Convenient, Informative Webinars Help Answer Your Questions About Accreditation

Part of our vision at Accreditation Guru is to inform and support organizations that are seeking accreditation. As part of that mission, we were thrilled to co-host a webinar with BestNotes, a healthcare IT software and consulting firm, to explain the accreditation process to their customers.

Many different factors can prompt an organization to pursue accreditation. These drivers may come from internal decisions, such as a commitment to quality and safety, or a desire to attract high-quality employees. Others may be external, such as regulatory or reimbursement requirements.

There are many advantages to accreditation that vary depending on the organization or the accrediting body. In general, some of the biggest advantages include:

  • Improvements to quality and safety
  • Risk reductions
  • Improvements to service delivery
  • Better documentation of organizational plans, policies, and procedures
  • Creating a specific plan to go “above and beyond”

A portion of Accreditation Guru’s webinar with BestNotes examined the similarities and differences between two accrediting bodies: CARF International and The Joint Commission. We compared fee structures, accreditation timelines, the scope of accreditation, and how long it lasts. Webinar attendees were better equipped to decide which accrediting body to partner with.

We specifically focused on these two organizations because they were the most relevant to BestNotes’ customers, which primarily included behavioral health and substance use disorder treatment providers. However, Accreditation Guru has experience with a variety of other accrediting bodies.

Because BestNotes is an electronic health record (EHR) software provider, we specifically discussed how an EHR can help behavioral health organizations prepare for accreditation and maintain compliance afterward. This includes encouraging better documentation, collecting and analyzing data, and making billing more efficient.

We always recommend that behavioral health providers implementing an EHR system do so as soon as possible when pursuing accreditation. This will give staff plenty of time to learn the software and give the organization time to troubleshoot any issues. This helps the provider prepare for accreditation more effectively and reap the benefits of an effective EHR.

During this webinar, we were able to share specific, relevant insights learned from our years of experience with the accreditation process. We explained some of Accreditation Guru’s additional services, including strategic planning, board development and training, risk assessment, and project management. We concluded the webinar with a Q&A segment for all participants.

“BestNotes was happy to partner with Accreditation Guru to present this webinar to our customers,” says Jon Winther, MBA, Chief Marketing Officer at BestNotes. “A lot of our customers are behavioral health providers in their ‘startup’ stage and just beginning to explore their accreditation options. Accreditation Guru shared information tailored to their specific needs, in an easy to understand format, with plenty of time for questions at the end. Our customers really appreciated the insights and felt better prepared to pursue accreditation for their facilities.”

Accreditation Guru has hosted similar webinars with other IT companies, insurance brokers, and billing companies. In each case, our webinar is tailored to the audience, providing relevant information for their specific accreditation process.

Interested in partnering with Accreditation Guru, or co-hosting a webinar for your own customers? We’d love to talk to you about how best to answer their questions and share expertise that can guide them on their accreditation journey. To learn more, get in touch with Peggy Lavin, LCSW, Director of Behavioral Marketing at Peggy@AccreditationGuru.com today!

What happens when a mandate for accreditation is on the horizon or comes through?

If your organization is impacted by either a Federal, State or Association mandate, it is important to get in front of it early so you don’t get caught in the crunch-which can happen when hundreds of organizations try to get accredited at the same time

How Accreditation Supports Recovery Principles

The national accrediting bodies have been among the moving forces in the integration of the recovery model into the care, treatment and services for people with mental health and/or substance use disorders. Recovery principles can now be seen throughout behavioral health standards of accrediting bodies as well as the outlined expectations that an organization will demonstrate conformance/compliance to these standards. And, the integration makes sense – this model not only complements the more traditional model of medication and “talk” therapies, but also expands the focus to include the person’s own goals and strengths and empowers them to be actively involved in the process.

The US Substance Abuse and Mental Health Administration (SAMHSA) has also integrated the recovery model in their publications, requirements for certified community-based behavioral health clinics, training materials, and grants. To that end – they’ve developed the Working Definition of Recovery. Several of the guiding principles shown here are addressed in the accrediting bodies’ standards.

