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“How Do You PQI?”

This is phrase that COA came up with a few years ago to introduce our newest toolkit. As an accreditation insider, we think it’s a clever phrase in that it conveys that:

• PQI is a necessity
• PQI is something that you do and that has motion, and
• PQI is customizable.

(We also like that it rolls off the tongue easily, unlike the word “accreditation.”)

Unfortunately, not everyone is an accreditation insider. We love our acronyms at COA, and use them everywhere–in our standards, in our process, in our technology (shout out to the VIP portal!). But acronyms and jargon can be confusing to anyone not in the know, and create barriers to understanding. “PQI” is no different.

So what is PQI, you ask?

Good question–and a common question we’re asked when staffing COA’s exhibit booth at a conference. The conversation usually goes something like this:

Inquiring person: What is PQI?

Us: It’s the foundation of the accreditation process.

Inquiring Person: Yes, but what does it mean?

Us: “Performance and Quality Improvement.” It’s our name for Quality Improvement or Quality Assurance.

Inquiring person: Thanks. What’s “Quality Improvement”?

Us: On a basic level, we like to say that a PQI system is collecting data about your work, analyzing it, making course-corrections based on the data, and then tracking to see if those changes are working.

Then we usually see a glimmer of understanding in their eyes.  We give the inquiring person our PQI Toolkit postcard, and hope that it makes its way to the Quality Assurance/Data Nerd at their agency.

Based on our conversations with stakeholders, in-process organizations, and peers, we at COA know that PQI is can be a conceptual, difficult-to-grasp concept. We also know that agencies need a lot of help developing their PQI systems. This is why we talk about PQI a lot, and why we create trainings and tools to help.

One long-awaited tool is a high-level introduction to PQI for anyone new to the concept.  Now when we’re manning the exhibit table and get asked “What is PQI?”, we are thrilled to be able to reply:  

“Check out our PQI whiteboard video!”

Transcript

The most effective social service organizations are those that have been accredited to meet the highest standards of quality.

For more than 40 years, the nonprofit Council on Accreditation has partnered with health and human service organizations globally to improve outcomes by developing, applying, and promoting accreditation standards.

COA’s Performance and Quality Improvement standards, or PQI, require organizations to generate and review organization-wide data to establish performance targets that improve services and outcomes for all stakeholders. It’s a comprehensive process that includes working with the entire organization instead of assigning the responsibility for quality improvement to just a few individuals.

Information generated by the PQI system is used to:

• Monitor progress toward achievement of strategic goals and long-term direction,
• Manage programs and operations efficiently and effectively,
• Meet funder requirements to promote the organization and its services throughout the community, and
• Support direct service staff to meet program goals and have a positive impact on people served.

The organization reviews findings and feedback while taking action to:

• Eliminate or reduce identified challenges,
• Replicate good practices,
• Recognize and motivate staff, and
• Improve services for the communities they serve and assist with fulfilling their mission.

And hopefully now you think the phrase “How Do You PQI?” is clever, too.

Want to dig deeper into PQI? Check out our comprehensive PQI Toolkit.

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Your organization has decided to embark on the journey of pursuing accreditation! This commitment can invoke many sentiments—happiness, anticipation, fear, anxiety, and maybe even a splash of frustration. These are all normal feelings. The accreditation process is a major project with a myriad of components. One way to be successful in your accreditation work is to use a project management approach, as it is critical to divide the required work into smaller, manageable steps. Here is a handy, step-by-step guide you can use to conceptualize the tasks that are on the horizon.

Work styles & organizational culture

COA has an organization-wide accreditation model. This means that not only are programs being reviewed, but also the administrative divisions as well. Getting many colleagues involved in the accreditation process will help the organization manage the workload and focus on developing, updating, or sustaining practices that are ultimately in the best interest of the consumers served. 

People have different personalities, which includes varied preferences and approaches to their work responsibilities. There are those who are process-oriented people that do a really great job poking holes in plans and asking questions that may not have been considered. Then there are staff who can reflect and acknowledge the progress that has been made within the organization through that point in time. Knowing some of these characteristics and preferences will be helpful in thinking about who should handle different aspects of the work.

How and why the organization is choosing to pursue accreditation is essential to framing the work that lies ahead. Even if the organization is mandated to achieve accreditation, what the organization hopes to accomplish through this process is valuable for all to hear. Ask yourself: What is the message we will convey to our board, advisory group, staff, consumers, and other relevant stakeholders about what accreditation means for the organization and its future? People want something they can believe in, something that resonates with them, so taking time to reflect and think about the “why” behind this journey is an opportunity to capitalize on building momentum.

Accreditation workload – forming the structure

COA accreditation includes all aspects of the organization’s administration and service delivery operations.  There are three types of standards: administration and management, service delivery administration, and service. Most organizations will have at least ten standard sections to review based on the three categories.  It is essential to have multiple staff managing different standard sections, because no one staff member will have all the answers (and that is a good thing)!

A question we often hear from organizations is “How will we manage the accreditation work?” You must consider whether your organizational structure serves as a sufficient framework to review the standards. This means that those individuals responsible for particular divisions would delegate tasks to staff within their department. For example, the director of human resources would review the human resources management standard section and assign tasks as needed to his/her staff. Similarly, program directors would follow the same process to review service standard areas.

Another option for managing the work includes the creation of functional work groups, which includes assembling teams with individuals from different departments and/or programs to review one or more standard sections. For example, an administrative work group can be formed to review multiple standard areas including risk management, administrative service environment, ethical practice, etc. This type of work group would include an interdisciplinary team of quality improvement, program, information technology, and other staff as needed.

Decision-making authority and flow of communication

Once a decision is made on whether to use the structural work groups, functional work groups, or a hybrid of the two, the organization must consider the decision-making authority. As teams begin to work on reviewing the standards against current practices, you may find that policies, procedures, and protocols may need to be developed or modified. The organization must be clear on who has the authority to implement new procedures and practices. 

Typically, if hierarchical work groups are used, the head of the department or program would be responsible for managing the approval process. Larger organizations may have a chief operations officer or director, and that person may be responsible for final approval. In smaller organizations, decision-making authority may be the sole responsibility of the executive director. In functional work groups, the decision-making authority may be less transparent, so the organization should establish the process for preliminary and final approval of procedures and new protocols. This will be particularly important once staff begin doing the actual work that is part of the Self-Study and Site Visit phases of the accreditation process.

