Help, I’m Mandated! Now What? Choosing an Accreditor

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Accreditation is daunting on its own – throw in a mandate with a tight deadline and its understandable that providers enter panic mode. Here’s a guide to help you gather the important details, understand what is required, determine milestones, and know how to compare and contrast accreditors.

My best advice is don’t delay! Expect that it will take up to six months to determine an accreditor and then 12-18 months to pursue and achieve accreditation.

First, Understanding the Mandate

Questions for the Entity that Mandated Your Accreditation

What accrediting bodies are accepted?

Usually a mandate will include a list of accepted accreditors.  If this isn’t included, reach out to the payer to find out what accreditors are accepted.

What service(s) is/are mandated?

Does the mandate apply to one service? Many services? The entire organization?  Is there a document that crosswalks which services are mandated and what standards need to be applied by the accreditors?

What is due and when?

There are different milestones that might be required.  Most often a state will designate when the accreditation must be achieved by. However, in order to reduce procrastination, I’ve seen states designate milestones on the way to an accreditation award – a date by which organizations must engage with an accreditor, a date by which organizations must have their site visit, and then a date by which an award must be received.

What type of accreditation award is needed?

Additionally, it’s important to clarify what type of accreditation award is due and when.  Some accreditors offer provisional or temporary accreditation. Do those accreditation awards meet the mandate?

Second, Evaluate Accreditors

Features to Consider

Once you know what needs to be accredited, by when, and by whom, reach out to all of the approved accreditors and get an understanding of the following features:

How much does it cost? 

Ask about application fees, accreditation fees, site visit fees (scheduled and unscheduled), and maintenance fees.  Is there a fee to purchase the standards?  If so, how many copies will you need and how often will updates be published in the future?  Make sure to ask about required fees and optional fees.  For example, trainings might be required and have associated fees.

What is awarded and how long is it valid?

What accreditation awards are available and how long are they valid for?  Keep this in mind when evaluating cost – how many accreditation cycles will your organization undergo over time (including provisional cycles)?

What is included in the accreditation review?

Will the accreditor require all programs to pursue accreditation or can you isolate individual programs?  Will the administration and management areas of the organization be reviewed?  Will every site be visited in the review (keep in mind when considering cost)? Does the approach of the accreditor fit your organizational culture?  Does the accreditation cover all of the desired service areas (current and future growth plans).

How long does it take?

Most accreditation processes take 12-18 months from deciding to pursue to decision.  However, the right time to sign up might vary with each accreditor.  For example, some accreditors want to hear from you when you’re ready for your site visit within 4-6 months.  Other accreditors want you to apply before your self-assessment period so that they can work alongside your organization in preparation for the site visit.

How is my organization supported throughout the process?

Are we assigned a point person to work with from the accrediting body? Do they offer trainings? How and when can we ask questions?  Do they provide templates and other tools to support us? Is there an online management system to assist with managing the process?

What is required to maintain our accreditation status?

Once accredited, what is your responsibility for self-reporting changes at your organization?  What is the process when your organization adds a new program or a new site? Are there annual reporting requirements and fees? What is your responsibility when it comes to implementation when standards change?

What do payers and regulators think?

Does the accreditor have other recognitions that will benefit your organization?  What is their reputation with states, federal government and other regulators/payers?

Third, seek recommendations

Ask Peer Organizations

Contact a few peer agencies that are already accredited. Think about the characteristics you should consider when identifying a peer – is it population served/size/location/mission?  Ask your peers about their satisfaction with the process, how they managed the work, and when appropriate, if they’d be willing to be a resource while you pursue accreditation.

Ask internally – Staff, Board Members, and Volunteers

Start a discussion about their accreditation experiences and what they liked or disliked about the process. This is also an opportunity to gauge interest to see who would be willing to be part of the accreditation team or even lead the accreditation effort within your organization.

Ask Your Membership Associations

If you belong to an association, ask if they support accreditation. Some associations have relationships with accreditors which might make your organization eligible for a discount when pursuing the process, some offer technical assistance, and many are willing to facilitate dialogue around accreditation.

Hopefully, this information will assist your organization with mapping out your journey towards seeking accreditation.

Please feel free to share other resources you’ve found helpful while navigating this topic in the comments below.