Accrediting bodies’ implementation of such a model involves workforce training so that staff can fully understand and embody the organization’s philosophy, thus permeating service delivery to positively impact the recovery of the people served.  In addition, the accreditation survey process itself supports the recovery principles. Surveyor(s) not only review written documents, but also observe interactions amongst staff at all levels and persons served and share their observations with the organization. This external survey can confirm, enhance, and strengthen the organization’s intent and commitment to recovery principles

While accreditation as a whole supports the recovery model, below are specific examples of ways in which accreditation and the recovery model intersect:

Person-Driven – An individualized plan of care, treatment, and services based on the needs, strengths and abilities, preferences/expectations and goals of each person being provided care, treatment or services is a core accreditation requirement. “Boiler plate” plans that repeat over and over the same information for each person served will result in survey findings (unsatisfactory conformance/noncompliance with standards) and the need for correction to achieve full accreditation. Furthermore, it’s an expectation that an accredited organization actively involve the person served in identifying their needs and preferences for aftercare and, as much as possible, making choices about where, type, and by whom.

Holistic – The needs of the person in relation to various life domains, such as physical health and housing, are addressed in case management/care coordination standards (assessment of the person’s needs and assistance in meeting these identified life domain needs). Since access to routine and needed physical health care can be a challenge for those who need it, the accrediting bodies offer options for the integration/coordination of physical health care. Health Home standards have been established to facilitate successful integration of physical health care with an organization’s traditional behavioral health programs.

Culture and Respect – Accreditation standards emphasize that the person served encounters respect in all aspects of their care, treatment, or service experience and this is reflected in the organization’s policies, procedures, rules, and expectations as well as the rights and responsibilities of the person served. Standards clearly emphasize that service delivery is provided by staff in an atmosphere of respect and understanding and sensitivity to cultural values, beliefs, and preferences.

Trauma – The approach of the accrediting bodies to trauma centers around their screening and assessment, planning and delivery of services, and workforce training standards. Standards require a screening and assessment process to identify people whose lived experiences either currently and/or in the past may have included trauma(s). Also, organizations need to demonstrate that the impact of trauma on the person served is considered in the planning and delivery of care, treatment, or services.

Peer Support – Peer support services are an important component of the recovery model. These services are part of the plan of care, treatment, or services, and are provided by trained individuals who share similar lived experiences with mental health and substance use challenges. Accrediting bodies not only recognize the utilization of this type of service by mental health and substance use treatment providers, but also have developed standards addressing the integration of these services into the planning of care with the active involvement of the person served.

The accrediting bodies require written plans, policies, or procedures promoting these recovery principles to form a framework for implementation and a communication to staff and people served of the philosophy, beliefs, and values of an organization.

For more information on the recovery model and/or how accreditation can benefit your organization, visit AccreditationGuru.com.

 

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.

What is Accreditation?

Accreditation is a review process to determine if human service, healthcare or educational programs demonstrate their ability to meet defined standards of quality. Once achieved, accreditation is not permanent—it is renewed periodically to ensure that quality is maintained.

Requirements differ per accrediting body, but the intent remains the same: to validate an organization’s commitment to meeting accreditation standards that result in a higher level of performance. Accreditation standards have been researched, vetted and field-tested and are updated regularly, as necessary.

Earning accreditation specifies that the organization (or specific program) is appropriately managing its resources and is continually providing the highest levels of service to its clients and stakeholders. Being accredited provides credibility and helps validate and improve the safety and quality of care an organization provides.

Organizations need to demonstrate conformance with the accrediting body’s requirements by implementing the accreditation standards and undergoing an onsite survey or, more recently due to the COVID-19 pandemic, virtual review.

For human service and healthcare organizations, the broad purposes of accreditation are to establish quality measurement criteria and to raise the level of services and professionalism within a given profession or industry (QUALITY) and to ensure services are delivered in a safe manner and in a safe environment (SAFETY).

Becoming accredited offers organizations professional recognition for meeting the highest standards in quality service delivery while providing clients with an appropriate tool for effectively evaluating service providers. Organizations that achieve accreditation have reached beyond the minimum licensing standards and made a long-term commitment to strong management, program consistency, outcome measurements and continuous improvement throughout their agencies.

Accreditation standards address such areas as:

  • Leadership and governance
  • Financial controls
  • Facilities security and safety
  • Workforce development – recruiting, hiring practices, background checks, performance appraisals, training and supervision
  • Performance measurement and improvement
  • Client rights and confidentiality
  • Program administration and service delivery

With all of the needed information in-hand during a survey, the accrediting body will determine whether accreditation has been earned and, if so, will accredit the organization accordingly.

The entire process may take anywhere from 12 to 18 months to complete. For behavioral health and social service organizations, accreditation is valid for 3 or 4 years and there is another full survey at the end of each accreditation cycle.

