1. Accreditation Planning and Preparation
April 14, 2015
Mildred Brooke
Health Management Consultants

2. Agenda Overview of Project Accreditation Requirement
Accreditation Process
Planning for Accreditation
Preparing for Accreditation
Regional Technical Assistance Sessions
Questions – submit through “Chat”. We will respond to questions at the end of the presentation.

3. Training & Technical Assistance
Webinar – Training session on planning for your accreditation process.
Workgroups - Regional Technical Assistance sessions to begin accreditation preparation. Send by 4/17/15 to with name, agency, address, phone, & address.

4. Accreditation in Maryland
Some MH and SUD programs in Maryland are already accredited.
“Deemed Status”: COMAR and (provider can request accreditation be accepted as part of program certification or approval process).
Behavioral Health Integrated Regulations Workgroup began exploring accreditation over 2 years ago.

5. Accreditation Requirement
Draft Regulations (1/7/15)
COMAR
Community Behavioral Health Programs Program – Application and Licensure Processes and Program Descriptions
(includes requirements other than those pertaining to accreditation)

6. Three Categories NO
License
&
Accreditation

7. No License & No Accreditation COMAR 10.63.01.04A (draft)
Health professional, in solo or group practice, who is licensed under the Health Occupations Article & who is providing services IAW the requirements of the professional board
Programs/organizations that hold meetings/provide support services but do not provide treatment
EAP of a business
Outpatient behavioral health & rehabilitation services in regulated space of hospital
Therapeutic Group Home

8. License & No Accreditation COMAR 10.63.01.05C (draft)
Substance-related disorder assessment & referral program operated by a State or local government entity
DUI education programs
Early intervention Level 0.5 programs

9. License & Accreditation COMAR 10.63.01.06C (draft)
Integrated behavioral health programs
Intensive outpatient treatment Level 2.1
Mobile Treatment Services
Outpatient treatment Level 1
Outpatient Mental Health Center
Partial hospitalization
Psychiatric Day Treatment Program
Psychiatric Rehabilitation Program (Adult & Minor)

10. License & Accreditation COMAR 10.63.01.06C (draft) continued
Residential – low intensity Level 3.1
Residential – medium intensity Level 3.3
Residential – high intensity Level 3.5
Residential – intensive Level 3.7
Respite Care Services
Supported Employment Program

11. License & Accreditation COMAR 10.63.01.07B (draft)
Group Homes for Adults with Mental Illness
Residential Crisis Services
Residential Rehabilitation Program

12. License & Accreditation COMAR 10.63.01.06E (draft)
Integrated behavioral health program
Intensive outpatient Level 2.1
Outpatient Level 1
Partial hospitalization Level 2.5
Residential 3.1, 3.3, 3.5, 3.7
IF license specifically authorizes may provide:
Withdrawal management service
Opioid treatment service

13. Important Dates BHA Regulations – Proposed Implementation Timeline
All dates proposed: 7/1/2015 Regulations effective 10/1/2016 Accreditation-based programs must be accredited 12/31/2016 ADAA & MHA regs repealed 1/1/2017 All programs (requiring licensure) must be licensed under new BHA regs 7/1/2015 No applications accepted for NEW approval/certification under ADAA/MHA regs

14. Important Timeline
Accrediting organizations predict agencies need months to achieve accreditation.
Accreditation requirement effective in 18 months (10/1/2016)-planned date.
Accrediting organization also needs time to prepare/respond to applicants.
Most accrediting organizations require any new policies or procedures to be in place for 6 months prior to survey & accreditation follows 1-3 months after survey.

15. Accreditation planning and preparation starts NOW.
Impact of Timeline
Any changes needed to meet accreditation standards implemented by 12/1/2015 (approximate date).
Accreditation planning and preparation starts NOW.

16. Accrediting Process (general)
Agency contacts accrediting organization & buys standards.
Agency prepares to meet accreditation standards.
Agency applies for accreditation & submits some documents & fee.
Agency contracts for survey & pays fee.
Agency has on-site survey.
Agency receives accreditation decision.
Agency submits quality improvement plan (if needed).
Agency has ongoing contact with accrediting organization.

17. Agency Process to Accreditation
Phase I: PLANNING Good planning supports successful preparation. Phase II: PREPARATION Multi-step process to become “accreditation-ready”.

18. Accreditation Planning Steps
Determine which programs need to be accredited.
Research approved accrediting organizations.
Discuss accreditation process with Board.
Discuss accreditation process with Staff.
Establish accreditation team.
Develop accreditation budget.
Develop accreditation plan.

