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Introduction

The Ministry of Community and Social Services endorses accreditation as a best practice for all ministry-funded agencies that provide developmental services, as part of a multi-dimensional approach to quality assurance and continuous quality improvement.

The review and selection of an accrediting body is an important process. The attached checklist can be used by agencies that are considering accreditation, as they review accrediting bodies and possibly select an organization with whom they would like to seek accreditation. The checklist was developed following a review of other tools and research on accreditation.

What is Accreditation?

Accreditation is a formal, external monitoring process whereby accreditation bodies set performance standards for service quality, measure the merit and worth of an organization in relation to the standards, and keep the organization accountable to the public. The process is based on self-assessment and review, as teams of peers and/or professional surveyors assess the quality of an organization and provide assistance aimed at improvement. Accreditation identifies to individuals, family members, and other key constituents, that the agency that has been accredited is in compliance with professional standards.

Overview of the Checklist

The attached checklist is designed to prompt agencies to ask a series of questions about the accrediting body, its operation, its standards, and the accreditation process. The domains identified in the checklist are those that the ministry considers fundamental to accreditation. The checklist is meant to be a starting point – agencies may have a number of other questions and criteria that are important factors in deciding whether their organization will seek accreditation, and which accrediting body is right for their agency.

The checklist covers a variety of domains related to accreditation, including:

A. The Basics

this section allows you to highlight quick facts about the accrediting body

• Experience in accrediting organizations such as yours – given that accreditation is a review of all aspects of your organization, it is important for the accrediting body, its staff, and surveyors/reviewers to have knowledge and experience of developmental services.
• Duration periods of accreditation – generally, accrediting bodies will accredit for one or three years; some also accredit for four years in exceptional circumstances.
• Costs – there are two different types of costs to consider:
  • Hard costs, which can be easily predicted. Examples include the intent to survey fee, materials (e.g., a copy of the standards manual), and on-site survey fees; and
  • Soft costs, which could include staff training, consultation fees, time for planning and implementing operational tasks (such as committee work, mock surveys), and costs associated with meeting specific standards (such as enhancements to physical spaces, technical enhancements).
• Type of accreditation – some accrediting bodies accredit agencies as a whole, while others accredit by program area. In either case, it is important that the accreditation process and the accrediting body’s standards take a comprehensive approach to the review of an organization. The standards should include an evaluation of the quality of support that is provided to clients, as well as standards on how an organization operates, is managed and governed, and plans for the future. More detail is provided in sections C (Standards) and D (Accreditation Process) of the checklist.

  Where an accrediting body accredits agencies by program area, agencies are often able to specify which program-related accreditation standards apply to their organization.

B. The Accrediting Body

this section examines the accrediting body’s own organization and operation. An organization that reviews and evaluates other organizations on quality of support and continuous quality improvement should apply a similar approach to governing itself.

Most accreditation bodies provide multiple services, and most accreditation standards reflect this diversity (e.g., consulting services, training, resources for agencies seeking accreditation).

C. Standards

Accreditation standards operationalize values and principles, and put public policy into daily practice. Standards provide a blueprint for effective and efficient operations, a quality improvement strategy, and a management tool to continually evaluate and improve services and programs.

Accreditation standards are developed with the input of key stakeholders, including people receiving services. Standards evolve over time to be responsive to, and reflective of, current values and concerns. Current accreditation standards focus on outcome achievements for people using services and organizational effectiveness.

Accreditation standards are typically reviewed and revised at regularly set intervals.

D. The Accreditation Process

Generally, the accreditation process involves a preparation (self-study) phase, on-site review, report and follow-up.

• Preparation phase – during this period, agencies have time to evaluate themselves and work toward conformance with standards prior to the on-site survey. Generally, accreditation bodies have tools and training available for assistance. Consider also the length of the preparation phase - depending on your agency and the advice from the accrediting body, the entire accreditation process could take one or two years.
• On-site review – the review typically examines different parts of the organization – interviews with clients and staff at all levels, a physical inspection of the site(s), review of the agency’s policy and procedure manual(s), and file reviews. The number of days for the on-site review varies, depending on the accrediting body, the type of accreditation (i.e., program area or the whole agency), and the size of an agency. On-site reviews may last anywhere from one day, up to 25 days.

Surveyors/reviewers who are external to the organization and the funding body typically conduct accreditation surveys. This instills confidence with individuals receiving service and their families that an objective, impartial, expert analysis is in place.

Generally, there are two different kinds of survey/review models:

• Peer review – the strengths of this model are that it is a generally less expensive review process (because surveyors/reviewers are paid an honorarium), surveyors/reviewers have current knowledge of the sector, the political and social environment; staff at the agency undergoing accreditation may feel less intimidated during the process, which could lead to more open communication; and it provides opportunities for professionals in the field to become surveyors/reviewers, share knowledge and stay current. The drawbacks of this model can include problems with inconsistency and objectivity with peer surveyors/reviewers; financial and staffing strains placed on peer sponsoring agencies; varying levels of knowledge and skill in the areas of data collection and analysis, interviewing and report writing; and that surveyors/reviewers need to be well trained and have an understanding of the areas in which they are accrediting, in order to assess standards in the way intended by the accrediting body.
• Hybrid model – this model encompasses the strengths of the peer review model, while addressing the drawbacks. However, as a result it is more costly than the peer review model, as employee wages of the surveyors/reviewers cost more than the honorariums or cost recovery mechanisms paid to peer surveyors/reviewers.

While the ministry recognizes that in-depth knowledge of, and experience in, the developmental services sector may most easily come from peer surveyors/reviewers, it is important to ensure that the surveyors/reviewers are impartial and without conflict of interest.

• Reporting Back – the accrediting body may provide immediate feedback (e.g., an exit interview) following the site review, with a written report to follow. Where an agency has not met one of the accreditation standards, the organization may be provided with an opportunity to respond to areas of non-compliance. Organizations may also want to consider whether there are appeal mechanisms in place.
• Follow Up – Accreditation does not end after the survey. The standards call for internal systems that promote continuous quality improvement. An agency’s accreditation status is time-limited, and re-certification is required to maintain the accreditation seal.

In addition to the considerations outlined in the chart, agencies may also wish to ask for references, and/or speak with contacts in other agencies who have been accredited by the organization(s) that is being considered, in order to have a full understanding of the accreditation experience.

Other Considerations Regarding Accreditation

While the ministry supports voluntary accreditation, and identifies it as a best practice for agencies, there are some additional considerations that agencies may want to consider when reviewing accrediting bodies:

• Accreditation requires additional financial resources.
• Accreditation standards contain many requirements that involve paperwork.
• Accreditation is a long-term commitment, focused on continuous quality improvement initiatives.

In general, agencies that have been accredited find that it was a very worthwhile process and “the right thing to do”.