition, many staff have commented that the red folder project helps them understand their role in accreditation.

The Surry County Health & Nutrition Center is using the new NCLHDA Dashboard for their 2019 fall site visit and Emily has continued to use the red folder process. According to Emily, “This process really works for us. We definitely plan to continue using our red folder project for our future reaccreditation cycles!”

If you would like to learn more about the Red Folder Project, contact Emily Mayes at or 336-401-8425.

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