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 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/READY.
  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 212.209.0240.

Best of luck!

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.

Organizational Benefits to Becoming Accredited

Achieving accreditation offers human service organizations professional recognition for meeting quality standards in service delivery. It also provides clients and other key stakeholders with an appropriate tool for effectively evaluating service providers. Organizations that earn accreditation have reached beyond the minimum licensing standards and made a long-term commitment to strong governance, program consistency, outcome measurements and continuous improvement throughout their agencies.

Accreditation requires an organization to undergo an objective review by an independent accrediting body. Becoming accredited signifies that an organization is effectively managing its resources and enhancing the quality of life of persons served.

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

Accreditation Maintenance: Key to Continued Achievement

Congratulations! You’ve worked hard to earn accreditation, which affirms that you meet designated national industry standards, and that you are focused on supporting your staff, organization-wide continuous improvement and most importantly, supporting positive outcomes for those in your care. You and your colleagues celebrated the achievement and have now returned to your daily routines with renewed vigor.

It’s easy to forget, however, that the countdown to reaccreditation begins the day you achieve your goal. Depending on the accrediting body, your organization will go through a reaccreditation review every 3 or 4 years and you will be required to submit annual accreditation reports. Complicating matters, accreditation standards are generally updated annually.

Here’s the good news:  With an accreditation maintenance plan – your organization can and should experience the initial accreditation effort as the ‘heaviest lift’.  In other words, by taking a few simple steps, reaccreditation should not be as time consuming or detailed as the initial accreditation process.

Maintenance can be as easy as a periodic check in or a more thorough review of standards.  Either way, the goal is to ensure the appropriate documentation is gathered along the way, rather than scramble to get everything together when the deadline approaches

Of course, every organization has different needs, so AG has developed a few different Accreditation Maintenance Plans to meet those needs.  Some agencies find that a few hours of focus per quarter at their discretion is enough to allow questions to be answered and updates reviewed, others prefer a more scheduled check in, and standards updates that we track on their behalf.  Whatever the need, we have found that given the time and resources spent achieving this initial distinction, working to proactively maintain accreditation for the long term will not only continue to strengthen your organization’s operations but it will improve services as it makes the reaccreditation process more efficient and effortless.

The bottom line:  The key to continued achievement is to establish a pattern of maintenance in your organization with continued focus on the overall implementation of accreditation standards, including client safety, risk management and performance and quality improvement.

Here are some ideas to consider when thinking about accreditation maintenance:

  • An effective and sustainable performance and quality improvement program must be clearly demonstrated as an ongoing part of the agency’s operations from year to year.
  • Best practices include sharing quarterly and annual performance summary reports with staff and board members. Annually sharing key performance metrics with various stakeholder groups to demonstrate increased transparency and open communications should also be considered.
  • An annual calendar of accreditation milestones helps keep your organization on track for reaccreditation and provides a solid review of the progress you’ve made to proactively prepare for the process.

If your organization needs help establishing or maintaining any of the accreditation standards or implementing ideas noted above, Accreditation Guru can help.  We place an emphasis on performance and quality improvement, risk management, annual reporting requirements, and updates to standards as they pertain specifically to your organization.  Check out our plans here or contact us directly for more information.

8 Questions to Ask When Starting on the Road to Accreditation

I am often approached by people who are just beginning on the road to national accreditation and have no idea where to start. Our conversations tend to follow a similar path, including which accrediting body they should work with (read here for 10 Steps to Selecting an Accrediting Body).

As part of our conversations, I often ask them questions to consider when planning for accreditation. I thought it would be helpful to share them with you here:

  1. Do I know how to best “sell” accreditation to my board of directors and staff? (click here for a video with tips) https://accreditationguru.com/how-best-sell-accreditation/
  2. What policies and procedures need to be written or updated to map to both the accreditation and licensing standards and current operations?
  3. All staff trained on procedures pertaining to emergency response preparedness and infection control and safety?
  4. Would it be helpful to conduct a mock survey? If so, who will complete it?
  5. Do we have documented stakeholder input in our quality improvement and risk management efforts? Do we even have quality improvement and risk management programs in place??
  6. Do our facilities need improvements to pass an accreditation survey? Yes, facilities are still reviewed during a virtual survey.
  7. Who will be our Accreditation Coordinator and who will be part of the Accreditation Team?
  8. Do we need assistance from an outside consultant to bring in expertise with our selected accrediting body, help streamline the accreditation process and provide much needed project management? Accreditation Guru is here to help!

Wishing you all the best on your accreditation journey! Please contact us with any questions or to explore assistance options.