Regardless of the structure chosen to manage the work, the individual responsible for overseeing the accreditation process needs to ensure that work groups and teams routinely provide information and updates to them. Sharing information and progress with the leadership team is a must, especially if the accreditation lead is not a part of said team.

Responsibilities associated with stages of accreditation process

There are six stages in the accreditation process, each with different responsibilities. Below are some salient tasks for which the organization is responsible.

Application & agreement

The application and agreement phase of the process is an opportunity for the organization to assess the cost of accreditation and explore the service standard sections that may be relevant to the programs provided. Once the organization has decided to pursue COA accreditation, the accreditation agreement is signed and the work begins.

Intake

Think of the intake stage as COA’s opportunity to acquire information from the organization on all your programs and locations in which they operate. When highlighting the scope of services at each program, be concise. COA uses this information to determine the appropriate service standard for each program. Do not spend many months in this stage of the process – it will prolong the assignment of service standards. The organization’s Site Visit will not be scheduled until all program documentation has been submitted to COA.

Self-Study

When the organization enters the self-study stage of the accreditation process, all standard sections have been assigned and the due dates for the Preliminary Self-Study and Self-Study have been scheduled, along with the start date for the Site Visit.

During this phase of the accreditation process, the organization should implement the structure for managing the standards review. Work groups should conduct an assessment of its current practices, policies and procedures against the COA standards. A self-assessment helps the organization to know where it needs to prioritize its time and resources.

Site Visit

Once the Self-Study has been submitted, the accreditation work groups should begin compiling documentation to have available during the Site Visit. Reserve a meeting room for the Peer Review team to use while they are onsite for the duration of the Site Visit. All documentation should be clearly labelled by standard section, including the relevant core concept standard. The information the Peer Review team will evaluate can be available in paper or electronic format.

Building and sustaining momentum

If you are following the steps as listed, by now the “why” behind accreditation has already been established. An inventory of the strengths of staff has been conducted, and the process for managing the accreditation work is in place. Now the organization needs to formally roll out this significant initiative and keep staff engaged throughout the entire process. 

Set a kick-off date

A kick-off event, such as an all-staff meeting, is a great way to launch the accreditation work. Use this time as an opportunity for the executive director to explain to staff why the organization is pursuing accreditation and why it is valuable. It is an opportunity to inform staff that pursuing accreditation can provide professional development and team building.

Themes and activities

Knowing the “why” behind the organization’s pursuit of accreditation may not be enough for some. For those who are charged with managing the accreditation process, consider ways to make different aspects of the work fun and exciting. Television shows, sports, movies, are all options that may be suitable to connect accreditation work groups. Visual display boards serve as a reminder and can foster healthy competition within the organization.

Final thoughts

The accreditation process can be overwhelming —there are many aspects that need to be managed. Hopefully, your creative juices are flowing with ways to make this organization-wide initiative manageable and fun. Remember, to get others involved, align the work with the strengths of staff and challenge the organization to always strive to be better.

Been through the accreditation process before? Share your thoughts on some things you wish you had known before you started the accreditation process. Recently completed the accreditation process? Let us know some of your pro tips that helped your organization through!

Welcome to the first in a new series of blog posts entitled Profiles in Accreditation! 

The organizations that COA accredits are diverse in both the communities they serve and their reasons for seeking accreditation (or reaccreditation).  Profiles in Accreditation will explore the accreditation experience through the perspective of these organizations. Through them, we can discover the value of accreditation, best practices, lessons learned, and recommendations.

Organization profile

Name: Lad Lake

Locations: Milwaukee and Dousman, Wisconsin

First Accredited: 2014

Reaccredited: 2018 

Snapshot: Lad Lake has been evolving to meet the needs of Wisconsin’s most vulnerable children for 170 years.  Serving more than 1,200 youth annually, the organization’s 300 staff accomplish its mission of “guiding the growth of at-risk youth to reach their potential and live responsibly” through four major program commitments: two residential care centers for youth who have experienced trauma from the child welfare and juvenile justice systems; alternative education for students with special learning needs; independent living services for youth “aging out” of the foster care system; and community services such as in-home therapy, specialized mentoring, and supervised visitation for parents and children. 

Interview with Lad Lake

For our first Profiles in Accreditation post, we asked Lad Lake President and CEO Daniel O. Magnuson, MA, MSW to share his thoughts on his organization’s journey through reaccreditation. He emphasized how accreditation provided a framework for operational success, as well as the importance of having the entire organization–including the board–engaged with the process.

COA: Why was it important to Lad Lake to seek accreditation initially?

DM: We sought our initial accreditation in preparation for the retirement of a long-serving CEO; we wanted to position Lad Lake for improved impact and financial sustainability.

COA: What were some of the drivers for seeking reaccreditation?

DM: As we implemented the initial accreditation plan in 2014-2015, we also completed a comprehensive strategic planning initiative.  COA’s accreditation framework helped us to focus and look at activities on an organizational level, which made the execution of our strategic plan more effective. Reaccreditation affirmed our internal sense that we were making significant progress in all domains of our performance, and in a dramatic fashion!

Additionally, accreditation provides Lad Lake with a competitive advantage with many of our stakeholders.  This will be increasingly important as the federal Families First Prevention Services Act is implemented.

COA: What about the COA accreditation process made you decide to partner with us?

DM: Our partnership with the Alliance for Strong Families and Communities and our executive leadership’s deep connection with the Alliance network made COA the obvious choice for accreditation.  It is the “gold standard” for our industry.

COA: What do you see as the main benefit of COA accreditation?

DM: COA accreditation provides Lad Lake with a framework for (and the discipline to stay focused on) our strategic priorities. It helps us to learn together, to adjust our approaches to achieve our intended impact, and to strengthen our financial sustainability in the face of changing market conditions.   

COA: Were there any unexpected results after completing the Self Study and PQI process?

DM: The primary unexpected result was the degree to which Lad Lake’s management teams embraced COA accreditation, especially reaccreditation. The standards, the policies, and the procedures developed in our self-study and PQI processes have, for the most part, become the way Lad Lake does business.  Accreditation is not “just another thing” on the plate of busy managers and leaders.  Rather, it is our primary frame of reference for accomplishing our work. 

