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Follow best practices in accreditation

October 24, 2017

The four accrediting bodies in behavioral healthcare have different standards and measure different things. However, there are some similarities when it comes to the site visit or survey portion of the process.

1. Choose the best timing

Decide when you want to be accredited, and then make sure you use the time well, says Carl Noyes, CEO of Retrospect Consulting Group and lead behavioral healthcare surveyor for the Accreditation Commission for Health Care (ACHC), who has been doing behavioral health surveys for 35 years. If you need to be accredited by a certain date, for example, you are going to need to plan ahead. It takes months before the site visit takes place, so don’t procrastinate.

“Agencies that don’t leave enough time to prepare often find themselves rushed,” says Noyes. After the site visit, it takes months before the accreditation actually takes place.

2. Study up on the application

Some organizations actually start to write new policies and procedures before they even know what the accreditation measures call for, says Noyes. The self-study, which all the accrediting bodies require, is essential. Use the self-study time, which is typically six to nine months, to assess your practices and align them with the standards, says the COA’s Kerry Deas, quality improvement manager for the Council on Accreditation (COA). “If you put all of that time in up front, then you usually don’t have much to do after the site visit,” Deas says.

3. Pick your document gatekeeper

Someone on staff must be in charge of the final approval of all documents that are presented in the site study. This needs to be one person, not a committee, who reviews the materials for compliance with the accreditor but also with state and federal rules.

4. Maintain a single manual

Some organizations have one policy manual for accreditation and a separate one for state and federal policies. Your policies and procedures should be compiled in one manual, says Noyes. Don’t waste your money on templated manuals, either.

“I’ve seen providers spend an inordinate amount of money on a template accreditation policy manual and pull it off the shelf on the day surveyors come,” says Noyes. “It’s very obvious, and any experienced surveyor will ask if there is one set or two sets of manuals. It doesn’t show the agency in the best light, and frankly, it’s a liability. You can see a staffer doing what they think is the appropriate thing, and then something goes wrong, and it comes out that there are two policy manuals.”

5. Take the high road

It’s not unusual to identify conflicts between state rules and accreditation rules, but experts recommend that treatment centers always aim to comply with the strictest standards to ensure full compliance. For example, ACHC requires a supportive employment specialist be including on an ACT (Assertive Community Treatment) team, but some states don’t have this requirement. ACT teams work with individuals with serious mental illness. One of the ways to help them stay in recovery is to help them find employment, for example, says Noyes.

6. Appoint a surveyor liaison

Your liaison can be someone on staff or an outside consultant, but it should be someone who is well versed on the standards of the accrediting organization. That person should have sufficient rank in the organization to be able to motivate employees to get things done.


7. Take notes

Peter Vance, LPCC, CPHQ, field director for survey management and development in accreditation and certification operations for the Joint Commission, recommends that organizations assign a scribe to follow the surveyor, taking notes. This gives the program the opportunity to have an internal person who is keeping track and monitoring everything that’s being said and done.

“There are lots of things discussed through the survey process that may not show up on the report, but are good as consultative material,” Vance says.

He recommends that the scribe use an old-fashioned paper and pencil method for notes. “We don’t encouraging recording, because we’ll be interacting with clients,” he says.

8. Conduct a mock survey

You can prepare a trial run by bringing an expert on site who might see details your leadership has overlooked. The best time to do this is six months before the real survey. “This will allow time for the provider to make any necessary changes,” Noyes says.

9. Remember that compliance time varies

CARF requires six months of compliance for all applicants. The Joint Commission requires that applicants have certain benchmarks met on the day of the survey. ACHC assigns a “readiness date,” at which time the organization must be in compliance. For example, let’s say you applied to become ACHC accredited in January, and you aim for June 1 to be full compliance. Any admission, staff hire or process must be in compliance from that date going forward.


10. Present your material strategically

Surveyors will expect your materials to be presented in an organized fashion rather than as a heap of binders with an excess of information.

“It comes off as desperation, as if you don’t know what you really want,” says Noyes. “A much better practice is to take your comprehensive manual, create another column, and crosswalk it to standards.” 

The documents should be bound and indexed. Also, appoint a knowledgeable staff person who can find and explain documents as needed. Deas of COA notes that reviewers will ask for additional documents during the site visit, beyond what is included in the self-assessment. Documents can be electronic or in paper format, says Deas says, but the main point is that you must clearly label how your documents correspond to standards.

11. Don’t cherry-pick

Surveyors are aware of the motivation to present your organization in the best light, but cherry picking patient records for review will not be successful.

“Often organizations try to find a ‘best record’ to review,” says the Joint Commission’s Vance. “That’s not necessary. We want to see samples of all the records.”

He says the purpose of accreditation isn’t to score well as much as it is an opportunity to find areas where you can improve.

Noyes says he might ask for records created by recent hires and several created by longtime staff. He will also ask for a list of all clients admitted in the last three months and choose several of those at random.

“We recognize that some staff are better at writing treatment plans than others,” he says. “Some are better at working with clients than others, but everyone should meet a list of minimal standards.”

CARF surveyors additionally talk to the client served, according to Brian J. Boon, PhD, president and CEO of CARF.

“We ask them to tell us about their experience and what orientation was like,” he says. “We may talk to family members. We talk to referral sources. The file is just one data point.”


12. Aim for continuous improvement

The purpose of accreditation is to improve your service, not just to get a gold star or to facilitate third-party reimbursement. Look at the site visit and the entire survey process as a way to make your services better for patients.

For example, CARF’s reviewers are all peers, which means that they work in behavioral health organizations that serve the similar populations.

“That’s why the orientation of accreditation from our perspective is quality improvement,” says Boon. “Yes, you have to have your package prepared. But you also have to be open for conversation and for improvement.”

13. Don’t skimp on data metrics

How do you use your data? It should be to improve services, results and outcomes. Most organizations struggle with this because data analysis is labor intensive, says Boon. He recognizes that in treating chronic mental illness and substance use disorders, good outcomes may not necessarily equate to full recovery. Reduced hospitalizations, clients’ maintaining engagement in social support systems and adhering to medication regimens can be considered in the outcomes measures.


14. Be honest

When the reviewers come to your site, tell them the truth, even if it doesn’t seem to paint your organization in the best light because the surveyors want to drive accreditation success.

“If a procedure isn’t quite meeting the standard, or if you don’t have an element at all, it helps to be honest with your reviewers,” says the COA’s David Haynik, LMSW, director of quality improvement. “If you hide the fact that evidence is lacking, you’re closing off communication with that group of reviewers.”

Accreditors’ goal is different than that of regulatory or compliance entities, such as state or federal agencies, Vance says. Accreditors aim to partner and work with an organization to identify a risk, which requires trust.

15. No wining and dining

In general, organizations can have snacks, water, coffee or food for a working lunch, but there are boundaries. Don’t offer surveyors dinner out or offer them “welcome baskets.” COA would actually prefer that organizations not pay for lunch, especially if it could be perceived as valuable and as “trying to persuade,” says Haynik.

And Vance of the Joint Commission says not to be disappointed if the reviewers opt not to join you for a working lunch. “The surveyor may politely decline because they want to do a working lunch on their own,” he says.

Alison Knopf is a freelance writer based in New York.

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