While accreditation is generally a private (non-governmental), voluntary process, it is often a significant decision-making consideration by potential clients, individual donors, foundations, governmental funding agencies, and billing and private insurance companies.

Here are just a few of the businesses and nonprofits that value the benefits of maintaining accreditation within their respective industries:

  • Mental healthcare and substance use treatment facilities
  • Service providers for people with intellectual or developmental disabilities
  • Foster care and adoption agencies
  • Group homes/residential treatment for children and youth
  • Early childhood education centers and day care providers
  • Hospitals
  • Nursing homes and assisted living facilities
  • Medical laboratories and blood banks
  • Credit counseling agencies
  • Colleges and universities – must be accredited by one of the federally-recognized accreditors for students to be eligible for U.S. federal student aid
  • Continuing education providers
  • Museums
  • Aquariums and zoos – Accreditation from angelfish to zebras!

More often than not, many people don’t realize how often accreditation actually touches their lives. Accreditation is everywhere!

If you are ready to explore how accreditation could be a benefit to your organization or if you have questions about the process, please contact us.

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.

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.

How to determine which accrediting body is the right fit for your organization

Selecting a national accrediting body to work with is a significant undertaking. The commitment goes beyond the initial accreditation cycle and, in most cases, it continues for many more years, sometimes even decades. Because of the investment in time, money and effort involved, the selection process should not be taken lightly. Watch our video for tips on determining which accrediting body is the right fit for your organization.

 

Accreditation – A Solid Foundation for a CCBHC

The Certified Community Behavioral Health Clinic (CCBHC) model has seen rapid uptake in the last decade because it improves the quality of life for individuals with behavioral health needs. It does this by improving community-based access to behavioral healthcare, regardless of an individual’s ability to pay, which is important. Studies have shown that, in the U.S., one in five adults have a mental illness, but fewer than half received treatment in the past year. In addition, individuals with behavioral health needs often have poor physical health outcomes due to a lack of physical health care access, so the CCBHC model integrates and coordinates physical health services for this population. In order to meet this mission, CCBHCs receive enhanced Medicaid funding that allows them to provide more services as well as services that are not always reimbursed, like community outreach and partnerships.

In 2002, eight community mental health clinics formed the first CCBHC pilot. The number of CCBHCs has now grown to over 400 operating in 40 states. More states are considering adopting this model now that the program has gone nationwide. “Certified Community Behavioral Health Clinics help connect Americans to easy-to-access, comprehensive mental health and substance use disorder treatment and supports in their own communities,” said Miriam E. Delphin-Rittmon, Ph.D., the U.S. Health and Human Services Assistant Secretary for Mental Health and Substance Use and the leader of SMAHSA.

But becoming a CCBHC can be complex. Agencies may need to expand services and hours, hire staff, and determine how and where to integrate physical health care into their operations so they have the capabilities they need to meet the qualifications. CCBHCs are nonprofit organizations or units of a local government behavioral health authority, including tribal government. They must directly provide (or contract with partner organizations to provide) nine types of services, with an emphasis on the provision of 24-hour crisis care and substance use disorder treatment, use of evidence-based practices, care coordination with local primary care and hospital partners, and integration with physical health care.

Some of the key expectations for certified community behavioral health clinics are closely aligned with the accreditation requirements of the national accrediting bodies. These include:

  • Advancing integration of behavioral and physical health care
  • Coordination of care, treatment and services through care coordination/case management
  • Delivering services based on individualized plan of care/treatment by well-trained, competent staff who match culturally/linguistically to the population(s) served
  • Providing patient-centered, trauma-informed, recovery-oriented best practices in their care, treatment and services
  • Enhancing quality to improve outcomes for individuals served
  • Collecting, reporting, and tracking data
  • Continuous quality improvement.

Because national accreditation requirements contain standards of care for addressing these same CCBHC criteria, achieving and maintaining accreditation with Accreditation Association for Ambulatory Health Care (AAAHC) CARF International (CARF), Council on Accreditation (COA), or the The Joint Commission can provide a solid foundation for a  behavioral health care clinic’s journey as a CCBHC. Through compliance with accreditation requirements, organizations will have a roadmap to follow for addressing many key CCBHC components. These areas are then assessed by surveyors/reviewers during on-site or virtual site visits, providing validation of good practices and potential feedback that can generate further enhancements.