Additionally, the COA accreditation and reaccreditation processes were completed in the face of very serious financial challenges.  These challenges required the development and execution of a difficult turnaround plan.  Rather than distracting our leadership from that plan, COA accreditation provided a disciplined process to focus our attention on the key drivers for our success. 

As CEO, I do not believe our financial turnaround, improved quality and financial sustainability could have been possible without the discipline of thought offered by accreditation and reaccreditation.

COA: Why was it important for you to have a high level of stakeholder engagement across your organization?

DM: One element of our organizational vision is to fulfill our mission with an “aligned, engaged, and happy workforce.”  This can be a tall order in an industry with such challenging work and shoe-string budgets!  The COA process, in concert with a clear strategic plan, helped us to articulate what we wanted employees to align and engage with.  It also helped us to communicate those directions across our organization.  This has grounded Lad Lake’s daily activities in a larger vision of improving the lives of youth and families in need.

COA: How has COA accreditation/reaccreditation impacted operational success at Lad Lake?

DM: Accreditation and reaccreditation has been transformative for Lad Lake.  In concert with our updated strategic plan, COA provided a framework to operationalize and monitor our process improvements across all domains of our organization, from impact to human capital to financial sustainability to governance. A host of key performance indicators focused the work of the board, management, and staff. 

The results have been extraordinary.  All our programs now share common goals in safety, health, social support, and hopeful futures.  Process improvement is closely tracked with client feedback and validated assessment methodologies.  Findings inform refinements in program design.  Risk management in many key areas has dramatically improved.  After years of financial losses, Lad Lake has moved to a position of financial sustainability.

COA: How did you communicate the value of accreditation and engage the entire organization during the accreditation process?

DM: We did so in various ways. Firstly, many managers and supervisors were (and are still) involved in various teams devoted to quality improvement and risk management.  Internal communication methods such as staff newsletters, email communication, and face-to-face meetings helped to extend the accreditation story to team members. Accreditation at Lad Lake is so closely aligned with our strategic priorities and key performance indicators that our board of directors discusses it at every meeting.

COA: At the board level, what were the driving factors for seeking accreditation?

DM: The board was particularly interested in accreditation to help it better understand and address the impact of the organization’s services on youth and families. The pending retirement of a CEO and the prospect of a new CEO coming aboard added extra urgency to Lad Lake’s initial pursuit of it.

COA: What was the biggest challenge for the board during the accreditation process?

DM: The board fully embraced accreditation.  They understood its value and likened the process to quality initiatives and accreditation in their respective industries.  Linking accreditation to our strategic planning and turnaround agenda required careful attention, but accreditation helped, not hindered, that process.

COA: What are the top three tips that you would give to an organization considering or currently undertaking the accreditation process for the first time?

DM: I would advise organizations to:

1.       Embrace accreditation as the way you do business, not as an extra initiative to take on.

2.       Embrace strategic planning. Find the right strategic planning process for you, and closely link accreditation with your strategic plan. 

3.       Communicate and engage your board of directors with COA.   Many parallels may exist in their industries (e.g., Six Sigma, ISO 9001, Joint Commission, etc.).

Thank you, Lad Lake!

We would like to thank Dan for his thoughtful insights into the accreditation process and acknowledge the entire board and team for embracing accreditation and collectively contributing to the continued success of Lad Lake.

Do you have an accreditation story to tell?
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You could be the next organization we feature!

It is no secret that the Council on Accreditation (COA) believes in what we do. We promote best practices and help our organizations to implement them with the aim that clients across the social services field will get the best possible quality of care. By accrediting the entire organization, we ensure that everyone—from human resources to finances to support staff—is working together to carry out that mission.

This is the “why” of organizational accreditation for COA and our accreditees alike. We are all here to do good; following best practices helps us do good in the most effective way possible.

Improving service quality is the most important benefit of organizational accreditation. But from our experience, it is not the only benefit! Every time an organization completes the accreditation process, COA asks about its impact. Several themes have come out of our survey responses.  

Organizational accreditation improves operations.

Whole-organization accreditation provides a framework for staff to look at how they fulfill their mission now and discover how they can do so better. The benefits along the way are multifold: more open communication, sound strategic plans, streamlined work systems, better risk management…the list goes on. When an organization looks at itself holistically, it can find the root of any problems and be better equipped to solve them.

94% of COA-accredited organizations agree that accreditation improves organizational learning and knowledge. 82% agree that it improves organizational capacity. COA accreditation has helped some organizations bring themselves back from the brink of bankruptcy; others have used it as a tool to position themselves to become leaders in the field.

Many have expressed that reaccreditation is not an end of itself, but a tool to help them achieve new heights of living their mission. COA is proud to help them do that.

Organizational accreditation boosts marketability.

Organizational accreditation is a professional, 3rd-party recognition that an organization meets the highest standard for both quality service delivery and administrative practices. The effort that an organization goes through to achieve accreditation proves just how much its staff cares about what they do.

This hard work helps organizations stand out among competitors and builds goodwill. 85% of our organizations agree that COA accreditation improves their organization’s marketability. 90% agree that it improves their relationship with external stakeholders. Clients and community alike are looking for signs of quality—accreditation gives them a big one.

Organizational accreditation helps secure funding.

Organizational accreditation verifies that an organization not only does quality work, but also has sound financial, administrative, operational, and oversight practices. This third-party verification can inspire the confidence funders need to support an organization as it continues to grow.

This can help in terms of government funding, as well. COA is recognized in over 300 instances in 50 U.S. states, the District of Columbia, Canada, and China. Our list of recognitions continues to grow, and with it the financial benefit to our accredited organizations. As of December 2018, 70% of our organizations agree that COA accreditation ensures funding.

Organizational accreditation can give staff a sense of fulfillment.

Accreditation encourages organizations to look at themselves frankly and work toward continuous quality improvement. This can allow staff to take a break from their daily grind and appreciate the big picture of their impact. Organizational accreditation also facilitates transparency and open communication, which can increase trust and the feeling that everyone is working as part of one team.  Finally, the quest for quality improvement provides staff with new professional opportunities, allowing them to lead the charge toward a brighter future for those they serve. 

