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.

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.

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.

Tamarack Center CEO, Tim Davis and the Importance of Accreditation

Accredited by The Joint Commission since 1986, the Tamarack Center provides top-tier residential psychiatric treatment to adolescents in Spokane, Washington.  In addition to a web page devoted to “Accreditation and Licensing” on their site, they also display the Gold Seal of Approval logo from The Joint Commission. Recently, Tim Davis, CEO at Tamarack Center expanded on the importance of accreditation and its significance to his organization.

Tamarack achieved accreditation because their contract with the state required it. Though the process and its aftermath helped turn Executive Director Tim Davis into a strong advocate for the benefits of being accredited.

In this interview with Accreditation Guru, Tim contends that accreditation limits liability, attracts top talent and convinces parents to trust their children’s care to Tamarack. You may even be able to negotiate a discount with your insurance carrier.

What are some of the prime benefits of accreditation?

With the world being so litigious, you want to limit liability. You don’t want to be out there without some form of accreditation, which is a statement about how you do things. Plus, you’re regularly reviewed by outside parties on a continuous improvement plan.

Over the last 35 years I’ve seen a lot of people who never thought about these things. Now realizing it’s not only smart to do, but it also offers huge protection in any disagreement or litigation.

The legal protection is so important, especially in [the behavioral health] world. Something bad can happen at any time, be it a successful suicide, a sexual assault, running away, being harmed or harming someone.

Typically, the basis of any lawsuit is that the institution had no idea what they were doing. From the parental perspective, it’s “I left my child in their care and they have no idea how to handle my kid.”

When it gets to that point, attorneys say that it’s helpful to show that you’re adhering to accreditation standards over a period of time. That you’ve thoroughly covered your processes and you’re dedicated to running the place with that in mind. You can even show surveys where they found deficiencies and you took steps to correct that issue as an ongoing daily process.

It ensures that you’re paying attention to the environment of care and ethical standards. Then, you have a much stronger defense. Otherwise, it’s he-said-she-said, back and forth. I value this kind of protection.

To what do you attribute a rise in knowledge about accreditation?

There’s a little more awareness each year. People go on the web and begin to understand. Now, insurance companies are spreading the word and getting more involved.

Really? That’s interesting. Do insurance companies offer discounts to organizations that are accredited?

[Laughs.] I’ve never heard of that, but they should.

[Accreditation Guru note: Some liability insurance companies will take into account accreditation when determining the cost of liability insurance for a residential program because they view accreditation as an acceptable risk reduction strategy. The cost saving may be the result of a direct discount on premiums or due to having accreditation status gives the program a better rating that results in a reduced rate.]

You mentioned that you operate in a distinct environment.

Over the years, there have been a lot of conversations about residential care for kids. There are a lot of unlicensed, rogue programs that certainly aren’t accredited who think they know how to heal problem kids.

A lot of boot camp style centers got a lot of publicity on Dr. Phil and NBC News, but the residential treatment centers that are accredited can’t do things that people consider to be rogue. They made a commitment to do just the opposite, with a set of agreed upon standards.

We talk about assessment and such a key part of anything you do is to try and understand what the conditions are and what your organization can do for them. I tell parents that we’re going to do a mountain of assessments and you can have access to all of this and decide on the course of treatment.

The rogue operators say “just let Johnny stay with us two months and you’ll get a different kid back.” Are they going to do legitimate service to families? One way to do that is to adhere to an agreed upon set of standards.

Why don’t more residential treatment centers become accredited?

It’s not an easy thing to do and it represents an expense. But our organization considers it money well spent.

When I talk with non-accredited places, I realize how fortunate I am. I’ve got a high bed rate, top-flight staff and a high level of safety. Other places may have a lower bed rate and take kids because they need to fill the beds, but they may not be equipped to deal with suicidal or psychotic kids and if they have three people with a high school equivalence working the floor and a psychiatrist who comes in two hours a month, that’s a nightmare.

Sometimes, nonprofits can be naive about the mission, thinking that all you need to take care of disturbed kids is “if you hug ‘em and feed ‘em, they’ll get better,” but that’s where accreditation comes in. It adds a level of seriousness and professionalism that you can’t get anywhere else.

My biggest battle with the state is that our accreditation defines the scope of care – we have 16 beds and we’ve decided that there are certain types of kids we can’t serve and the state goes crazy when we declare that a placement might be out of our scope of care, which is the foundation of our contract.

Nonprofits that don’t define their scope of care get into a tremendous mess when they take people for whom they can’t provide appropriate services. I talk with people who are licensed, including nurses and doctors and tell them that they never want to work in a place that is not accredited because it provides a bit of a safety net for your license if something goes haywire. And it will.

In behavioral health they can come after you, but in most cases you will be protected because the heart of the argument is “what kind of place is this?” Is it a ragtag outfit or a professional medical environment? All you need to know is that it’s accredited.

There’s always going to be resistance to accreditation in the beginning due to the amount of work. And yeah, it’s more work, but it’s not insurmountable. With The Joint Commission, there are many ways you can meet a standard, they’re not dictatorial. Accreditation gives you and your staff accountability in this highly unpredictable, litigious field of work.

Does accreditation help with your marketing? Do parents know about it?

We’re small and we’re almost always full, so we don’t do much marketing. But we do speak with parents all the time who ask “why should I leave my child here? What can we expect?” And accreditation is a big part of that conversation.

I actually show them The Joint Commission manual and tell them “here are the things for which we are held accountable” and I let them spend as much time as they want asking me about our internal processes, making sure that something in the manual is happening.

