Accreditation
CQL Accreditation Using Quality Measures 2005 Frequently Asked Questions
What should a provider look for in choosing an accrediting body?
The organization must consider what is important to them. CQL has a person-directed approach. We believe what sets us apart from other accrediting bodies is that CQL looks at the quality of services from the perspective of the person receiving supports and services. We recommend using CQL’s self-assessment tools to see if CQL would be a good match with your agency. CQL views the accreditation process as a partnership. CQL Accreditation is not an event but a collaboration and ongoing relationship. CQL Accreditation applications, manuals and tools
How do the Personal Outcome Measures ® fit into the new process?
The Personal Outcome Measures ® remain at the core and center of our work. We affirm their importance and value as a learning, planning and evaluation tool. Listening to and learning from the person is at the center of organizational life. Since they were first introduced by CQL in 1993, the reliability and validity of the measures and the interviewing process have guided our work and the work of hundreds of organizations. Our focus on the person is as strong as ever. This core value is found throughout each section of the Quality Measures 2005 ®.
How long can we continue to be accredited with the Personal Outcome Measures ® using the current accreditation process?
Organizations can continue with the current process through 2008. After 2008, the only accreditation process available will be based on the Quality Measures 2005 ®.
What about the new measures and services for Families with Young Children, Children and Youth, and Behavioral Health?
The Quality Measures 2005 ® and accreditation process are indeed applicable to those individuals and service systems. Data gathering about people is based on the earlier Personal Outcomes editions specific to those groups. The organization-focused sections of the Quality Measures 2005 ® are applicable across all service settings and populations.
When site visits are conducted, what is reviewed?
CQL conducts site visits as part of the review of Basic Assurances ®. These site visits contribute to information gathering in a number of Indicators/Factors. We want to make certain that the places where people spend time are safe and promote dignity and respect.
How much does CQL look at health issues?
CQL uses the Personal Outcome Measures ® to determine if persons receiving supports and services are in the best possible health and live, work and recreate in safe environments with individualized supports. CQL employs other information gathering strategies including focus groups with people receiving services and supports, direct support professionals, and targeted interviews that include individuals with chronic health issues. They look at the organization’s quality management system around health and safety. They look at the nursing system to assure, for example, that medications are managed appropriately and administered safely. They discuss medical and other emergency procedures. It would vary from organization to organization. The Basic Assurances ® are focused on the health, safety and human security for all people.
How does the initial review differ from the follow-up visits?
The initial review looks at the roles and responsibilities within the organization, and how the provider interacts with the consumers in meeting needs. The first visit includes assessment of the Basic Assurances ®, Shared Values and Personal Outcome Measures ®. Subsequent visits look at Responsive Services ® and Community Life SM with a community assessment. The next visit (one-year follow-up) looks at the interactions the organization has within the broader community. It includes a review of Basic Assurances ®, Responsive Services ® and Community Life SM. An additional visit in the second or third year reviews the Integrated Quality Management Plan.
What if an organization wants to only have Basic Assurances ® reviewed?
It is possible that an organization may want to request a review using the Basic Assurances ®. By reviewing only Basic Assurances ®, an organization could earn a Basic Assurances ® Certification for a period of two years. It would not be considered an accredited organization.
What if an agency has offices in multiple cities and for whatever reason, one office does not meet CQL criteria for accreditation. Is a portion of the agency accredited?
CQL accredits the entire organization; not sites or programs. They will visit a representative sample of sites/states and when they finish, the entire agency is either accredited or not.
What if the agency provides additional services beyond the MRDD field (i.e. children’s services)?
CQL accredits the entire agency and not individual services. The review would include all of the services provided by the agency. This would be discussed prior to the survey in the planning process with the assigned lead reviewer.
Focus groups are one method of information gathering that CQL uses. Who selects participants for the focus group?
For the initial review, CQL asks the organization to arrange at least four focus groups—one for people receiving supports and services, one for direct support professionals, one for family members, and one for community members. There may be additional focus groups needed for other reasons. For example, if the organization provides what we refer to as episodic services, we might ask the organization to set up a focus group of those service users. The organization makes all arrangements for the focus groups including participant selection. For subsequent reviews, there are other focus groups. CQL will use other information gathering strategies to include a sample of people whom we interview using the Personal Outcome Measures ® and people for targeted interviews around specific assurances. CQL always selects the sample. CQL asks the organization to identify people for targeted interviews who meet specific criteria. Some of the people for targeted interviews are identified by the organization (i.e. the person who made the most recent complaint) and some are selected by CQL from a list provided by the organization on the accreditation application (i.e. person who has agreed to a restrictive intervention). CQL respects that some people choose to be excluded from the sample or the information gathering process.
