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Getting Ready for Accreditation
Presented by:Chris Eiel
Recovery Management ConsultantsLincoln, Nebraska
(402) 429-5931
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?
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
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
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)
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
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
Accreditation Challenges
• Cost (always think amoritization!)• Time• Governance and staff resistence• Skill set challenges• Increased work loads for select staff • Added responsibilities and stress
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
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
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
3 Areas of Preparation
• Administrative
• Facilities / vehicles
• Clinical / program
Administrative• Policies, procedures and plans
• Meeting minutes
• Outreach and marketing
• Ethics
• Corporate compliance
• Rights (42 CFR and HIPAA)
• Finance
• Human Resources
• Legal issues
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
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)
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
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?
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)
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
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
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 …
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
Interviews• Interviews will involve:
• Governance and board
• Leadership
• Clients and some stakeholders
• Clinicians
• Supervisors
• Support staff members
• “off-the-cuff: interviews
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
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!
Results
• Most survey bodies award different levels of accreditation:
For example
• Non-accreditation
• One-year accreditation
• Three-year accreditation
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
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?
Accreditation Readiness Guide
Checklist
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