Getting Ready for Accreditation Presented by: Chris Eiel Recovery Management Consultants Lincoln, Nebraska (402) 429-5931

Introduction What is your name? What is your current position? What is the name of your organization and what does your organization do? Are you accredited? What do you think your biggest challenges will be preparing for accreditation?

Schedule Hour 1: The basics of accreditation Hour 2: Preparation - administration Hour 3: Preparation – facilities Hour 4: Preparation – clinical/program Hour 5: Your part in the survey process Hour 6: Readiness checklist

What Is Accreditation? ‘An evaluation process in which an objective group (the accrediting body) examines a behavioral health organization to ensure that it is meeting certain standards established by experts in the field. ’ Hospitalguide.mhcc.state.md.us

Accrediting Organizations CARF – The Commission on Accreditation of Rehabilitation Facilities (Tucson, Arizona) The Joint Commission (Oakbrook Terrace, Illinois) COA – Council on Accreditation (New York, New York)

Why Accreditation? Requirement of state and federal governments Required for membership on provider panels of HMOs and PPOs Required of certain major insurance companies Self improvement

Accreditation Benefits To enhance and standardize care and treatment To enhance and improve management and business practices To reduce risk Possible qualification for insurance premium reductions

Accreditation Challenges Cost (always think amoritization!) Time Governance and staff resistence Skill set challenges Increased work loads for select staff Added responsibilities and stress

Accreditation Process Make to decision to get accredited Decide what accreditation organization you wish work with Contact the accrediting body Purchase the appropriate accreditation preparation materials Standards manuals Preparation guides Etc. Do a self-evaluation (called a GAP analysis

Accreditation Process (cont’d) Write and/or implement documentation and procedures that meet the intent of the standards Hold continuous meetings with all staff members re: accreditation Complete the accreditation application Have a “mock survey” Respond to the findings of the “mock survey” Get ready for a successful survey

Everyone aboard!!! It is important that all your governance, leadership and staff members support your efforts at accreditation. Have meetings often and on a regular basis. Disseminate information several ways Make sure everyone (if possible) participates

3 Areas of Preparation Administrative Facilities / vehicles Clinical / program

Administrative Policies, procedures and plans Meeting minutes Outreach and marketing Ethics Corporate compliance Rights (42 CFR and HIPAA) Finance Human Resources Legal issues

Administrative (cont’d) Outcomes, quality improvement, performance improvement, Six Sigma, etc. Information management Health, safety and the environment of care (see next slide) Accessibility Input and planning Training and education

Health and safety Policies and procedures Safety drills Infection control Control and storage of hazardous materials Incidents and incident reports Training First aid / CPR Vehicles Facilities (see next slide)

Facilities & vehicles Reasonable and prudent person doctrine  Cleanliness and orderliness (exterior and interior) Medicine rooms and storage Inspections Vehicles Cleanliness Vehicle documentation Accessibility First aid and extinguishers

Clinical / program Written program procedures for: Screening, admission, continued stay, transfer, and discharge Waiting lists and exclusionary lists Staff meeting minutes (for case conferences or UR meetings) Training and supervision Polices for medicine handling Medication management? Medication monitoring?

Clinical / program (cont’d) Policies on seclusion and restraint Quality assurance Critical incident reporting issues Interviews: program staff members clients referral sources or other stakeholders Client records (see next slide)

Clinical / program (cont’d) Client records: Screening and admission forms Orientation process Assessment(s) Summaries Treatment or care plans Aftercare or continuing care plans Discharge summaries Consistency and clarity

Documentation Have all documents in logical order: Administrative policies and procedure Clincial/program policies and procedures Health and safety documents Training records Personnel files Quality assurance reports Outcomes and/or performance improvement reports

Documentation (cont’d) Have all documents in logical order: Personnel files Client records Waiting lists or exclusionary lists Meeting minutes Governance and leadership Clinical staff Advisory committees Other …

Documentation (cont’d) Have all documents in logical order: Outreach and marketing Legal documents Licenses and incorpopration documents Corporate complaince plan By-laws Other? Critical incident report and analyses Complaint and grievance files and analyses

Interviews Interviews will involve: Governance and board Leadership Clients and some stakeholders Clinicians Supervisors Support staff members “off-the-cuff: interviews

Being surveyed All facilities and vehicles should be clean and in good order All documents should be organized All staff should be aware of when the survey is All staff should know what to expect The organization should have “role plays” for all staff involved in the survey process Don’t argue with the surveyors

Being surveyed (cont’d) Look at the survey as a way to garner feedback from neutral experts Be prepared to get some recommendations and suggestions One member of your staff should be assigned to be liaison between the organization and the surveyors All drivers should be knowledgeable about the organization If you don’t know the answer, say so!

Results Most survey bodies award different levels of accreditation: For example Non-accreditation One-year accreditation Three-year accreditation

Staying accredited It’s important to stay accredited: Purchase current standards manuals every year Review and update all policies and procedures on a regular basis Stay current with health and safety drills and inspections HR practices should be current QA and outcomes processes should be utilized to manage all clinical and business services

Q and A Before we look at the ‘readiness guide’ are there any questions you would like to ask or topics you’d liked discussed?

Accreditation Readiness Guide Checklist