How does CQL determine the participation of community groups in the community meetings?
The provider identifies and invites community groups with which it interacts. Examples of community groups that have participated in this process are the mayor’s office, churches, employers, other community service providers such as Meals on Wheels, and a variety of others.
CQL has a process for training interviewers. Can organizations or providers send representatives to become a certified trainer/interviewer?
Yes. CQL offers certification as an interviewer or as a trainer. A certified interviewer completes training in the Personal Outcomes Assessment Workshop and successfully completes inter-rater-reliability. A certified trainer participates in the Personal Outcomes Assessment Workshop taught by an experienced CQL staff, observes a CQL staff conducting a workshop, successfully completes inter-rater reliability and conducts a workshop under the supervision of a CQL staff person. There is a fee for this training. CQL Certification
An organization may be allowed to do some of the individual interviews themselves. How comfortable is CQL allowing that?
The Quality Measures 2005 ® process was designed to be collaborative. Organizations are encouraged to share in the CQL Accreditation process. Depending on the organization’s experience with the Personal Outcome Measures ®, the organization is expected to be involved in the collection of the Personal Outcome Measures ® data. Organizations, who have certified interviewers and/or trainers, collect most of the data with validation by CQL Review Team Members. In organizations, where experience is limited, CQL collects most of the data. The CQL Review Team Members work with the organization to determine the most effective way to gather information which promotes organizational learning and assures the data are reliable. Some examples include CQL staff observing the organization’s staff conduct interviews, joint decision-making, or review of the organization’s methods for reliability.
Community assessment is a component of the review. How does CQL examine the community assessment?
The assigned reviewer will examine the process the organization used for the community assessment as well as the outcome of the assessment. The reviewer will validate the community assessment.
How do you determine the review team size?
The size of the review team is based on several factors. Each survey is tailored according to the number of individuals supported, the geographical area served, the variety of services provided by the agency and the number of people in the sample.
Does CQL accredit organizations that provide only case management and no other services?
Yes, although the review may look slightly different from the typical organization review as the case management provider may be seen as a network. CQL may use focus groups and individual consumer/family interviews and not site visits
Does CQL accredit small agencies?
Yes, CQL does accredit small agencies. One organization reviewed by CQL supported two individuals.
What if several small agencies want to form an affiliation to share the cost of accreditation and one of the agencies does not meet criteria for accreditation?
CQL will view those affiliated providers as a network. During the survey, they will visit homes or sites of each participating agency. At the end of the visit the network is either accredited or it is not. Creating an artificial network for the purpose of accreditation might not be advisable.
How often do you make changes in the accreditation criteria?
In the past, it was every three years, but the standards have remained constant for the past ten years. We introduced the Quality Measures 2005 ® in 2005 and have made improvements in our process during the last year. The Quality Measures 2005 ® has continued to be grounded in the Personal Outcome Measures ® with an increased emphasis on gathering information to demonstrate systems and practices in measuring Shared Values, Basic Assurances ®, Responsive Services ® and Community Life SM. Because an agency will have an accreditation visit every four years with two follow–up visits within the accreditation cycle, an agency will be notified of changes and/or modifications.
How do you ensure staff alignment with values?
CQL employs different techniques to ensure alignment with values as part of the Quality Measures 2005 ® review. First, the organization completes a self-assessment and CQL validates the organization’s values by talking with people in the organization and community, looking at the organization’s systems and practices in services, fundraising, and all the work they do. We use the probes to guide us in determining the presence of the Indicators and Factors in Shared Values.
How do you handle items that may be in conflict with what the state requires? Is the agency penalized?
CQL has developed a Crosswalk between Quality Measures 2005 ® and the CMS HCBS Quality Framework. The Quality Measures 2005 ® meet or exceed all state and federal guidelines. The organization is expected to comply with all federal, state and local laws. CQL has found very few true conflicts between CQL expectations and state requirements; most often these are complementary to one another. Sometimes, organizations see conflicts that CQL does not view as a conflict. For example, the state may require each person have behavioral objectives to address skill deficits. This is not in conflict with CQL, although, we may not be concerned about the wording of the objectives. Generally, state and/or federal requirements are more prescriptive than the CQL outcomes. In other cases, a state has developed a policy or practice usually to protect people but which may impact the person’s right. CQL would look at how the organization is responding to/advocating for an individual.
