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. 

thought bubble

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

SAVE THE DATE-WHO WANTS TO BE A COA KNOWLEDGE-AIRE Kickoff event flyer

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

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.

Stan Capela

Stan Capela spent 40 years in the field of program evaluation working the first ten at Catholic Charities for the Diocese of Brooklyn and Queens and the last 30 at HeartShare Human Services of New York formally known as Catholic Guardian Society of Brooklyn and Queens. During his time there he has had the opportunity to do a wide range of program evaluation, staff development workshops and presentations at various conferences such as American Evaluation Association, Canadian Evaluation Society, American Sociological Association, and Society for Applied Sociology to name a few. In addition, he participated on a variety of committees that played a role in developing a competency based child welfare training program known as the New York City Training Consortium. The program is overseen by the Council of Family and Child Caring Agencies. Finally, Stan participated on an internal committee at his current organization that developed a management training program that was the recipient of the COA Innovative Practice Award in 2012.

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:

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

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

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

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

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! 

Accreditation, Licensing, & Certification: What's the difference? Graphic

Community demographics are continuing to evolve nationwide, making the need for culturally competent organizations more prevalent than ever. In this article, we will discuss what this means for you as a provider of social services, and how your organization can progress in this realm by exploring the what, why and how of cultural competence.

The what

First, let’s define cultural competence. It can loosely be defined as the ability to respect, engage, and understand individuals who have different cultural or belief systems, where the elements of culture include, but are not limited to: age, ethnicity, gender identity, gender expression, geographic location, language, political status, race, sexual orientation, socioeconomic status, tribal affiliation, and religion.

Tip: See more definitions of cultural competence from these experts in the field.

The why

The term competency in regards to culturally responsive practice has been debated. Can one ever truly be culturally competent? There might not be a consensus, but as a provider of social services promoting cultural competence will enable you to better meet the needs of the individuals, children, and families you serve. Understanding your community and those you serve facilitates stronger partnerships, resulting in higher quality programs and service delivery. Research shows that organizational culture impacts its effectiveness. An organization that commits to cultural competence is not only better equipped to successfully address community service gaps and needs, but also creates an internal culture that fosters responsive and respectful interactions.

Here are just a few of the many benefits, it:

The how

Seek stakeholder feedback

Connect with your community! The best way to do that is to offer formal and informal ways for clients and community members to provide feedback about the work that you do. That’s why COA highlights the importance of stakeholder involvement in performance and quality improvement systems in its standards. As an organization, you get a sense of what’s working and what’s missing the mark. You can then tailor your services and outreach efforts to ensure that they are culturally appropriate. Most importantly, when you incorporate client and community feedback it makes those you serve active in organizational decision-making processes and promotes engagement and empowerment.

Conduct a community needs assessment

Conducting a community needs assessment is an effective way to identify strengths and resources in your community. It also highlights current gaps and service needs. Collaborating with community partners can enhance this assessment. You can also review other external needs assessments conducted by organizations with a community-wide focus. KIDS COUNT data center, a project of the Annie E. Casey Foundation, allows you to access local, state, and national level data and statistics on demographics and child and family well-being that can be incorporated into your assessment process.

Incorporate community demographics into your strategic planning process

Strategic initiatives should be responsive to changing community demographics and service needs. COA recommends that organization leadership review a demographic profile of their defined service population at least once every long-term planning cycle. However, it’s not enough to collect and review demographic data; it must inform an organization’s planning and operations. Promote cultural competence by establishing goals and objectives that are culturally appropriate for those you serve. Want to go a step further? Incorporate a cultural competency plan into your strategic planning process.

Foster a culturally responsive workforce

Promote cultural competence by having a diverse and inclusive workforce. A first step is ensuring that your human resources practices are culturally appropriate. Organizations should strategically recruit and employ personnel that reflect cultural characteristics of the service population. Is this a challenge for your organization? Create a plan that establishes goals for recruiting and employing individuals that represent your service population and community.

Another way you can commit to promoting cultural competence is by providing relevant education and training opportunities to personnel at all levels. Opportunities should not only focus on work with clients, but also address the internal workplace and interactions amongst other staff. Education and training should be tailored to the needs of your organization, but may include: language classes, interpreter training, mentoring programs, and diversity workshops. You can also conduct workforce assessments to inform ongoing personnel development opportunities to ensure that all staff is trained on culturally responsive policies, procedures, and practices. Once personnel have the necessary education and training, it’s time to integrate culturally responsive practices into everyday work with clients. As a provider, your goal should be to provide respectful, effective, and equitable care. This stems from adopting a service philosophy that is culturally responsive to those you serve, and culturally appropriate program-level policies and procedures.

