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10 steps to prepare for accreditation

November 23, 2016
by Alison Knopf
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For providers who have never been through accreditation, or those who are preparing for a renewal, here’s a list of basics from Tom Sefcik, MSW, MBA, of PowderHorn Consulting,  a firm that advises providers in the accreditation process for CARF and the Joint Commission.

1 Read the manual

Before you do anything, pick up a standards manual and read it. It’s hundreds of pages long, “but skim through it, because you need a good working knowledge of it,” Sefcik says.

2 Learn the language

Each accrediting body has its own language. “CARF speaks [within] programs, but the Joint Commission does organizations,” he says. For CARF accreditation, pick the programs or tracks you want accredited, and for Joint Commission accreditation, the entire organization will be evaluated. Don’t use “program” and “organization” as if they’re interchangeable terms; they’re not.

3 Choose your accreditor

Whether Joint Commission, CARF, Council on Accreditation (COA), or Accreditation Commission for Health Care (ACHC) is your preferred accreditor depends partly on what you need. Some states now mandate Joint Commission, CARF, or both, in order for providers to receive state or Medicaid reimbursement, says Sefcik, adding that the same is true for commercial insurers. Even some self-pay treatment centers opt to secure accreditation to earn the accreditor’s seal on their website for marketing purposes. He says the bonus is that the process provides validation and education as well.

4 Examine the details seriously

Once you agree to submit to the accreditation survey, be prepared to comply with all of the standards. For example, there are more than 1,500 standards in CARF. “You know how to do an assessment, but do you have all of the data elements that you need in the assessment, in the treatment plan, in the transition to discharge, and post-discharge?” he asks. “If eating disorder shows up in the assessment, it better be in the treatment plan too.” Note that the Joint Commission uses a “tracer” approach, in which it follows the patient from the first phone call through discharge, so disconnects would be apparent if details aren’t documented.

5 Select a point person

A point person should manage the top-to-bottom accreditation process in the organization. Anyone from an administrative middle manager to the owner can fill the role of point person, but it has to be someone who can commit the appropriate amount of time to questions and follow up. According to Sefcik, in most behavioral health organizations, staff are working at more than 100% capacity, but figure a 20% time commitment for the point person.

6 Prepare for the long haul

It will be months between your first review of the manual and your first survey. Sefcik says he just started working on a process that will have a seven-month lead time. To keep up with standards, note that CARF makes manual changes in July, and Joint Commission makes changes in January.

7 Be prepared with documentation

Surveyors will be looking at the overall history and functioning of your organization and programs, as well as how you manage patient information. They might talk to patients as well. “Go through that checklist to make sure you have everything you need,” says Sefcik. It’s important to make everything as easy as possible for the surveyor. Aim to produce the documents electronically rather than heaping paper documents—with sensitive information—on the surveyors.

8 No wining and dining

No accrediting organizations will allow the influence of a treatment center to skew the rigorous, objective evaluation process. Sefcik, who was formerly a CARF surveyor, tells Behavioral Healthcare that if he was at a site during lunch hours, he would provide for his own lunch to maintain the proper boundaries of the relationship. He recommends setting up the room where the surveyor will be working with simple refreshments such as juice or energy bars.

9 Clean house

Even if you hire a fabulous cleaning service just before the survey site visit, it might not be the ultimate fix, says Sefcik. It’s more important to do a general cleanup and maintain the facility year-round. For example, outdated food in the refrigerator must be disposed of and surfaces that see a lot of daily use should be tidy. “When I’m walking around doing my own inspections, I look for the ‘green fuzzies,’” he says. “Get rid of that stuff.”

10 Start the day off right

Anticipate that the surveyor will arrive early in the morning. Make sure the receptionist is prepared to greet the surveyor and gives him or her a few minutes in the waiting room to relax if requested. Many evaluators will want to look for the posting of patient rights or the patient orientation handouts in patient reception areas. After all, the main point of the survey is to make sure you are doing the right thing by patients.

Finally, Sefcik says treatment centers that do an 11th-hour push to prepare for the site visit aren’t looking at the process the right way. Instead, providers should always operate with the accreditation site visit as the daily standard for quality and patient care.

“Accreditation will make you a better organization and push you into a better way of thinking,” he says.