Almost three quarters of COA-accredited organizations agree that accreditation improves workforce engagement, and over half agree that it improves staff retention. Many of our organizations describe how empowering it is to see the change in mindset that accreditation can bring.

Organizational accreditation holds the team to its goals.

As anyone with a broken New Year’s resolution knows, it is easy to put great plans in place and never carry them out. Accreditation (and reaccreditation!) forces organizations to follow through with those great plans, holding them accountable to be the best they can be.

94% of COA-accredited organizations agree that our whole-organization accreditation improves transparency and accountability. Through it, staff become not only accountable to their clients and stakeholders, but to themselves.

Time and time again, accreditation has proved transformative for our organizations, supporting their mission and allowing them to provide clients with the quality service they deserve. COA is grateful and humbled to be a part of this important process.

Have you experienced other accreditation benefits not listed here? Share them with us in the comments!

SOURCE: All statistics are pulled from 2018 survey data from organizations accredited by the Council on Accreditation (COA). 

Active military and Veterans play an integral role in our everyday lives. Although we can’t always witness them in action or grasp the full breadth of their influence, we have confidence in their bravery and the safety they provide to our society on a daily basis. While we have this understanding, we also recognize that Veterans in this country often need support when they return home. Not only because of the inherent trauma of combat, but also because of the challenging economic situations that they often find themselves and their families in. We must continue to strive to do better by our Veterans. An example of progress in this area is the Supportive Services for Veteran Families (SSVF) program. This program addresses the varying needs of an individual Veteran and their family, by providing assistance with housing, transportation, child care, and the financial barriers that they may face.

SSVF was established in 2011 as a Rapid Rehousing and Homeless Prevention program to support homeless Veterans and their families in finding permanent housing and prevent homelessness for those at imminent risk due to the housing crisis at the time. In 2019, the U.S. Department of Veterans Affairs (VA) is making $326 million in grants available to providers through a competitive application process, in order to assist them with providing SSVF services. These services assist Veteran families with outreach, case management, and assistance accessing and coordinating other services that promote housing stability and community integration. The program has had several successes since its inception.

In 2015, Virginia Governor Terry McAuliffe announced that Virginia would be the first state in the nation to functionally eliminate Veteran homelessness. The philosophy underlying the state’s initiative is housing first — a policy that holds that providing homeless people with safe, supportive housing is a precondition for attending to the issues that caused them to slip through the cracks in the first place. Supportive services in permanent housing typically keep residents linked to social workers and include health services — many single homeless adults have some kind of serious physical, mental or substance abuse-related problem — and job readiness programs .

Virginia is not the only state that has seen successes with this population. SSVF, Phoenix, Arizona was the first community in the country to end homelessness among veterans with lengthy histories of homelessness. The tenet of the program as described by one veteran, “I’m coming up on nine months sober, and a big part of it is because I have a roof over my head.” The program allows participants to prioritize their recovery because they are no longer consumed with the fundamental human need of finding shelter.

Many capacities/elements are considered when applying to be a SSVF provider, one of which is a provider’s accreditation status. The Council on Accreditation is recognized by the VA as an approved accreditor of SSVF services. SSVF providers that are COA accredited are eligible to receive a three-year funding award from the VA, while non-accredited providers are limited to one-year funding awards. Recognition of specific accreditors is often used as a tool for oversight entities, in this case the VA, uses accreditation to meet/or exceed oversight requirements. The VA also allows SSVF providers to use their funding to pay for accreditation. This incentivizes providers to become accredited and allows the VA to verify that these providers have gone through a rigorous third party review by an accreditor. Essentially the VA uses accreditation as a tool to indicate a quality provider with quality services, services that are best equipped to support U.S Veterans and their families.

Jill Albanese, Supervisory Regional Coordinator at the VA, oversees providers of the SSVF program and has been with the department since the creation of the program. Jill graciously took time to explain how the VA’s recognition of COA accreditation played a role in them determining funding for these grantees. Check out our discussion below.

COA: What was the genesis of recognizing an accreditor for this funding?

JA: When SSVF was being created we wanted to find a way to monitor and oversee the program consistently within our limited resources. We looked into how other non-profit oversight entities were doing this work and began learning more about the accreditation process.

COA: Why is accreditation status a component of the SSVF grant?

JA: We wanted agencies to become accredited, however we did not want to mandate it and limit services in a community if a provider does not yet have an accreditation status. To further incentivize accreditation we allow providers to use SSVF funds to pay for accreditation and allow accredited organizations to be eligible for three-year funding awards.

COA: Were those incentives effective?

JA: Yes, I would estimate that about half of all SSVF providers are accredited.

COA: How has recognizing COA accreditation impacted the VA’s oversight of the SSVF program?

JA: We’ve seen increased consistency amongst accredited SSVF providers. In addition, we have consistent oversight practices for accredited organizations that allows us to reduce the duplicative work that we do to monitor the programs. We use an Accreditation Tool that shows our auditors which review steps would have been covered for them to achieve accreditation. We can spend less time monitoring those sections already reviewed under the accreditation process and more time focusing on offering technical assistance to our providers. It saves time for auditors and providers.

COA: Can you tell us about the roll out of the accreditation provision?

JA: Initially, we gave priority funding to applicants that were already accredited at the time. Then we worked with each accreditor recognized to determine specific service sections that we felt most appropriately fit the SSVF program. The accreditors then crosswalked their standards with our regulations and we were able to achieve further consistency between provider agencies.

COA: What have you heard from providers related to the accreditation process?

JA: I recently spoke with a provider about this, they described the process as totally worth it. In fact, this particular provider is excited to now be mentoring another agency through the accreditation process. I’ve also heard positive comments on the standards themselves. The process is rigorous, particularly before the Site Visit, but overall providers seem to appreciate the organizational change it creates.

COA: How do you think the accreditation process has impacted SSVF providers?

JA: Anecdotally, there seems to be an increased sense of organization about them. Particularly in day-to-day work we’ve seen providers transform their processes and procedures, which has an improved impact on the services delivered. It has increased the expectation of quality amongst SSVF providers, which has led to increased quality amongst the providers applying for SSVF funds.

COA: As the oversight entity, have there been any challenges to having an accreditation component for the grant?

