All About Accreditation: 9 Questions from Human Services Professionals

Earlier this year, Relias hosted a two-part webinar series with Jennifer Flowers, CEO of Accreditation Guru. These covered the basics of accreditation and the human services industry: what is it, why to do it, review of accreditation bodies and stories from those who have been there–surveyors and consultants.  We wanted to make sure these webinars were helpful, practical and gave you information and tools you could use right away.

Hundreds of attendees asked pointed questions about accreditation and the challenges they face. We weren’t able to get to all of them but we consolidated the questions into the below post so you could review all the topics/questions from the webinar, some answered live, some answered here.

If you missed the webinars, you can watch the recordings and download handouts at these pages:

Becoming Accredited? What You Need to Know

Lessons From the Field: Stories From Accreditation Surveyors and Consultants

And now on to the Q&A…

1. Do the accrediting bodies accredit each program/service or the whole organization?

Both Council on Accreditation (COA) and Joint Commission accredit all programs/services for which they have accreditation standards. Commission on Accreditation of Rehabilitation Facilities International (CARF) allows an organization to determine which programs/services will seek accreditation; it is not required every eligible service area become accredited.

For all three accrediting bodies, all sites that provide the services seeking accreditation must be included in an onsite survey. For example: if a residential facility has 20 sites, it must seek accreditation for all 20 locations, not just a portion of the sites.

2. How long does the accreditation process take?

Most organizations take between 12 – 18 months to become accredited, depending on their initial state of readiness and progression moving through the process. In general, an organization should assume that it will take at least one year to become accredited. Organizations need time to select an accrediting body; conduct a self-assessment; write/edit policies, procedures and plans; develop supporting protocols; make organizational improvements, as necessary; and undergo a comprehensive onsite survey.

Furthermore, both CARF and COA require conformance with their accreditation standards for a minimum of six months prior to an onsite survey. The Joint Commission expects that an organization will be in compliance with all accreditation requirements by the time of a survey (it does not require a “track record” for behavioral healthcare organizations).

If there are major changes at an organization, such as a merger, acquisition, or other major change in services/programs provided, location(s), capacity, or corporate structure, you will need to contact your selected accrediting body, usually within 30 days.  For those organizations already accredited, if necessary, your accreditation may be extended until the accrediting body can determine if the change is major enough to warrant a special extension survey. Failure to notify your accrediting body of major changes to your organization risks a potential loss of accreditation.

3. Are there specific processes for government agencies seeking accreditation?

The process for county/local/municipality and state-administered human services agencies seeking accreditation is similar to that of private agencies. The public agency accreditation process involves the review of an agency’s administrative operations and service delivery within programs for which the accrediting bodies have applicable standards and an onsite review of the public agency’s practices and service environments. Both CARF and The Joint Commission have the same standards for public and private agencies, while COA has separate sets of standards for each.

4. Can you explain further the difference between policy and procedure?

Policies are brief statements that establish the authority for procedures; reference state, local and/or federal mandates; are approved by the board of directors when new or revised; and are presented in a standard format.

With regard to board approval of policies, many organizations use a board committee to review polices and make recommendations to the full board. A board’s signature is not required on the actual policy, but the vote to approve should be noted in board meeting minutes.

Procedures are clear statements of what needs to be done, how to do it and who does it.  They are written in plain and simple language; written in present tense; step-by-step instructions, ideally formatted with bulleted actions. Procedures should be written with staff members as the targeted audience, not accreditation surveyors. They should have statements of the purpose and scope, with details as to those it applies to, as well as exceptions and exclusions and be presented in a standard format. Procedures are operational instructions and do not need to be board approved.

5. What service areas do each accrediting body (CARF, COA, Joint Commission) focus on? Which is generally the best fit for behavioral health and substance abuse service providers?

All three accrediting bodies have the ability to accredit the full continuum of child welfare services, behavioral healthcare organizations, and community-based social services. While one accrediting body may have a larger presence within the behavioral health or child and family services arenas, there is no “best fit” for service providers.