Arguably one of the most important things that you can do as an organization is create safe and supportive environment where personnel can explore and gain an understanding of different cultures. You can do so by creating a cultural advisory committee to address workforce diversity issues or holding “cultural conversations” where staff can discuss diversity issues and learn from one another. Offering these types of forums reinforces a culture that is accepting and responsive to diversity.

Establish and maintain a diverse and inclusive board

One major responsibility of a nonprofit board is establishing and adopting organizational policy. Policies and procedures that support culturally responsive practice provide the framework for being a culturally competent organization. That is why having a board that reflects the demographics of the community it serves is so crucial. It’s no secret that board recruitment can be a challenge. If your organization is struggling to establish a board that is diverse and inclusive, establish a stakeholder advisory group that is representative of the community you serve and create a board recruitment plan that outlines strategies for getting everyone at the table. Need a little guidance? BoardSource is an excellent resource on board diversity, equity, and inclusion.

Are you feeling overwhelmed?

Don’t be. One of the most important things for organizations to keep in mind is that cultural competence is an evolving, active process; it’s not something that is attainable overnight. In fact, some researchers say there is a cultural competency continuum. The takeaway here is that every step you make towards becoming a culturally competent organization is a step in the right direction.

Want to learn more?

There are plenty of resources floating around the Internet that address cultural competence. Here are a few that you may find helpful:

National CLAS Standards

The National CLAS Standards are a set of guidelines that aim to reduce health care disparities and advance health equity. COA developed a crosswalk to demonstrate how COA standards align with the National CLAS Standards and support the provision of culturally and linguistically responsive services.

National Center for Cultural Competency (NCCC)

The National Center for Cultural Competency (NCCC) aims to promote health and mental health equity through the promotion of culturally and linguistically competent service delivery systems and offers a variety of resources and publications geared towards the promotion of cultural competence.

Standards and Indicators for Cultural Competence in Social Work Practice

Are you a social worker? The National Association of Social Workers (NASW) developed standards and indicators for cultural competence in social work practice.

Substance Abuse and Mental Health Services Administration (SAMHSA)

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides a host of information around cultural competency in the field of behavioral health. Check out this manual which focuses on helping providers and administrators understand the role of culture in the delivery of mental health and substance use services.

Okay, your turn!

What are some challenges your organization faced in this area and how have you attempted to overcome them? Can you share any tips, tools or resources that lead to your success? Please leave a comment below and help others learn from your experiences.

When beginning the accreditation process – specifically the completion of the Self-Study – one of the most intimidating challenges can be trying to figure out how to organize the work and delegate it to your staff. You don’t need a certificate in project management to accomplish this task (although having one won’t hurt!). What you do need is prep time, focus, and a solid understanding of what’s expected.

This post will discuss how to form effective workgroups that can assist your organization with completing the necessary work in order to achieve accreditation – and hopefully improve your organization’s operations as well. Now let’s get started.

When talking with organizations in COA’s network, we see a variety of types of workgroups. Some small organizations do not form new workgroups; they simply utilize a currently existing structure to fill the role. On the other hand, large organizations may develop multiple workgroups that focus on different aspects of the Self-Study.  Only the organization can determine what the best model is going to be, but we can certainly explore some basic characteristics.

According to Kozlowski, S. W. J., & Bell, B. S. (2013), workgroups have the following qualities:

One is the loneliest number

If your workgroup only consists of you thenyou should probably revisit your plan to achieve accreditation. Even for small organizations, all levels of staff should be involved in some way. There are multiple benefits to involving many people. First off, staff will have a better understanding of the importance of accreditation if they are embedded in the process. If the process is presented to them in a positive way then they can take ownership. A common question is “how can you present accreditation to staff in a positive way?” While it’s difficult to imagine how anyone can view accreditation in a negative light, talk with your staff – particularly those that you want to engage in workgroups – and bring the focus to achieving client outcomes. The purpose of accreditation is to improve outcomes for those that receive your services. Every action that takes place in accreditation should be tied to the end user: the consumer.

Another way that staff can buy-in to participating in a workgroup is to view it as a professional development opportunity. In fact, you would be remiss if you didn’t. Think about your shining case managers, clinicians, administrative assistants, residential managers, and foster care workers who have impeccable paperwork, organized with to-do lists, and always volunteer for new projects. Working on COA-related activities can improve their administrative and leadership skills, expand their knowledge of social service management, and program development.

“Every action that takes place in accreditation should be tied to the end user: the consumer.”

A chance for collaboration!