JA: SSVF is a dynamic program that is constantly changing. Our mission is always the same, but the method changes, in some instances these changes can be rapid. It helps that the accreditors are ready and willing to make changes when that happens.

COA: Are there any components of accreditation that you find particularly valuable as an oversight entity?

JA: The individual governance standards, and policies and procedures are extremely helpful. It provides agencies guidance and structure. If a provider loses a staff member having these components of accreditation in place help them stabilize, which is good for Veterans.

COA: What impact do you feel the accreditation process has on the individuals served by SSVF programs?

JA: Ultimately, the individual Veteran has been able to expect a greater emphasis on consistent services. Anecdotally, the providers seem to run smoother operations.

COA: Has the role of an accreditor created any efficiencies for the VA as an oversight entity?

JA: Program review has become more efficient. Grantees are more organized for the process, which allows us to save time on things that usually require a lot of back and forth. It saves a lot of time day-to-day.

COA: Is there anything else you want to share that we haven’t covered in these questions?

JA: It’s amazing to see the differences from one year to the next with these providers. They’re eager to share their progress and the successes their clients have achieved.

Thank you!

We would like to take a moment to thank Jill for her time and insights, but mostly for the work she does every day to support Veterans in this country. COA looks forward to our continued collaborative partnership with the VA.  

Accreditation is a journey. One with a clear destination, but a less defined path. There are mile markers along the way; however, there isn’t necessarily one straight, easy road to the finish line. Is there a recommended route? Are there any anticipated hurdles? If you are tasked with leading the accreditation process for your organization, you may not know where to start. This is where COA’s Accreditation Coordinators come in.

Every organization seeking COA accreditation is assigned an Accreditation Coordinator, a COA staff member that serves as a single point-of-contact throughout the accreditation journey. The role of the Accreditation Coordinator is unique to COA’s facilitative accreditation process. They work closely with the organization’s designated single point-of-contact, which COA refers to as the Primary Contact. Through this partnership, an organization obtains the support they need to navigate the road ahead. 

Roles and responsibilities

Accreditation Coordinator

An Accreditation Coordinator works concurrently with a number of organizations. Their caseload can vary as well as the needs of each organization. The coordinators can also specialize in distinct accreditation programs or service types (Financial Education and Counseling, Employee Assistance Programs, Opioid Treatment Providers, etc.). Communication is a key element to this role. They’re responsible for answering questions, providing feedback on submitted documentation, and referring organizations to training and resources. Whether it’s to discuss specific documentation, standards, practices, or policies, they’re available on a daily basis to address inquiries from organizations. And because each organization comes with unique questions and circumstances, researching program models and administrative practices is also part of the work.

While the day-to-day routine of an Accreditation Coordinator involves providing tailored support to organizations, it is also valuable to note the role’s limitations. Accreditation Coordinators are not consultants and do not provide consultation to organizations. They can help Primary Contacts interpret the standards and answer questions, but are unable to dictate how implementation will look on the ground. Organizations are responsible for the application of the standards. And while they review and provide feedback on select pieces of evidence, specifically six key documents referred to as the Preliminary Self-Study (PSS), it is not within their role to review the entire Self-Study (aka all of the evidence that is required based on the assigned standards). The Site Review Team assesses the Self-Study prior to the Site Visit and will provide the ratings after conducting the on-site review.

Primary Contact 

The Primary Contact is COA’s champion at the organization level and is in charge of spearheading the accreditation process. In this role, they’re responsible for engaging organization staff in all things COA. While the Primary Contact is the single point-of-contact, accreditation is by no means a one-person job. Accreditation is a huge team effort, from pulling together Self-Study evidence to preparing for the Site Visit, and the Primary Contact is the team captain. It’s no coincidence that we have repeatedly heard the role compared to “herding cats”!

Exploring the relationship between the Accreditation Coordinator and the Primary Contact 

COA’s mission is to partner with human service organizations worldwide to improve service delivery outcomes by developing, applying, and promoting accreditation standards. The relationship between the Accreditation Coordinator and the Primary Contact brings that partnership to life. The two work together throughout the accreditation process, from start (the intake call) to finish (the notification of accreditation). They’re there to kick off the expedition, advise you of the twists and turns, help navigate roadblocks, and ultimately make sure your organization hits all the necessary milestones en route to the final destination. Along the way, Primary Contacts should provide the Accreditation Coordinator with updates on their progress, highlighting successes and challenges. That information helps COA gauge the organization’s strengths and needs and informs the provision of targeted supports.

Learning about the challenges of navigating the process is vital to COA. We want to know about the unexpected obstacles in order to assist with readjusting your approach and preventing you from spiraling off course. For example, Performance and Quality Improvement (PQI) can be one major hurdle for organizations. As the Primary Contact it can feel daunting to try to implement a culture of PQI, especially if your organization doesn’t have the framework in place. As an Accreditation Coordinator, some of my favorite moments working with Primary Contacts have come from discussing the evolution of PQI. It could be talking through the development of a PQI committee (“Who should be on it?” “How often should they meet?”) or figuring out performance and outcome measures (“Can you explain outputs and outcomes again?” “What are some examples of operations and management performance measures?”). Standards and technical assistance inevitability guide the conversation, but it’s through this exchange that we learn how an organization goes about creating change. And isn’t that what it’s really all about? PQI helps an organization become stronger to better serve their clients and community.

The relationship between the Accreditation Coordinator and Primary Contact is not one-size-fits-all. We are there to support in whatever capacity is most beneficial for the organization. For some this may take the form of structured monthly check-in calls, while others prefer Q&A exchanges over email. We recommend that organizations new to the accreditation process or new to the role of Primary Contact have more regular communication with their Accreditation Coordinator. Seasoned individuals may not need to rely on their coordinator as much; they remember the journey and have their path mapped out. Regardless of the frequency of contact, the door for communication is always open.

