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

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