A Brief Introduction
The Council on Accreditation (COA) is an independent accreditor of the full continuum of community-based behavioral health care and social service organizations in the United States and Canada, and is one of the three leading accreditors of such service providers. Over 1500 organizations -- voluntary, public and proprietary, local and statewide, large and small have either successfully achieved COA accreditation or are currently engaged in the process.
COA is widely recognized by states and national organizations as an accrediting body with the capacity, scope, and ability to contribute significantly to the improvement of the behavioral health and social service delivery systems. Originally known as an accrediting body for family and children's agencies, COA has earned public recognition from mental health and substance abuse organizations.
Characteristics of COA's Accreditation Standards and Process
COA's accreditation process involves a detailed review and analysis of an organization's administrative operations and service delivery against national standards of best practice. All of an organization's programs for which COA has standards are subject to review - COA reviews and accredits the entire organization, not specific programs.
As is fitting with its mission and values, COA's accreditation process is designed to facilitate organizational improvement. COA views accreditation as a structured means of achieving positive organizational change, rather than as an adversarial process. COA's accreditation process is open and facilitative and provides an organization with all the tools needed for ultimate success.
COA's Accreditation Process
Unique aspects of COA's accreditation process include the following:
- A commitment to the role and importance of the family and community with an emphasis on individual, family, and community strengths.
- The volunteer commitment of close to 1100 professional, trained peer reviewers who contribute their time and skill to make COA's accreditation process work.
- A self-guided, detailed process whereby the organization undergoes organization-wide quality improvement and demonstrates to COA and to the peer review team that it is in compliance with the standards.
Once COA receives your organization's completed Application for (Re)accreditation, we will complete our review of it in approximately 2-4 weeks. COA will then send the organization a letter accompanied by a Financial Agreement, which, among other things, contains the (re)accreditation fee. The organization can either pay the accreditation fee in total, or pay fifty percent (50%) at the time of signing the Financial Agreement, with the balance due in sixty (60) days. Regardless of which option the organization chooses, the file is then transferred to Accreditation Programs, the relevant Standards and Self-Study Manual is sent within 48 hours, a telephone conference call is scheduled with an Intake Coordinator within 3-4 weeks, and an Accreditation Coordinator is then assigned to your organization. The Accreditation Coordinator in partnership with the organization's contact will develop the (Re)accreditation Timetable, which will include the dates for the submission of the Self-Study and the site visit.
The self-study process takes between four and six months to complete and involves participatory self-evaluation and change. Most organizations are able to complete the entire accreditation process in 12 to 14 months - that is from the point of application to the point of decision-making. COA can implement an accelerated time frame for any organization faced with an internally or externally imposed deadline. It is COA's experience that a 12-14 month time frame provides sufficient opportunity for the active involvement of all parties -consumers, personnel, and stakeholders - and sufficient time for the organization to undergo growth-promoting change.
Accreditation Standards
COA's standards are continually revised and updated. The standards development process involves consumers, service providers, professionals, academics, representatives of COA's sponsoring and supporting organizations, managed care professionals, and others in drafting, reviewing and approving changes and/or additions to the generic organizational and service-specific sections. In April 2001 COA published the 7th edition of its Standards and Self-Study Manual.
Organizations must comply with both organization and management and service-specific standards. The organization and management standards encompass those aspects of operations that apply to all organizations regardless of the services provided.
Whether an organization offers residential treatment, an employee assistance program, or an adoption program, there are policies and practices of governance, fiscal management, human resources management, monitoring and evaluation, and service planning with which the organization must comply. The service sections set forth additional requirements for specific service areas. Each service section is organized to provide a definition of the service and standards pertaining to access to services, service elements, and human resources. These components delineate the special elements of the service.
Intake Phase
Accreditation Programs has reorganized its intake and assignment process by creating an intake team whose primary function is to assist organizations with the initial stages of the accreditation process. This newly formed intake team will focus on explaining the process, assessing an organization's readiness for accreditation, and understanding its service delivery. This new process allows COA to comprehend the diverse make-up of each organization and match it with the appropriate Accreditation Coordinator. COA believes that the new intake process will better assist organizations in their pursuit of accreditation.
The Self-Study
The self-study is a written document that the organization submits to COA prior to its site visit. COA's Standards and Self-Study Manual specifies how an organization is to demonstrate compliance with the standards and includes, for each standard, a four-level series of indicators against which the organization's compliance will be evaluated. The indicators are numbered one through four: one indicating full compliance with the standard; two, substantial compliance; three, partial compliance and; four, non-compliance.
The Site Visit
Approximately eight weeks after the organization submits its self-study, a team of two or more peer reviewers conducts a site visit. This team consists of experienced professionals who have been trained in COA's process and who, as a team, have the requisite experience to review the organization's services.
Prior to the site visit, this team will review the organization's self-study materials and make preliminary decisions regarding compliance.
On site, the team will conduct activities intended to verify and clarify the information contained in the self-study. Such activities include, for example, case record review, for which on-site review is essential. During this process the review team will determine the level of compliance for each standard. COA reserves the right to defer or deny accreditation on the basis of any single standard if it is a cause of serious concern.
Following the Site Visit
Based on the findings of the review team, COA produces a Preliminary Accreditation Report (PAR), which is reviewed by an internal committee. The PAR committee provides the organizations with recommendations for further demonstrating compliance with those mandatory or critical standards rated out of compliance during the site visit. The PAR is sent to the organization 45 days following the site visit. Organizations then have 45 days to provide their response to the Accreditation Commission, COA's decision-making body, for review.
In order to assure the integrity of the Commission's decision regarding accreditation, the Commission reviews all material anonymously (i.e., a code is assigned to the organization by COA staff and all information identifying the organization is deleted). COA's Board of Trustees or its Executive Committee then formally ratifies the recommendations of the Accreditation Commission.
The organization will receive a Final Accreditation Report (FAR) following the successful completion of the process. This report will provide the organization with a complete set of ratings for all applicable standards, a list of the organization's strengths and a list of the organizations areas for improvement. This bound report can be used at the organizations discretion with stakeholders.
COA accreditation is effective for four years from the date of the initial accreditation. All organizations must certify annually between accreditation reviews that they continue to be in compliance. Organizations can choose a three-year accreditation cycle if they want to or are required to by funders or other regulatory agencies. Organizations that come up for reaccreditation following publication of new standards are required to comply with the new standards.
