10 Steps to Selecting an Accrediting Body

Selecting a national accrediting body is a significant commitment for an organization that goes beyond the initial accreditation cycle. In most cases, it continues for many years, often for decades. Because of the investment in time, money and effort involved, the selection process should not be taken lightly.

Accrediting Bodies

Child and family service agencies and behavioral healthcare organizations overwhelmingly choose from three main accrediting bodies: CARF International, Council on Accreditation (COA) and the Joint Commission (formerly known as JCAHO). Each accrediting body emphasizes the critical elements of performance improvement, risk reduction, financial controls, client rights, and health and safety for staff and individuals served. And each also conducts an onsite survey[1] to determine the organization’s level of compliance with the accreditation standards. However, there are significant differences between the three that impact the process and determine their “fit” with an organization.

Choosing an Accrediting Body

So, how do organizations choose between the accrediting bodies? Here are 10 key steps to help with the selection process:

  1. Determine if the accrediting bodies being considered are approved by federal or state authorities to meet your organization’s applicable mandates or recognitions.
  2. Check partner or “sister” organizations for accreditation status and decide if it would be helpful for all to use the same accrediting body.
  3. Look for any potential mergers or acquisitions on the horizon.
  4. Determine if your organization is medically based or looking for partnerships or referrals from the physical healthcare market.
  5. Determine the direct accreditation costs. Each accrediting body will be happy to give you an estimate.
  6. Determine if your goal is to accredit a specific program or service or all your programs/services.
  7. Know your baseline — Take Accreditation Guru’s free Accreditation Readiness Assessment online at https://accreditationguru.com.
  8. Obtain and review the accreditation standards from each accrediting body.
  9. Check with your payers (Medicaid, private commercial insurances, Title IV-E for QRTPs) to verify which accrediting body is approved for reimbursement.
  10. Contact accredited entities providing similar programs/services or other accredited members of any national or state association that you are a member of and ask for the pros and cons of their accrediting body.

Once these steps have been completed, you should have a better understanding of which accrediting body is suited for your organization. Then the real fun of preparing for accreditation can begin!

For assistance navigating the road to national accreditation or if you would like to discuss which accrediting body would be the best fit for your organization, please contact us at info@accreditationguru.com or 212-945-8504.

Best of luck!

[1] During the recent COVID-19 pandemic, the accrediting bodies moved to their own virtual survey method. At the writing of this article, they are presently conducting a mix of onsite, virtual and hybrid visits.

Accreditation – A Bedrock of Risk Management

When insurance companies are considering coverage for an organization, they are generally looking for those that can demonstrate high performance in risk prevention, safety, quality, outcomes, and qualified and competent staff. Accreditation standards often drive good practices in these same areas, particularly with risk management and performance improvement. Thus, the accreditation status of an organization can be indicative of the frequency and severity of costly claims.

Dan Rains, CSP, ARM, Risk Control Manager for Berkley Human Services, offers insight, “Accreditation speaks volumes about the quality of an organization. It demonstrates commitment to a continuous improvement culture with data-driven quality assurance processes and visionary leadership. These are all things that are important from an underwriting perspective which can have long term impact on losses and total cost of risk.”

Sean Conaboy, MSW, MPA, Insurance advisor with NSM Insurance Brokers, Behavioral Healthcare/Human Services Practice provides additional insight. “Insurance companies are interested in how an organization mitigates its risks, and one sound mitigation strategy is national accreditation. That’s why the first questions on an insurance application are regarding both licensure and type of accreditation.”

Accreditation as a Risk Reduction Strategy

By shifting an organization from a reactive stance after an adverse event to an ongoing proactive risk management approach, accreditation can become the bedrock for effective risk control and mitigation. The standards and survey process of accreditation guides an organization in a process of identifying and assessing actual and potential risks as well as implementing activities to prevent occurrence and to reduce severity should there be an occurrence.  Connaboy agrees, “When an applicant for insurance notes that they are accredited by a national accrediting body, the underwriter reviewing the application can assume that the organization has a strong infrastructure based on sound risk control activities and practices. At the end of the day, insurance companies want to know how well-run an organization is – and being accredited provides the framework for a well-run organization.”