19. 1. Programs to be Accredited
Review current programs to determine which, if any, need to be accredited.
Consider any new programs under development that will need accreditation.
(Accrediting organizations issue short-term “provisional” accreditations before program implemented & follow-up after implementation)

20. 2. Accrediting Organizations
Explore approved accrediting organizations.
Review accreditations offered.
Review standards.
Review requirements, schedule, & fees.
Assess compatibility with agency.
Confirm which accreditations needed for agency’s programs.

21. 3. Board Involvement Present accreditation plan.
Discuss accrediting organization’s process.
Set expectations: Board, management, staff
Identify needed resources.
Seek participation & buy-in.
Provide updates on progress.

22. 4. Staff Involvement Present accreditation plan.
Discuss accrediting organization’s process.
Set expectations: Process will result in some operational and/or administrative changes.
Offer training as needed.
Solicit Input and feedback.
Seek participation and buy-in.
Provide frequent communication & updates.

23. 5. Accreditation Team Need participation from multiple competencies.
May have difference leads for various sections of standards.
Develop accountability to stay on plan & meet deadlines.
Need frequent communication – some overlap in standards.
Structured approach more likely to lead to success.

24. 6. Accreditation Budget
With accrediting organization develop estimated cost of accreditation (majority of cost depends on number of surveyors needed therefore, affected by number of programs & number of locations).
Determine when payments will be due to accrediting organization.
Estimate any other costs to achieve accreditation (resources, training, materials, etc.).
Identify financial resources.
Plan on annual costs with survey every 3 years.

25. 7. Accreditation Plan Includes: Steps in process Timelines Milestones
Responsible parties
Monitor:
Progress
Decision-making process

26. Accrediting Organizations
Receive “approval” from DHMH to be recognized as accrediting organization for behavioral health treatment programs in Maryland.
Develop working relationships with BHA and OHCQ.

27. Behavioral Health Providers
Apply for and maintain program licenses from OHCQ.
Achieve accreditation from approved accrediting organization by required deadline.
Maintain accreditation(s).

28. Planning & Preparing for Accreditation
Requires resources.
Needs commitment.
Agency-specific project.
Team approach within agency.
Structured approach.

29. Accreditation Review
Accrediting organization seeks to confirm agency’s compliance with accreditation standards by reviewing agency’s evidence of compliance. Evidence is often written policies & procedures but includes other documents as well as interviews and observations.

30. Accreditation Preparation
Conduct gap analysis.
Develop any needed “new evidence”.
Revise any existing “evidence” requiring update/change.
Develop training plan for staff to prepare for any new/revised policies, procedures, etc.
Implement any new policies, procedures, etc. (6 months prior to survey).
Prepare for survey.

31. 1. Gap Analysis Identify “repositories” of existing evidence:
For each section of accreditation standards (financial, HR, etc.) identify source document(s) with relevant policies, procedures, plans, etc.
Compare existing evidence to standard & its requirements:
For each accreditation standard, note source document for “possible evidence”.
For each accreditation standard requirement, note if “evidence” is satisfactory or if “evidence” needs to be revised or developed.

32. 2. & 3. New/Revised Evidence
Organize any new/revised “needed evidence” by section of accreditation standards (financial, HR, etc.).
Prepare needed evidence (new and revised) & incorporate into existing “repository” (Financial Management P&P, Personnel P&P, etc.)
Add new/revised evidence to training list.
Determine if any new/revised evidence affects other operational or administrative activities.

33. 4. Training Plan
Check for any required training by accrediting organization.
Prepare annual training plan.
Document all training conducted & received.
Include Board.
Clinical staff.
Administrative & Management staff.
Share resources.

34. 5. Implementation Plan
Any new/revised evidence implemented 6 months prior to accrediting organization’s on-site survey.
Document effective dates for any new/revised evidence.
Review impact on other clinical & administrative functions.
Monitor.

35. 6. Preparation for Survey
Notify Board.
Notify Staff.
Inform individuals you serve.
Consider “mock survey”.

36. Success - Acknowledge Accreditation
Inform stakeholders.
Publicize accreditation status.
Review continuing commitments to accrediting organization.
CELEBRATE!

37. Benefits of Accreditation
Consistent with current medical practice.
Sets minimum standards.
Reduces redundancy.
Increases simplifications & flexibility.
Promotes evidence-based practices.

38. Regional TA Sessions Begin in May and run through the summer
Half-day sessions to conduct gap analysis
Participants can share strategies & resources
If interested send to by 4/17/2015
with name, agency, address, phone number, & address.

39. Questions Submit questions through “Chat”.
Presentation will be available on website.