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 - administrationHour 3: Preparation – facilitiesHour 4: Preparation – clinical/programHour 5: Your part in the survey processHour 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 governmentsRequired for membership on provider panels of HMOs and PPOsRequired of certain major insurance companiesSelf improvement
7 Accreditation Benefits To enhance and standardize care and treatmentTo enhance and improve management and business practicesTo reduce riskPossible qualification for insurance premium reductions
8 Accreditation Challenges Cost (always think amoritization!)TimeGovernance and staff resistenceSkill set challengesIncreased work loads for select staffAdded responsibilities and stress
9 Accreditation Process Make to decision to get accreditedDecide what accreditation organization you wish work withContact the accrediting bodyPurchase the appropriate accreditation preparation materialsStandards manualsPreparation guidesEtc.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 standardsHold continuous meetings with all staff members re: accreditationComplete the accreditation applicationHave 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 waysMake 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 marketingEthicsCorporate complianceRights (42 CFR and HIPAA)FinanceHuman ResourcesLegal issues
14 Administrative (cont’d) Outcomes, quality improvement, performance improvement, Six Sigma, etc.Information managementHealth, safety and the environment of care (see next slide)AccessibilityInput and planningTraining and education
15 Health and safety Policies and procedures Safety drills Infection controlControl and storage of hazardous materialsIncidents and incident reportsTrainingFirst aid / CPRVehiclesFacilities (see next slide)
16 Facilities & vehicles Reasonable and prudent person doctrine Cleanliness and orderliness (exterior and interior)Medicine rooms and storageInspectionsVehiclesCleanlinessVehicle documentationAccessibilityFirst aid and extinguishers
17 Clinical / program Written program procedures for: Screening, admission, continued stay, transfer, and dischargeWaiting lists and exclusionary listsStaff meeting minutes (for case conferences or UR meetings)Training and supervisionPolices for medicine handlingMedication management?Medication monitoring?
18 Clinical / program (cont’d) Policies on seclusion and restraintQuality assuranceCritical incident reporting issuesInterviews:program staff membersclientsreferral sources or other stakeholdersClient records (see next slide)
19 Clinical / program (cont’d) Client records:Screening and admission formsOrientation processAssessment(s)SummariesTreatment or care plansAftercare or continuing care plansDischarge summariesConsistency and clarity
20 Documentation Have all documents in logical order: Administrative policies and procedureClincial/program policies and proceduresHealth and safety documentsTraining recordsPersonnel filesQuality assurance reportsOutcomes and/or performance improvement reports
21 Documentation (cont’d) Have all documents in logical order:Personnel filesClient recordsWaiting lists or exclusionary listsMeeting minutesGovernance and leadershipClinical staffAdvisory committeesOther …
22 Documentation (cont’d) Have all documents in logical order:Outreach and marketingLegal documentsLicenses and incorpopration documentsCorporate complaince planBy-lawsOther?Critical incident report and analysesComplaint and grievance files and analyses
23 Interviews Interviews will involve: Governance and board Leadership Clients and some stakeholdersCliniciansSupervisorsSupport staff members“off-the-cuff: interviews
24 Being surveyedAll facilities and vehicles should be clean and in good orderAll documents should be organizedAll staff should be aware of when the survey isAll staff should know what to expectThe organization should have “role plays” for all staff involved in the survey processDon’t argue with the surveyors
25 Being surveyed (cont’d) Look at the survey as a way to garner feedback from neutral expertsBe prepared to get some recommendations and suggestionsOne member of your staff should be assigned to be liaison between the organization and the surveyorsAll drivers should be knowledgeable about the organizationIf you don’t know the answer, say so!
26 Results Most survey bodies award different levels of accreditation: For exampleNon-accreditationOne-year accreditationThree-year accreditation
27 Staying accredited It’s important to stay accredited: Purchase current standards manuals every yearReview and update all policies and procedures on a regular basisStay current with health and safety drills and inspectionsHR practices should be currentQA and outcomes processes should be utilized to manage all clinical and business services
28 Q and ABefore we look at the ‘readiness guide’ are there any questions you would like to ask or topics you’d liked discussed?