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.

Who should an organization have directly or indirectly involved in the accreditation process?

In this short video, Jennifer explains which teams’ and individuals’ involvement  are required for a successful accreditation outcome.

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 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.

The Final Deadline for Implementing FFPSA is One Year Away – Here’s What You Should Know

In 2018, the Family First Prevention Services Act (FFPSA) mandated that Qualified Residential Treatment Programs (QRTPs), in part, must be licensed by their state and achieve national accreditation to receive Title IV-E funds following the initial two weeks after a child enters their care.[1]  The time originally allocated to submit program plans was two years with the potential for taking a two year delay.

Although agencies and states have evolved in their understanding and communication of many aspects of the federal bill, presently only twelve states, plus the District of Columbia and two tribes have submitted Title IV-E Prevention Program plans, which indicates when the state intends to implement FFPSA. Additionally, we now find ourselves just one year out from the final implementation deadline of October 1, 2021.

From an agency accreditation perspective – this means that while there is still time to become accredited, it will need to be done with a consistent effort, focus on efficiency, and a continuous eye on timing. 

In general, it takes 12 to 18 months to prepare for national accreditation; depending on the original state of readiness and the accrediting body selected. If you have not yet discussed the subject within your organization, now is the time.  Below, we have compiled some facts and important steps you can and should be taking now if you wish to become a QRTP.

FACT:  TIMING IS EVERYTHING: This is a crucial piece to understand and communicate within the organization.  When an agency’s board and staff understand the time constraints that you are working within – the probability of quicker responses, approvals and/or comments will increase.

Important Steps

Select an Accrediting Body –The accrediting bodies approved under FFPSA are: CARF International (http://carf.org), Council on Accreditation (COA) (https://coanet.org/) , The Joint Commission (https://www.jointcommission.org/), or other accrediting bodies approved by the Department of Health and Human Services (HHS).[2]   We have a helpful chart that compares the three accrediting bodies.  Contact us for that and/or for input on which accrediting body would be best suited for your organizations’ needs.

Know Your Baseline – Benchmarking your organizational starting point against the expectations of accreditation will allow you to focus more time on the less developed aspects of your plan.   It will also help anyone who is working with you to start with this information and move you forward from there, rather than taking the time to fact find on your behalf.  One way to establish your readiness for accreditation is to take our Free Readiness Assessment.  

FACT: BUDGETING NOW WILL SAVE TIME LATER:  Plan now to secure budgetary allocation with the board’s approval for the entire amount ahead of time.  As the process can take a year or more to complete; accreditation could theoretically be spread over two budget cycles and you may be tempted to push off getting part of the total spending approved until the second budget cycle. However, this simple task can literally add weeks to the project – when you need to stop for approvals and get payments routed for signatures before proceeding to next steps.

Important Steps:

Include Benefits in the Proposal:   You are already aware of the importance of understanding all accreditation costs up front, but clearly identifying and including the benefits to the expenditure in your proposal when routing to key decision makers is also crucial.  To ensure you have a clear outline of benefits of accreditation, you can review our articles, blog posts and videos that can help clarify the points that make the most sense for your organization. Go here and type in “benefits” in the search area to pull up relevant info.

FACT: BOARD AND STAFF BUY-IN IS KEY:  Preparing staff and board members for the accreditation process is one of the most overlooked but (in our experience) one of THE most valuable investments you can make prior to starting the process.  Organizations often think that one person will lead the charge on finding a team and holding the team accountable to the tasks at hand.  But this is often done at the expense of day-to-day responsibilities.  By clarifying not only what the accreditation process entails but why it is happening – more people will have a sense of the timeliness involved and be motivated to help.

Important Steps:

Plan for Getting Buy-in as an Event.  Appointing one person, or team of individuals (perhaps an accreditation communications committee) to be the accreditation point of contact for agency staff and other stakeholders can assist in making the accreditation process an enjoyable one for all. Allowing a bit of latitude can be beneficial and a bit of fun, for example, kick-off events, holding an accreditation fair to exhibit new accreditation policies and procedures to one another, trivia contests, accreditation field days, team picnics, etc. There are people who enjoy accreditation, so find them and utilize them!

Consider a consultant.   Achieving accreditation is an involved process that will require your employees to spend less time on their day-to-day responsibilities. To ensure efficient time management, consultants go beyond providing training functions and serve as sounding boards to answer questions from staff so no one is spinning their wheels or getting lost down a rabbit hole trying to figure out what the accreditation standards mean.  Contact us to start a conversation on how we can help you get this done on time and budget.

With the FFPSA deadline looming, impacted organizations should begin the accreditation process now to get ahead of the influx of other providers seeking to become accredited and have enough time to thoroughly complete the necessary work. Once the process begins, effective project management and support from leadership will help ensure that accreditation activities stay on track despite other priorities that may arise.

Accreditation Guru assists organizations in creating a customized accreditation timeline based on its strategic planning and provides support along the way to successfully meet each milestone.  A accreditation calendar provides a visual tool to keep leadership and staff focused for an efficient process.

[1] Public Law 115-123,section 50741 (page 190); available at: https://www.congress.gov/115/bills/hr1892/BILLS-115hr1892enr.pdf

[2] Two additional accrediting bodies have been approved for QRTPs since the passing of the law: Educational Assessment Guidelines Leading toward Excellence (EAGLE) (http://eagle1.org/) – a faith-based accrediting body – and Teaching-Family Association (https://www.teaching-family.org/)

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 in Action™?

Accreditation in Action™ is an ongoing blog series that highlights organizations which have been through the accreditation process. Here accredited entities discuss their journey and the benefits realized. If you would like your organization featured, call us at 212.209.0240 or email Peggy Lavin.

Increasing Consumer Confidence through Accreditation

When a consumer has made the life changing decision to seek treatment for a mental health or substance usage issue or a parent/spouse/friend is struggling with where their loved one will receive safe and quality care, treatment or services, national accreditation of an organization can be re-assuring.   Increasing the confidence of the consumer or significant other is a significant benefit of accreditation.  Accreditation signals to the consumer/significant other that the organization’s physical environment has been surveyed for safety and its service delivery, surveyed for quality.  After this rigorous survey, the organization has been awarded accreditation based on its compliance with standards for safety and quality of care, treatment or services. For this reason, an accredited organization may post its accreditation status on its website and proudly display its accreditation award certificate in its main entrance(s).  A brief overview of the meaning of accreditation and the accreditation process is often provided to consumers/significant others verbally or in an admissions brochure. Each accrediting body’s logo includes a symbol of approval which an accredited organization may add on its social media and marketing materials.  Accrediting bodies post on their websites a list of accredited organizations so that key stakeholders including consumers/significant others can locate safe and quality care, treatment or services.

Accreditation tells the consumer/significant other that your organization has gone beyond basic state licensing requirements to achieve a higher level of safety and quality of care, treatment or services based on industry standards.

To read more on the advantages of accreditation, click here.

For questions and assistance with your accreditation and/or post accreditation, please contact us at 212.209.0240 or email Rocio@AccreditationGuru.com

Using a consultant to help with the accreditation process


When beginning on the road to national accreditation, many organizations struggle with the extra workload involved and a general unfamiliarity with the accreditation process. As a result, they may decide to work with an accreditation consultant to help with the heavy lifting involved. Our video outlines what to look for when considering hiring a consultant, including success rates, reputation and the amount of customization available for your organization.

If you have questions about how Accreditation Guru can help your agency proactively prepare for accreditation, please contact us at 212.209.0240 or Info@AccreditationGuru.com.