Additionally, legal conformance and regulatory compliance are universal, risk-reducing requirements of all accrediting bodies. Accrediting organizations also encourage and assist organizations to go beyond what is regulated and strive for a higher level of quality and safety through a continuous improvement process that incorporates monitoring the effectiveness of risk reduction activities as well as outcomes achieved.

Risk Exposures and Controls

Risk exposures and controls are addressed in a variety of ways during the accreditation process, notably in standards and in areas addressed during the onsite survey. Below are some examples of the high-risk exposure areas and controls that may be used to mitigate the exposure.

Risk: Transporting Clients/Persons Served

Control Examples:

  • Criteria for authorizing drivers
  • Use of vehicle telematics
  • Appropriate safety restraints and adequate passenger supervision

Risk: Abuse/Molestation

Control Examples:

  • Zero-tolerance policies/Culture of safety
  • Criminal background and reference checks
  • Mandated reporting policy/procedures

Risk: Cyber Attack

Control Examples:

  • Initial and periodic staff training on cybersecurity
  • Policies and procedures addressing staff use of computers and passwords (remote access)
  • Software protection of information
  • Updating computers and backup/recovery procedures

Risk: Lack of Qualified/Competent Staff

Control Examples:

  • Policies and procedures for verification of credentials
  • Oversight and supervision of staff
  • Staff training
  • Written job descriptions linking duties/responsibilities to qualifications/competencies

Effective risk controls also include emergency response preparedness. An accredited agency is usually required to have a written disaster plan including, if applicable, evacuation and relocation of staff and clients, as well as specific plans to meet the needs of individuals with disabilities and other special needs during emergencies. The organization must also address coordination with governmental authorities and emergency responders.

Accreditation and the Risk Management Model

The standard risk management model includes identification, analysis, evaluation, and mitigation of risk. Accreditation can help organizations to identify risks they perhaps have not thought about, such as requiring a possible potential disaster be used in an emergency management plan. Requirements to conduct a risk assessment help organizations analyze and evaluate risks to determine how severe or costly they might be and can help identify risk controls to mitigate the risk. Additionally, accreditation helps organizations to reduce or mitigate risk through standard compliance in key areas, such as safety standards, fire code compliance, IT data management, human resources policies, emergency planning, and more.

How Can Accreditation Guru Help?

Although reducing risks is common with accreditation, there are differences in the risk management/risk reduction requirements between the accrediting bodies. Please feel free to contact us to learn more about the differences in risk management standards across the national accrediting bodies.

In addition to helping organizations achieve their accreditation goals, Accreditation Guru’s consulting team is also available to assess your organization’s risk management/risk reduction processes. Our service includes a holistic, systemic assessment of your risk management process or an assessment of one or more specific critical risk exposures.

 

For more information or questions about the contents of this article, please write or call Jennifer Flowers @ Jennifer@AccreditationGuru.com / 212.209.0240.   This post contains original content and was written for Accreditation Guru, Inc. Use of this copy is permitted with credit and reference within the same body of copy to Accreditation Guru, Inc.

Performance Measurement and the Growing Need for Metrics

 

One of the central components of national accreditation is the focus on performance and quality improvement (PQI) programs. This is the process of collecting, aggregating and analyzing data to discover trends and patterns and make improvements (or expand upon achievements) where necessary. However, it is not just the accrediting bodies, but funders, licensing organizations and individual donors who are looking for data on outcomes to help demonstrate mission fulfillment.

Nonprofits are increasingly being held accountable for measuring their service outcomes. And for health and behavioral service providers, the focus on process – or fee-for-service arrangements – is obsolete: the new priority centers on positive patient results, which must be documented.

As the saying goes, “what cannot be measured, cannot be improved.”

If you have questions about how Accreditation Guru can help your organization develop a robust performance improvement process, please contact us at 212.209.0240 or Info@AccreditationGuru.com.