How will CQL look at Mandt or CPI?
CQL encourages organizations to listen to what people want in their lives. CQL’s Basic Assurances ® Factor Eight is Positive Services and Supports. The Indicators in this Factor stress CQL’s expectations. We expect each person to have a person-centered plan with person-directed supports and services. We expect the organization to provide continuous and consistent support for each person. CQL expects the organization to provide positive behavioral supports to people. We expect the organization to treat people with psychoactive medications for mental health needs consistent with national standards of care. CQL requires people be free from unnecessary, intrusive interventions.
Does CQL have levels of accreditation (such as a one-year, conditional, etc.)?
CQL did have levels in the previous accreditation process using Personal Outcome Measures ® 2000, but has phased those out. Now with the Quality Measures 2005 ®, an organization is either accredited for a four-year period or not at all. However, if an organization is unsuccessful in demonstrating 100% of the Basic Assurances ®, the organization is given some time to develop and implement a plan to address any systems and practices that are of concern. During a follow up visit, CQL will validate the presence of any Basic Assurances ® factors which were not present in the initial visit without an entire review of Basic Assurances ® and Shared Values.
How do we begin the process?
The first step after you decide if CQL is a good fit for your organization is to contact CQL at 410.583.0060 or info@thecouncil.org. Then you can apply for accreditation. Once the application is received by CQL, you will be contacted by a representative to begin planning. You may also request a consultation visit prior to the initial survey. A visit will be scheduled and tailored to your organization.
What is the turnaround time from receipt of application to first visit?
Plan at least six months ahead. In other words, apply six months in advance of when you would like to receive your first visit.
What would cause an organization to lose their accreditation?
Organizations maintain accreditation by meeting the threshold for Personal Outcome Measures ® Outcomes and Supports, continued demonstration of ongoing learning, evaluation and growth supporting Shared Values, presence of 46 Basic Assurances ® Indicators in systems and practice. After the first year, the organization is expected to continue to meet the first year criteria, plus addressing targeted areas in Responsive Services ® and Community Life SM and demonstrated commitment to integrate Community Life SM into operations and strategic thinking.
If specific findings or recommendations are made, does CQL notify the state?
It would be up to the organization to notify the state of any adverse findings. CQL would work with the organization to assure notification of any required entities. Also, all CQL reviewers are mandated reporters; thus, if abuse, neglect or exploitation is discovered, the reviewers would follow the requirements for reporting.
When CQL completes a report from their reviews, who receives the report?
The report is provided to the organization to be accredited; it is not routinely copied to the state agency.
What are the qualifications of the reviewers?
All CQL reviewers have experience in supporting people; a minimum of a bachelor’s degree is required, although most have master’s degrees and some even doctorates; and reviewers hold broad and varied clinical backgrounds such as nursing, social work, psychology, behavioral analyst and more. The organization may have some choice of reviewers assigned.
Is there a difference in standards for non Medicaid Waiver providers?
No, all providers have to meet the same CQL criteria.
Will CQL provide sample policies?
CQL does not have “ready made” policies but we are available for technical assistance. CQL can also connect applicants with accredited providers who have developed similar policies.
What would be the initial investment for an organization?
This is a somewhat difficult question. There are many options available. The organization might review the Quality Measures 2005 ® materials, contact other organizations that are accredited, arrange for a consultation, or they might complete the self-assessments that are included in the Quality Measures 2005 ®. They might begin by learning about and using the Personal Outcome Measures ®. Really, this is an individual decision.
What is the time commitment from the agency for preparation and management of accreditation? How many hours may be needed?
It is difficult to specify how much time is needed. It depends upon the size and complexity of the organization and where you may be in already achieving the outcomes. Some larger organizations devote one or more staff positions; some smaller agencies manage it within current staff responsibilities.
If providers agree with the person-centered philosophy and criteria but do not believe the funds are available to support the philosophy, how do they meet the criteria?
CQL believes that one of the responsibilities of successful organizations is to support people using available resources creatively and efficiently. Sometimes, that means looking outside of traditional models and being responsive to people and communities. Quality is not about spending more money but using the resources wisely.
How is cost determined?
Cost is based on the size of the agency, number of individuals supported, geographic area served, number of interviews to be conducted, number of CQL reviewers needed, and variety of different services. It is tailored to the organization. For organizations supporting fewer than 20 people or greater than 600, cost is individually negotiated.
Is the entire cost to be paid at the time of application, or can it be spread out over the accreditation cycle?
There are payment options available on request.