Another commonality in workgroups is that they are all part of the same organization. Note that it’s within the organization, but not necessarily within the same department, division, or satellite office. Workgroups foster cross-departmental collaboration. For example, let’s say that you are going to create a workgroup that focuses solely on drafting and reviewing procedures for the organization.  For medium-large organizations, having this type of committee helps ensure that there is consistency across the organization, standards are still being met, and duplications are avoided. Including staff from different departments and different levels can provide different perspectives. Perhaps a member of management reviews a procedure and thinks “wow, this is great and will really help improve the reliability of our data.” Then a member of the direct service staff, who is also part of this committee, reviews the same procedure. She may have a comment such as “the intent of this procedure is spot-on, but the ability to put this in practice is unrealistic.” What’s better than a well written procedure? – A procedure that is actually practical. Having a diverse group of individuals within your organization as part of the accreditation workgroup is essential to change that is effective.

Find common ground

Common goals are an essential characteristic of workgroups. Having common goals relates to proper planning. If you establishing one committee or 3 committees to complete the work, there needs to be a goal that is achievable. You may think, “The goal is to get accredited.” Good point, that is the goal, but that’s the goal of the entire organization; not of the workgroup. The workgroup’s goal may be to establish a working PQI system, assess current practices to COA standards, or assemble the Self-Study.  The goal of each workgroup will clearly delineate its role in completing the larger mission: achieving accreditation – and as we discussed earlier ­- to improve outcomes for consumers.

To further break down the goal, we need to identify specific tasks that support the actual completion of the workgroup’s goal. Planning, again, comes into play. Recognizing that planning is not everyone’s strong suit, there are some resources out there to assist. While COA doesn’t endorse any specific resource, we do find these helpful. Meister Task is an efficient task management application that can be used to organize individual tasks as well as collaborative tasks. Consistent with our definition of workgroups, there are both individual tasks and tasks that people must work on together. This web application can help support and provide structure to both. Another great application is Wunderlist.  It provides some of the same functionality with a different style. If you are not quite ready for that level of organization and need some foundational support, try reading Getting Things Done: The Art of Stress-Free Productivity by David Allen. It’s an easy read that will help you organize your life, as well as your accreditation work. Remember, if you do utilize any of these resources, it’s recommended to take a full day to sit back and focus on implementing these systems for your work.  

Assigning the work

However you handle the workload, a workgroup has tasks that are completed individually and some that are completed by more than one person or a subgroup of the committee. When tasks of the workgroup are being assigned to its members you will want to consider the strengths and weaknesses of each member. Initially, it may be your gut reaction to assign tasks that are good matches to individuals’ strengths; however, also consider matching someone’s weakness to a task to help them further develop. Perhaps pairing that person with someone who does have more experience can be a great learning opportunity. Make the most out of your accreditation experience and use it to support a positive learning environment.  Maybe you can even develop mentorships within your staff, with the accreditation work as the central theme.  

Involve social interaction, have you ever tried to hold a committee without social interaction? Typically that’s an email with directives to everyone involved with no discussion. Sometimes effective; most of the time not. At the beginning of the process of forming your workgroups, you will be concurrently developing the buy-in of the workgroup members. Meeting in-person, with sugary treats, that typically helps (personal favorite: Insomnia Cookies). If you can’t have fresh cookies delivered, consider holding the meeting outside of your organization, at least for the first time.  Use this common goal, develop strong collegial bonds that last past COA Accreditation. And finally, manage your meeting efficiently. Here are some tips from Mindtools.com.

Introducing accreditation to your culture

Maintaining boundaries that are consistent within the organization may be a little bit more challenging for an accreditation workgroup. The group may be perceived by others in the organization as closed-off or working on something has nothing to do with the rest of the staff. One remedy for this perception is to provide communication about the status of the workgroup throughout the process to the rest of the organization. The workgroup is not charged with setting completely new and rigid policy, determining who at the organization is underperforming, or planning a coup d’état. Transparency is key, solicit feedback from staff who may not be directly involved. Always ask for volunteers, although don’t expect a waitlist. The accreditation workgroup is not a clique; it is a model for how people work as a team to achieve a seemingly insurmountable task.

Lastly, it is important to maintain key components of the organization’s culture. You can expect shifts, bumps and slides during the process, but the core of your organization will grow stronger. Your culture is the cornerstone of stability for your staff, who spend 40 hours of their lives there each week. It is a safe place for consumers whose lives you change. It is part of the connective tissue that holds your community together. Change may be inevitable but the culture of your organization is the reason for your continued success.

Share your tips!

What tips do you have for developing a strong workgroup or sustaining it once it is in place?  Please leave a comment below and help others learn from your experiences.