Tips for Primary Contacts

We know that serving as the Primary Contact is not an easy task. Often the work of accreditation is piled onto an already full plate. Here are some tips and tricks from COA’s team of Accreditation Coordinators: 

• Use your Accreditation Coordinator as a resource. If you feel stumped or confused, don’t hesitate to reach out to your Accreditation Coordinator. Ask questions, it is what we are here for! That said, sometimes we get such excellent (and complex) questions that we need to consult with the team or the Standards Development department, which requires additional time. So it may take us time to get back to you with a response, but don’t worry; we will get back to you as soon as possible.
• Send us an email or schedule a call. The Accreditation Coordinator’s daily responsibilities are often collaborative – meeting frequently with organizations, our team, and other COA colleagues – which can sometimes impact our availability. We know Primary Contacts have busy schedules too. No one enjoys playing phone tag, it is best to schedule a call or send us an email. Our typical response time is 24 to 48 hours.
• Become friends with the MyCOA portal. We recommend that all Primary Contacts (and staff working actively on the process) participate in one of the regularly scheduled Intake Webinars in order to review all of the portal’s features and functionality. We don’t want to brag, but it is pretty cool! We encourage you to get familiar with the portal since this is where you will be completing the majority of the work. Check out the Step Pages, search for tools, and click all the buttons! Well not all the buttons. 
• Attend a COA face-to-face training. There is no better way to familiarize yourself with all aspects of COA than attending either the in-person 2-day Intensive Accreditation Training or 1-day Performance and Quality Improvement Training. These in-person trainings provide Primary Contacts with an opportunity to learn from COA subject matter experts, meet COA staff and network with other organizations. We recognize this might not be a feasible option for all organizations due to limited resources and capacity. Therefore, we also offer a variety of complimentary live webinars and self-paced trainings covering similar curriculum.  You can learn more and register through the Training Calendar. 
• Don’t panic! This might be the most important tip on this entire list! The accreditation process is meant to be rigorous, but achievable. The goal is that you end the journey stronger than when you started. Change doesn’t happen overnight and it isn’t always easy, however, it is possible. The best advice for Primary Contacts is to not get overwhelmed; take the process one step at a time. Creating a work plan and communicating expectations to your team (don’t forget to enlist their help) is a good place to start. Have fun with it too! We have seen many primary contacts tap into their creative sides to invent games or enjoyable activities to get their team on board the COA train.

Training and resources

Want to know how to create a policy? We have a tip sheet for that! Want to know how to develop a strategic plan? We have a template (along with a self-paced training and blog post) for that! We’ve included just a few of the many resources that can help organizations on the road to achieving COA accreditation. We recommend exploring the full breadth of resources by accessing the tool search in the MyCOA Portal.

• Accreditation Learning Plan
• Getting Organized: Creating an Accreditation Workplan
• Preliminary Self-Study Fact Sheet
• Three-Part PQI Recorded Webinar Series
• PQI Tool Kit
• Preparing for the Site Visit 

You are not alone

Many of us at COA have a social work (or social work adjacent) background, and the work we do to support Primary Contacts in their efforts to create change in their organizations, mirrors the work organizations do with their clients. We conduct an assessment. We create a service plan. We deliver supports and linkages to necessary resources. The makeup of our caseloads may be different, but we are all working towards a common goal – positive client outcomes and high quality services.

And as you learn from us, we learn from you. You are the change makers, advocating for those that you serve and making an impact on your communities. For many of us, the stories that you share and the work that you do are why we walk through the doors at COA. You are our direct connection to the field. Our collaboration allows us to gain a better understanding of service delivery and program models, as well as how the implementation of best practice looks on the ground for organizations of all shapes and sizes.

At the end of the day, an organization is ultimately responsible for their accreditation process, however, you are not alone on the journey. COA’s Accreditation Coordinators are there to support you and your team.

When the Family First Prevention Services Act (H.R.253) was passed, it recognized that the best placement for children is in the least restrictive setting. This is also true for undocumented children in the custody of the Office of Refugee Resettlement (ORR).

In that regard, since 1997, the Flores Settlement Agreement has defined the rights of these children. In essence, it obligates the government to keep the children in the least restrictive setting and sets standards for their care.  Recently, however, the Departments of Homeland Security (DHS) and Health and Human Services (HHS) have put forth a proposal to withdraw the agreement.

The agreement was never meant to be a de facto law so much as a framework, and in the original agreement there was a sunset clause expiring the agreement after 5 years provided the government implemented the terms of the settlement as federal regulation or Congress superseded it. Neither has happened. In fact, in 2015 the settlement was expanded to include all minors who come across the border without legal authorization (not just the unaccompanied ones who become custody of the federal government).

Despite the absence of the required federal regulation or congressional action, DHS and HHS have begun the process to withdraw the agreement. In doing so, families could be detained and placed in less regulated facilities, broadening the allowances for emergency loopholes for not meeting standards of care, and making it easier for government to revoke legal protections for unaccompanied minors.

This proposed rule change includes a comment period that ends November 6th, 2018 after which Judge Dolly Gee will determine whether the regulations are eligible to supersede the Flores Settlement Agreement. COA is urging interested parties to provide comments which put forth recommendations that emphasize the well-being of a child, and which ensure that migrant children receive trauma-informed and evidence-based care in the least restrictive setting.

The best practice of care for these children was established by the Flores Settlement Agreement and is contained in COA’s UC standards. It includes wraparound services to support their integration into society and placing them with kin or resource families in the most home-like settings. It has been two decades since the Adverse Childhood Experience (ACE) Study was conducted and the lessons learned have been indelible to the field: childhood trauma has long lasting effects. We cannot discuss the needs of this population without discussing the need for trauma-informed care.

So what can we do as human service professionals? Well, there are a few options:

• COA has put forth standards we consider best care for unaccompanied children. These standards are available our website. All comments and feedback will help shape the voice we provide DHS and HHS.

• Share your comments about what is best for children. Go to the Regulations.gov website for instructions on how to comment. Need some help with this? Here’s a resource to help you craft your response.

• Reach out to your representatives and ask what their plan is for the comment period and how they are defining proper care for unaccompanied minor children.

The accreditation process is most valuable when staff throughout the agency are engaged, but this isn’t always easy. Harris County Protective Services for Children and Adults shares the fun, interactive methods they used to promote the culture of COA and gain staff buy-in.

The phrase “THEY ARE COMING” typically strikes fear in the hearts of agency staff and leadership preparing for a reaccreditation Site Visit. Even scarier is that a lot of the staff not directly involved in the process never know exactly who “THEY” are.   

Since the last Site Visit 4 years ago, our organization had experienced many changes to leadership. Our Quality Improvement Team had transitions in roles and was now staffed with a diverse team with a fresh set of eyes for COA.

