1. Getting Ready for Accreditation
Presented by:
Chris Eiel
Recovery Management Consultants
Lincoln, Nebraska
(402)

2. 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?

3. 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

4. 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

5. 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)

6. 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

7. 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

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

9. 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

10. 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

11. 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

12. 3 Areas of Preparation Administrative Facilities / vehicles
Clinical / program

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

14. 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

15. 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)

16. 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

17. 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?

18. 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)

19. 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

20. 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

21. 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 …

22. 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

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

24. 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

25. 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!

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

27. 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

28. 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?

29. Accreditation Readiness Guide Checklist