It’s a big part of helping parents feel comfortable putting their child here. They know that there is some system in place that we have been doing for years and our standards of care are at the same level as the best providers across the country. It’s comforting for them.

Spokane is a small place, so if something bad happens, people talk about it and if it turns out that a place has no accreditation, I use it as an opportunity. I tell people that I have this written road map about how to care for people ethically and efficiently. Then, outside people come in and put you under the microscope and say “are these guys doing this or not?”

We’re licensed in Washington state five ways and the license reviews and audits are really specific. They’ll look at the fridge or run a white glove over something, but they’re not getting the full picture of care. Accreditation does.

So when there’s an incident in town, you spring into crisis coordination mode?

People inevitably ask “how could that happen?” The worst answer you can give is that the system broke down. If you can answer that a person made a mistake or willfully performed a bad act, people are more understanding because as humans, those things can happen. The public is less understanding of people who run something where the system allows a mess.

You had no background in accreditation when you took over at Tamarack, right?

I was a clinical guy and knew little about the management side of nonprofits, but The Joint Commission laid out what I had to do if I’m managing the thing properly.

Like everything, there was a learning curve, but the key – when I look back – is to understand the philosophy of each standard. What’s really important is that once you get this, then the whole accreditation process makes ten times more sense.

You ask yourself, “is it really important to do that?” If the answer is no, then ask, “why not, if that’s the standard?” You’d be amazed how many times we ask “is it important to do that?” and at first people might say “that’s stupid, we don’t need that.” And then, inevitably, you look around the table and people are shaking their heads saying “yeah, this makes sense.”

For new young management like me, the standards themselves served as a mentor or guiding force.

To learn more on how achieving accreditation can help elevate your organization, call us at 212.209.0240 or email Rocio@AccreditationGuru.com for assistance in setting up a commitment-free phone call with our CEO, Jennifer Flowers.

Accreditation’s Significance in Time of Crisis

Since late February 2020, child welfare agencies and behavioral health care organizations have been forced to focus on two critical functions – infection control and emergency management. Depending on the services provided and location of the organization, providers have been forced to change their operations in ways that include having all employees work remotely, provide telehealth services or even “closing the gates” and delivering residential services without people going on or off the property.

In these trying times, the framework provided by implementing national accreditation standards certainly helps service providers better manage the necessary pivot in operations and service delivery in this time of crisis.

Accreditation Standards – Detailed Plans and Strategic Safety Net

Accreditation standards that address risk prevention and management, infection prevention and control, performance and quality improvement, technology and information management and staff training are all being put to the test these days.

Effective risk management controls include, but are not limited to, emergency response preparedness. An accredited agency is required to have a written disaster plan for evacuation and relocation of staff and clients, parent-child reunification following a disaster, 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. Further, staff needs to be trained on how to respond to medical threats and emergencies and how to handle potential safety risks they may encounter on the job.

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 like this one.

The accreditation process also helps organizations review and strengthen their policies and practices through compliance with national standards of care. This includes creating processes for gathering and using data for continuous improvement of the quality of the services provided. 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, but they also must identify, observe and measure the effects of a program’s services on clients.

“Plan and procedures for disaster readiness are a lived concept for CARF-accredited organizations. The readiness mindset of our programs has helped organizations and their staff to transition services to better support children and families during this pandemic.” – Leslie Ellis-Lang, MMFT, Managing Director, CARF Child and Youth Services *

Technology-Based Service Delivery – AKA Telehealth

Due to the pandemic and resulting COVID-19 funding legislation that now expands coverage for telehealth services for Medicaid and Medicare beneficiaries, a vast number of service providers were given the opportunity to make a seemingly overnight shift to employees working remotely and providing telehealth services.

The existing accreditation standards in place that address the management of technology-based service delivery allow companies to reference their strategic plan and immediately embrace the full-time use of this technology.

Any accredited organization that engages or plans to engage service recipients in technology-based service delivery needs to develop policies and procedures to guide telehealth service delivery to address privacy and security measures. They must also assess the appropriateness of technology-based service delivery for each individual and monitor effectiveness of using this model.

Accreditation standards further address competency-based training for personnel on the use of equipment and software, privacy and confidentiality issues, and recognizing and responding to emergency or crisis situations from a remote location.

While many organizations may not have developed a detailed pandemic response plan, wouldn’t it have been helpful to have already addressed and planned for the use of telehealth services and having employees work remotely under the framework of accreditation standards?

Accreditation Drivers

“Accreditation is not just a box to tick and this is even more apparent during times of crisis,” says Jody Levison-Johnson, President and CEO, Council on Accreditation (COA). “COA has standards that address key preparedness and response issues. These fall under the broad standards categories of human resources management, safety and security, and emergency preparedness – all of which are critical during times of crisis.” *

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 service. Applying the standards often leads to an increase in consumer confidence in service delivery. Read “Increasing Consumer Confidence Through Accreditation“.

“(The Joint Commission) recognizes the challenges behavioral healthcare organizations are facing during this difficult time and we want to hear from all behavioral health care providers what else we can do to help.” – Julia Finken, Executive Director, Behavioral Health Care Accreditation *

This Too Shall Pass

“This too shall pass” is comforting and indeed it will (or be better controlled). But, as the pandemic stretches on and businesses start to develop a “new normal” for addressing the various health and economic needs of the public at large, a pre-laid foundation of strategic plans and detailed response initiatives can provide a more effective pivot for a company.

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

Keep Your Momentum Going!

*For additional information from the accrediting bodies:

CARF International

COA “Preparing for Response to COVID-19”

The Joint Commission