National Accreditation – Where Do We Begin?

Often when people are approaching the accreditation process for the first time, they find the number of steps involved overwhelming and are unclear where to start. If you are able to break it down into seven key steps, the accreditation journey can be much smoother and easier to approach.

Choose an accreditor

There are a number of factors to consider when selecting an accrediting body, including the fit with accreditation requirements, time necessary to become accredited, costs, etc. Details may be found in our earlier blog posts: Choosing an Accrediting Body Part I and Part II.

Obtain a copy of the accreditation standards

Being familiar with the accreditation standards is critical to the planning process, especially when considering who on staff will be involved and what documents are required. Council on Accreditation (COA) posts their standards on their website and are easily accessible online. With both CARF and The Joint Commission, copies of standards need to be purchased from the accrediting body. However, CARF and The Joint Commission will each provide access to their online standards for organizations beginning or thinking of starting the accreditation process. Simply contact them and make a request.

Decide whether to use a consultant

Using a consultant can provide the extra set of hands that you always wish you had when tackling large projects like accreditation. However, it is always up to the organization to implement the accreditation standards and have its own policies and procedures that map to current operations. With consultants, be sure to ask for references and select one that has experience with your selected accrediting body, is knowledgeable about the process and the applicable standards, and has experience with an organization of similar size, structure, and services. Be cautious of anyone who offers a “quick fix”.

Conduct a gap analysis

Whether conducted by staff or by a consultant, a gap analysis provides invaluable information about accreditation readiness and identifies opportunities for improvement. The results can then be prioritized and included in the necessary project management tools.

Implement new policies, procedures, and processes

When it comes to accreditation, the old adage certainly applies, “If it isn’t documented, it didn’t happen.” Often new policies, procedures, and processes need to be created to guide staff on proper protocols. For nonprofits, new and updated policies should be approved by the board of directors. Be sure that all new (and existing) policies and procedures map to the accreditation standards, current operations and any other licensing or regulatory requirements.

Undergo the survey

The accreditation survey is when reviewers from the accrediting body are onsite at your organization to verify implementation of the standards.  It is not an audit.  During the onsite survey, the Review Team will clarify and confirm written documentation and review such items as case records/client files, board of directors’ and other meeting minutes and employee files. They will also conduct interviews with staff, leadership/board members and persons served, as well as review facilities and make observations of program activities.

Fix any findings

It is very common that the Review Team finds areas in need of improvement and, therefore, a report of findings will be sent to your organization following the onsite survey with the opportunity to correct or improve the noted items. Rather than think of this as a negative, take the stance that your organization will be even more stable as a result of having gone through a rigorous third-party review as additional improvements are made to various documents, processes, and procedures.

Once all is said and done, the accreditation process is one that takes an organization above and beyond being licensed, and is a true commitment to quality both for its operations and services. Hopefully, the steps listed above make approaching the accreditation process less intimidating.

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