As a team new to the process, one of the first things we did was an assessment of staff feelings and knowledge about COA.

Challenge #1: Even though our organization has been successfully reaccredited since 1978, staff still remained in panic mode. 

When it was time for our formal Site Visit COA continued to be viewed as a separate entity, a “THEY” of sorts. We wanted to be sure that the view was of our partner helping us to identify strengths and areas for improvement in ways that may not be immediately apparent. We realized that part of the issue was that historically, we had not engaged and educated ALL staff (and not just those involved in turning in evidence). We needed to reframe staff perceptions as COA being a positive experience and focus on the benefits of the visit instead of just focusing on meeting deadlines to turn in evidence.

Challenge #2: What did we do to engage staff before? What resources do we have to engage over 19 different programs with field and on site staff?

We convened a think tank of new and seasoned staff from Quality Improvement, Communications and our Training Institute. At the last Site Visit we were only able to reach staff via email blasts and a creative “Go for the Green COA Poem.” Though staff comments about COA from past surveys and focus groups was reviewed, it was hard to track who actually opened the emails and who really took-home the message of what COA is all about. 

We wanted to do something different and FUN that would appeal to our two majority generations in the agency identified from our annual staff survey: millennials and baby boomers.

Out of our think tank was born the theme for our COA Kick Off Week online Challenge, “Who Wants To Be A COA-Knowledgaire”, which included a teaser video about COA starring our own “COA Queen” which addressed and made light of staff feelings about COA. 

Teaser Video

We also found online templates for interactive Power Point Shows that were clickable to reveal correct (or incorrect, buzz!) answers that staff could complete each week to gain knowledge instead of having to read long text.

If staff passed the Grand Challenge Quiz (via Survey Monkey) with 90 or above, they were eligible to redeem limited edition swag items.  The swag items, though a small investment from the Quality Improvement department ($2,000), made for an effective incentive that got many unfamiliar faces involved and increased word of mouth.

At the end of the challenge, almost 50% of our staff had participated visiting us in person at each site to collect their unique swag, a huge participation success for a governmental agency.

The Quality Improvement Team showing off their COA swag.

We have additional engagement activities planned for the months leading up to our visit to keep the momentum going and to continue promoting our Site Visit as an opportunity to showcase our programs and to learn about the up and coming best practices for social service agencies and nonprofits. To learn more about HCPS on their website and Facebook. 

Resources

• Flip card Trivia
• How to make a power point show auto-run and clickable
• WHO WANTS TO BE A MILLIONAIRE GAME TEMPLATE sample template by Mark Damon

The views, information and opinions expressed herein are those of the author; they do not necessarily reflect those of the Council on Accreditation (COA). COA invites guest authors to contribute to the COA blog due to COA’s confidence in their knowledge on the subject matter and their expertise in their chosen field.

Emmony Pena

Emmony is a Licensed Master Social Worker from the University Of Houston Graduate College Of Social Work with a focus on program development and evaluation. She has 5 years of experience in Data Analysis and Process Improvement through her graduate research assistant experience at MD Anderson and in her current role as Quality Improvement Professional at Harris County Protective Services. Emmony’s goal is to engage staff in performance and quality improvement activities and in plan-do-study-check act cycles.

Emmony monitors the implementation of the agency’s Performance and Quality Improvement plan and provides technical assistance and leadership to programs in the areas of Council on Accreditation standards, data collection, logic model development, focus groups, case review audits and trainings.

Certifications: CANS Assessment (Child and Adolescent Needs and Strengths) Certified

A big thank you to Stan Capela of Heartshare Human Services of New York for this guest post!

My name is Stan Capela and I have been a COA Peer Reviewer and Team Leader since 1996. By the end of April, I will have completed 112 Site Visits. At the glorious age of 65 after devoting 40 years to the field of social services, I’m beginning to reflect back on my journey. I want to share my experiences with you in honor of Volunteer Month.

Before I share my story let me give you a snapshot of a Volunteers numerous responsibilities. First you are assigned a Site Visit. I started as a Peer Reviewer, working with a team of colleagues to review an organization. Ten years ago, I became a Team Leader and gained more responsibilities such as; making contact with the organization, setting up travel for the Peer Review team, developing the Site Visit schedule, assigning standards sections to the Peer Reviewers, and leading the entrance and exit meetings where the team interacts with the organization. The latter gives the Peer Review team a chance to introduce themselves to the organization and provide information about how the review will take place.

Wait! I’m getting ahead of myself. The entire review process begins with a Self-Study submitted by the organization and reviewed prior to their Site Visit. When the review team arrives on-site most of their time is spent reviewing case records, policies and conducting interviews. By the time the exit meeting occurs, the Team Leader and review team are ready to provide an overview of the organization’s strengths and challenges. If you want to learn more about the Site Visit process then I recommend reading Recipe for Conducting Quality Accreditation Site Visits which I co-authored with Joe Frisino, a member of the COA Standards Development team, in New Directions for Evaluation.

The decision to become a COA Volunteer starts with the simple question, why? And traveling through my many memories leads me to that answer.

I remember on my first Site Visit I was eating dinner and mistakenly bit into an olive and broke my tooth. The executive director of the organization we were reviewing offered to have one of her board members who was also a dentist patch me up. I declined since I felt it would be a conflict of interest. After all it was just a cracked tooth.

Another significant memory is when I interviewed two girls, one 8 years old and the other 12 years old. They both had been abused and while talking with them they expressed how much they appreciated the staff helping them get through their pain.

There was also a memorable exit meeting where I remember commenting on the risk management minutes and asking who was responsible for creating them. A woman stood up and I complimented her on her work. That moment made the executive director stand up in that same meeting and say, “it goes to show you, we are all a part of a team dedicated to helping people in their time of need.” At the conclusion of that exit meeting the employee I engaged with beamed with pride as leadership walked over to say that they didn’t realize they were in the presence of such a star.

Once I was making the rounds and asked an employee to tell me a story that would make me remember the organization. He told me about Johnny and the mailbox. Basically, it was an individual with developmental disabilities who lived in a group home. One of his goals was to get the mail and distribute it. One day he went outside to the mailbox and found a baby inside. Johnny being trained properly brought the baby inside and gave it to the site manager. Many years later there was a knock on the door. The site manager opened the door and saw a very professional looking woman who asked for Johnny. The site manager said Johnny passed away a few years ago. The woman said I was the baby and wanted to thank him.

