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!

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). 

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.

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.