Getting Ready for Accreditation

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

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