I remember another time that I was scheduled to meet with a client during a Site Visit. The client was transgender. During the interview the client expressed appreciation for how the staff treated her while she was transitioning. It felt good to hear how well the staff supported her and addressed her needs.

I have many more stories but these are just a few. So again, why? It’s about interacting with people and observing inspiring team work. When I conduct an entrance meeting as a Team Leader, I start by saying I know this is a lot of work, but we’ll get through it together. You should look at this Site Visit as an opportunity to invite people into your home and share your world with them. I try to get the point across that we are a family of helpers who have dedicated our lives to helping people in need and going through the accreditation process provides an opportunity to affirm what we do.

It’s very easy for me to answer the question why become a COA Volunteer after all these experience in these roles. My time as a Volunteer has made me feel like the richest person on the face of this earth. Again, why? Simple, I have decided to help people in my work at HeartShare Human Services of New York and in these roles at COA. In all my roles I’m able to make sure we all strive to meet the highest standards to reaffirm that the work we do meets the needs of the people we serve.

The views, information and opinions expressed herein are those of the author; they do not necessarily reflect those of the Council on Accreditation (COA). COA invites guest authors to contribute to the COA blog due to COA’s confidence in their knowledge on the subject matter and their expertise in their chosen field.

One of the most frequently asked questions we get from organizations, is what the differences are between these three entities: accrediting bodies, licensing authorities, and certification organizations. Commonly there is overlap, but sometimes there are distinct differences. Before we explore those differences, there are a few points to highlight:

• Accreditation, licensing, and certification may vary by location and by the entity providing the credential. While we hope this article is helpful in providing a basic understanding, always be sure to check with your local jurisdiction to determine what is required.
• There is often an interdependence between these three categories. We discuss this correlation later in the post.
• Accreditation, licensing, and certification are not interchangeable terms. They each have a unique meaning and implication.

Now let’s walk through the definitions and examples of each category, and then take a look at some examples of how they can overlap.  There’s an infographic at the end of the post that gives an overview of this discussion. 

Accreditation

• Accreditation is both a process and a credential
• The accreditation process is voluntary
• Only organizations, agencies, or programs can be accredited

If an organization is accredited this means they conducted a thorough self-assessment and compared themselves to recognized standards of best practice. Accreditation means that the organization, agency, or program was able to demonstrate evidence of implementation to all of the relevant standards. It is a rigorous process conducted by a third party organization.

The process is voluntary; however regulating bodies often require accreditation in order to be licensed or certified. The accreditation process typically repeats every 2-4 years, depending on the accrediting body. Normally, individuals or private practices are not able to become accredited; however, some exceptions may exist.

Example:

The Council on Accreditation (COA) develops standards and guidelines for the accreditation of services delivered by behavioral health and social service agencies. The accreditation process is designed to assist agencies in implementing organizational structures (i.e. financial management), and processes of care (i.e. case-management) that will help them achieve better results in all areas, and ultimately improve the well-being of their clients. Organizations use their accredited status to demonstrate accountability to clients, funders and donors.

Accreditors of human and social services

The most common accreditors of human and social services are as follows:

Council on Accreditation (COA)
CARF
Joint Commission

Here’s a comparison between the above accrediting bodies.

Licensing

• Licensing exists primarily for public safety and the well-being of consumers
• Typically, licensing is involuntary
• Individuals, facilities, programs, organizations or agencies can be licensed

Individuals are often licensed by their respective state to practice counseling, social work, or nursing. Organizations may need to be licensed in order to provide a specific service such as services for substance use disorders or residential treatment. Practitioners and programs are required to be licensed or face penalties, including suspension or closing of agency.

Examples:

Under New York State law, no organization may operate an adult group home without a license.

In most states, including New York, individual social workers must have a clinical license in order to provide psychotherapy without supervision.

Certification

• Certification demonstrates the capability to provide a specialized service or particular program
• Typically, certification is voluntary, but sometimes regulatory bodies require certification in order to provide a specific service
• Individuals, facilities, programs, organizations or agencies can obtain certification

Certifications at the organizational level can definitely vary, including the terminology. Some structured evidence-based models require certification. In these cases, the certification can be called “authorized provider” or “approved site.”

Example:

We also often see certifications for individuals. Many schools of social work have certificate programs. For example, Tulane University in New Orleans, Louisiana offers a certificate in Family Practice. This is an opportunity for students to get a specialized education and accrue experience in this specialized area which they can include on their resumes. 

Understanding the correlation between accreditation, licensing and certification

More and more, regulating bodies are requiring that organizations become accredited or certified in order to be a licensed provider in their respective state.

Examples:

Effective January 1, 2017 in California foster care providers must be accredited or in the process of being accredited to qualify as a licensed provider. We call this a recognition, the state is recognizing the value of accreditation and using it to identify credible and accountable organizations who have implemented best practices. 

In Nebraska, organizations must be certified in Functional Family Therapy (FFT LLC) to be a licensed provider. In this example, the state is relying on a certification to ensure that specific models are implemented and relying on FFT LLC to track the fidelity of the program model.

Final takeaways

• Always pay attention when you see the words “license,” “certification,” and “accreditation.” Whether you are applying for a grant or soliciting funds from a donor, be sure to use the appropriate terms and understand what the entity is requesting.
• Don’t be afraid to ask about what the terms mean. With so many different regulating bodies out there, you want to be sure that you are all on the same page.
• Never make false claims about your credentials; you will always need documentation to support your status. Not that organizations would intentionally make a false claim, but accidentally using the wrong terminology can lead to problems.
• Stay on top of the changes and requirements of your regulating or accrediting bodies. This can be a challenge in our ever-evolving field. When there’s transition, licensing, certifying, and accrediting bodies must adjust as well. A great way to bolster your risk prevention activities is to have an internal process that regularly reviews changes in requirements. Subscribe to COA’s newsletter for standards updates.

We hope you now have a better understanding of these terms, or at least with recognizing when you need to ask more questions to ensure that your organization remains in good standing with all entities that have a stake.

Here’s an infographic summarizing what we went over in this post, feel free to share it!