When considering which accrediting body to partner with, there are several components that should be thoroughly evaluated, including, but not limited to:

• Fit with accreditation requirements
• The accreditor’s reputation with an organization’s scope of services
• Is there a potential merger/acquisition on the horizon? Note that if one organization acquires another, the new organization can be folded into the accreditation previously held (generally through a limited, additional review). However, the accreditation cannot move “upstream” without a new application.
• Cost – accreditation fees vary between the three bodies, but should not be the sole consideration
• What is your baseline? Take Accreditation Guru’s free Accreditation Readiness Assessment
• Desire to accredit all programs or not – CARF allows for one (or more) programs to be accredited at a time
• Time required to prepare for an achieve accreditation

All accreditation standards are applied consistently regardless of an agency’s size. That is to say, that the standards are the same whether an organization has a staff of 6 or 600; it is all about how the agency is able to implement the standards.

Each accrediting body calculates its own application fees, survey costs and annual fees. Costs may vary widely based on the revenue size of the organization being reviewed, and/or the number of programs and locations. Staff time, operational improvements and consultants may all add to overall expenditures. Organizations are encouraged to contact an accrediting body to obtain a price quote.

6. Are confidentiality agreements a typical part of the process to comply with HIPAA and employee confidentiality?

An organization’s accreditation process, including the onsite survey, is of a confidential nature. During the onsite survey, reviewers have access to confidential information and files, including the private information of consumers and employees. The accrediting bodies each require reviewers to sign a confidentiality agreement and to adhere to its intent. Confidentiality agreements are further held between the organization being review and the accrediting body.

7. What to do if your CEO is not (fully) on board with accreditation?

Having leadership embrace the importance and benefits of accreditation will not guarantee a successful outcome, but if leadership does not support accreditation, then you are guaranteed to have problems along the way.

One should present the specific benefits of accreditation and discuss leadership’s role in this process early on in order to both gain the necessary buy-in from the CEO and have the resources (financial and personnel) earmarked for accreditation. Prior to the initial meeting, it is helpful to follow these steps:

• Conduct an assessment of what you think leadership may object to and craft responses prior to engaging them
• Create your “elevator speech” about the key benefits of accreditation
• Be honest about the challenges of the accreditation process, but optimistic about what it will bring
• Attempt to quantify the benefits in dollars and time-savings, as well as in reduced risk and a new focus on quality improvement

Leadership and staff involved in the accreditation process will have a hand in improving and influencing the future of the organization. It is so much more than just “passing” an onsite review and hanging a plaque on the wall.

If there happens to an Interim CEO, or brand-new CEO, he/she may not be expected to know everything about how the organization operates right away, but they will still need to be directly involved in the accreditation process in a number of ways, such as working directly with the board of directors, implementation of the long-term strategic plan, policy making and working effectively with senior management to provide structure, values and leadership to the organization. One of the most useful tips prior to an accreditation survey for new CEOs would be to conduct a mock interview to allow them to become familiar with the types of questions asked, practice their answers and receive feedback on the responses given.

8. What is the process for for-profit organizations to become accredited?

The process for-profit human services organizations seeking accreditation is similar to that of nonprofit agencies in terms of standards and onsite review process. The for-profit board still needs to review and approve policies and at least some board members will be interviewed during the onsite survey.

Under CARF, only, the Governance (Section 1.B) set of standards is optional. This section is helpful, however, to provide a framework for the continuous improvement of the governing body and how it functions. Unless there is a specific reason why an organization would not want the governing board to be reviewed, such as it was not vested with legal authority to direct the corporate entity, it is recommended that the Governance section is applied. Note, policy approval, for CARF, is addressed under Leadership, Section 1.A, which is a required section.

9. How might Relias and Accreditation Guru provide assistance with preparing for accreditation?

Relias has been supporting behavioral health and children’s services organizations successfully through their accreditation surveys for over 15 years. The Relias library of courses covers topics from compliance to HR to client populations served and evidence-based treatment.  Our learning management system has the tools and reporting to easily demonstrate compliance during a survey or audit (including policy and procedure management, tracking live training and non-training staff requirements). Our accreditation department provides valuable feedback to the product roadmap and our courses are developed with accreditation standards in mind. These same accreditation experts create and maintain training crosswalks that map Relias courses to accreditation standards. Clients find these tools invaluable to help them develop training plans.

Accreditation Guru provides customized solutions to help guide organizations through the (re)accreditation process via an efficient and systematic approach. Support includes such services as onsite assessment and gap analysis reports; development/editing of required policies, procedures and plans; quality improvement and risk management program design; mock surveys; staff training and more. There are also numerous blog articles and tips sheets available at www.AccreditationGuru.com as well as a link to a free accreditation readiness self-assessment.