Recognizing this solid foundation, SAMHSA encourages accreditation for a CCBHC by an appropriate, nationally recognized organization such as AAHC, CARF, COA, or The Joint Commission. SAMHSA’s intent for a CCBHC is to improve access to and quality of mental health and addiction care, treatment and services for all persons in need. This intent is reflected in the mission of each of the national accrediting bodies: AAAHC, CARF, COA, and The Joint Commission.

Accreditation Guru has experts who can provide consulting to assist organizations throughout the CCBHC accreditation/reaccreditation process. Recently, AG was proud to partner with BestSelf Behavioral Health, a CCBHC, in their achievement of accreditation through COA. BestSelf provides outpatient, integrated behavioral and physical health care using evidence-based practices. Its programs and services include education and vocational supports, mobile mental health and substance use disorder services, homeless outreach and housing, community and school-based programs, and coordination with law enforcement and medical, mental health and child protection professionals. “COA accreditation has allowed BestSelf to focus on quality and maintain best practices as well as operate our Opioid Treatment Program,” says Rebecca S. Steffen LCSW-R, Vice President of Quality Improvement & Accreditation.

We would love to discuss your clinic’s accreditation needs, click here to contact us.

  1. The National Council for Mental Wellbeing, CCBHC Success Center, 2021 Impact Report, https://www.thenationalcouncil.org/wp-content/uploads/2021/08/2021-CCBHC-Impact-Report.pdf?daf=375ateTbd56 (October, 2021)
  2. National Alliance on Mental Illness, Certified Community Behavioral Health Clinics, https://www.nami.org/Advocacy/Policy-Priorities/Improving-Health/Certified-Community-Behavioral-Health-Clinics (October, 2021)
  3. The National Council for Mental Wellbeing, CCBHC Success Center CCBHC Overview, Success Center, CCBHC Overview, https://www.thenationalcouncil.org/ccbhc-success-center/ccbhcta-overview (October, 2021)
  4. Substance Abuse and Mental Health Services Administration, Criteria for the Demonstration Program to Improve Community Mental Health Centers and to Establish Certified Community Behavioral Health Clinics https://www.samhsa.gov/sites/default/files/programs_campaigns/ccbhc-criteria.pdf (October, 2021)

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.

Educating Your Board of Directors

“Education is the most powerful weapon which you can use to change the world.” – Nelson Mandela.

Education forms the foundation from which most everything else is created, making it one of the wisest investments a nonprofit can expend its precious resources on. Taking the time to educate your board of directors is one way you can develop that foundation so they are best prepared to serve your organization and its clients.

Keep in mind that many nonprofits do not formally educate their board members. Often, a nonprofit will assume that if someone is professional or a leader in their industry that they also have the knowledge to be an effective member on the board. Ultimately, this assumption can lead to increased risk and liability for your organization.

If you’re not educating your board members, who is?

Some questions to reflect on when considering topics to educate your new board member (or existing members for that matter):

  • Does each of your board members clearly understand the organization’s mission, vision, services, and programs well enough to make meaningful contributions in a leadership capacity?
  • What do orientation materials for new members include, and how are they used for onboarding new people?
  • Does your organization have an inclusive, formal orientation procedure in place for all incoming board members?
  • How do you train your board members for ongoing success?

Here are some ideas to consider implementing as you think about educating your board:

  • Board members should be diverse enough to bring different skills to the table. That said, you may need to consider educating them on mission-specific areas of your nonprofit. For example, teach them about the foster care and adoption process, or about how your homeless shelter changes the lives of its clients for the better.
  • From day one, help board members understand their roles and responsibilities. Knowing what is expected of them will encourage the confidence they need to be the leaders that your agency – and your clients – are counting on.
  • Customize educational opportunities to fit the needs of your board. Applicable areas of concentration can include fundraising, financial literacy, governance, and strategic planning. More often than not, there are board members who do not understand how to read financial data reports and the elements contained within. Arming them with this knowledge will also give them insight on the importance of their fundraising efforts as well as strategic planning.

The more effectively you educate your board members (especially regarding the agency’s mission), the more they are able to share with others throughout the communities you serve. They can use their newfound knowledge to both inform and strengthen relationships on your organization’s behalf, both now and well into the future.

Next week: Now that you have your board and they’re well prepared, it’s time to ensure they are everything your organization needs. How to engage and evaluate for board effectiveness.

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.

The New Normal – Using Accreditation as a Guide for a Post-Pandemic Organization

Since the onset of the pandemic, organizations have needed to continually  find ways to meet their mission while keeping staff and the individuals they serve safe from harm.  The details resulting from changes may vary by organization, but in general have focused around increased infection control, improved emergency management plans, and changes to programs and service lines. Many of you have heard of, or may have implemented, new programs around modifications or closures, staff working remotely, and the broad adoption of telehealth services, with a resulting impact on funding and reimbursement.

As the world adjusts to a new, post-pandemic “normal”, the framework provided by implementing national accreditation standards can help guide service providers to better manage operations and service delivery in the still-shifting environment.

  • Accreditation Standards – A Framework for Success

Accreditation (maintenance and preparation) guides an organization through a thoughtful, structured, and planned process to create an infrastructure for risk management and performance improvement that can be seamlessly implemented during times of crisis.

Accreditation standards that address risk prevention and management, infection prevention and control, performance and quality improvement, technology use and information management, as well as staff training, offer detailed guidance that can help organizations create management plans to prosper under the new normal.

Emergency response preparedness is a part of risk management, and accreditation standards provide a framework for creating and implementing these plans.

Effective risk management practices improve organization-wide safety for staff and individuals served, and may offer organizations an opportunity to renegotiate lower liability insurance rates. Accrediting organizations will be looking closely at COVID and other emergency management plans during surveys now. This can be an opportunity to ask questions of your reviewers to help hone your plans and pick up good practices they have seen from other similar organizations.

Creating processes for gathering and using data to continuously improve the quality of services provided is a core element of the performance and quality improvement focus of accreditation.

It is not enough to collect and analyze data related to outputs such as the number of clinical sessions provided or the total number of clients served – they also must identify, observe, and measure the effects of a program’s services on clients. For organizations dealing with third-party payors, this data can be helpful as a basis for improved contracting, faster payment approvals or even in-network standing to improve reimbursement options.

  • Technology-Based Service Delivery – Here to Stay?

Due to the pandemic and resulting COVID-19 funding legislation that expanded coverage for telehealth services for Medicaid and Medicare beneficiaries, many service providers shifted to employees working remotely and the agency providing services electronically, also known as telehealth.

Because of risk management practices established via accreditation, many organizations were able to quickly adopt and implement the framework of telehealth, but also address core competency issues for staff. Additionally, privacy and security measures, monitoring effectiveness of using this model, and training staff in recognizing and responding to emergency, or crisis, situations remotely are just a few of the policies and procedures addressed.

As the future of the pandemic remains unclear, organizational funding fluctuates, and the changing needs of the individual served continue – programs and services will need to keep pace by evolving as well. Accreditation standards can speed adoption of program and service line changes, by providing solid evidence-based policies and practices at your fingertips.

  • Reassuring Community of your Commitment to Quality

The three major accrediting bodies for human service organizations (CARF International Council on Accreditation and The Joint Commission) research and develop their unique set of accreditation standards that address a commitment to helping child welfare and behavior health care organizations provide safe and high-quality care, treatment or services. Applying the accreditation standards is a mark of distinction that often leads to an increase in consumer confidence in service delivery. In the post-pandemic period, confidence in care providers may need a boost. Read “Increasing Consumer Confidence Through Accreditation“.

  • Evolving for Support and Safety

All three national accrediting bodies have evolved their on-site review processes over the last many months to incorporate a virtual option in an effort to keep your staff, and theirs, as safe as possible and to minimize disruptions and safety concerns.  They also maintain COVID resources and responses, such as FAQ’s, posted on their websites* to assist organizations through the many challenges of the pandemic. As conditions change, accreditation organizations will continue to be a resource for communication of best practices.

  • Towards a New Future

As the pandemic waxes and wanes and organizations start to develop a “new normal” for meeting their missions, accreditation can provide access to guidance, resources and a framework to weather the ups and downs without sacrificing safety or quality of care.

Is your organization on the path to accreditation?  Don’t delay your preparation for achieving accreditation.  Scheduling time to focus on accreditation lets you address key initiatives now to stay ahead of the game in the future. Develop a work schedule that includes accreditation preparation whether you are applying for the first time or maintaining your accreditation status.

Accreditation Guru can help guide you through the preparation process through knowledgeable, experienced, and efficient consulting.  We’d love to hear from you – reach out to us for more information.

*For additional information on COVID from the accrediting bodies:

CARF International

COA “Preparing for Response to COVID-19”

The Joint Commission