Why not accreditation?

Many of the National Council for Community Behavioral Healthcare's 1,300 members—community behavioral health organizations across the country—are accredited, most often by the Joint Commission or CARF. But some members operating in states that don't require it choose not to go the accreditation route. And to understand the debate among behavioral healthcare organizations about accreditation, we need to look at two problems—state overregulation and an industry-wide lack of standards of care.

In preparation for this article, I shared my thoughts with the National Council's membership and asked for their opinions on questions such as: Can accreditation be a vehicle for reducing excessive oversight? Are standards of care important? Has your organization benefited from accreditation? I received an overwhelming response to my questions.

None of the responding members dismissed the value of accreditation. A number pointed to the barriers to accreditation: initial and ongoing fees to obtain and retain accreditation; administrative and clinical departmental initiatives, committee meetings, and the resultant documentation, all of which entail great investments of staff time; and in some cases compliance with life safety codes beyond local requirements. For some organizations, these barriers are insurmountable.

A great majority of those who responded are accredited and highly value their accreditation. I've incorporated a sample of members' comments into this article; they provide a window into our membership—their commitment to excellence and their struggles to achieve excellence regardless of the burdens.

For some, accreditation is a goal. Kevin J. Eastman, chief operating officer of Weber Human Services in Ogden, Utah, responded, "Coincidentally, I was in a discussion about this very topic. For years now, our agency has been working to position ourselves to be able to meet accreditation standards. I fully believe that the work we have done towards this has already transitioned into better care and treatment for those we serve."

Others, like Shirley Havenga, CEO of the Community Psychiatric Clinic in Seattle, are leaders of organizations that have been accredited for many years and attribute their early success to the accreditation process. "One of my first goals, more than 12 years ago when I merged two mental health centers, was to bring the newly formed organization to a position wherein we could seek accreditation. The learning process from those many months of preparation did more to align practice, based on national standards, with policy than any single thing I could have done as the new CEO."

Susan Rushing, CEO of the Burke Center in Lufkin, Texas, shared the value of an ever-evolving accreditation process and her organization's fight to maintain standards in a tragically underfunded system:

No longer do surveyors sit in offices and read manuals or watch our spiffy PowerPoint presentations on agency planning. They look at what actually happens to a subset of patients and they interview staff on the specifics of each selected case. We were surveyed under this process last year and it was a humbling experience…. With the cost pressures we all face and with the clinical model we in Texas are mandated to use, adherence to accreditation standards has never been harder. Or, in my opinion, more necessary. As a management team, we use standards compliance as the stackpole around which we build services. A year ago, we reluctantly closed our long-standing residential substance abuse treatment facility because we could no longer operate in compliance with accreditation standards at the rate Texas paid...¦less than $80 per day, inclusive. This was a very hard decision for our Board but our commitment to accreditation provided the "bright line" we would not cross as an agency.

Discussions about accreditation identify unnecessary and unproductive duplicative oversight between state authorities and accrediting organizations as an ever-increasing burden. Responding members outlined the tremendous numbers of procedural, reporting, and governmental requirements that emanate from the contracts held with state authorities and dizzying numbers of reports, audits, and unique service delivery requirements.

Community-based mental health and addictions service agencies are sometimes state-run, but more often they are regional authorities or not-for-profit organizations run by boards of directors. And yet most state authorities continue to oversee and monitor these organizations with a degree of scrutiny and involvement unheard of in any other part of the healthcare industry.

Marsha Morgan, chief operating officer of Truman Medical Center Behavioral Health in Kansas City, described the burden of oversight to which her organization is subject:

I only wish that accreditation would be a vehicle for reducing excessive oversight. We have tried to negotiate putting this concept into practice, to no avail. We continue to have 4-5 surveyors from the State once a year for more than a week, county surveyors 3-4 times per year, and JCAHO [surveyors] every 3 years (although now that the surveys are unannounced, we are to always be ready for a visit). In addition, we submit reports to all these entities depending on their requirements. The other thing that happens with surveys are the additional "look behind" surveys. We have had experience at TMC where there will be a State survey and then CMS comes in for a review of the survey.

And so the question always comes up: If an organization is accredited, will the state authority grant deemed status? That is, will the state authority accept national accreditation in lieu of its own accreditation-like process? After all, state reviews aren't any more protection than accreditation is against Medicare or Medicaid audits. And they aren't any more indicative of quality; state reviews often are conducted in the same way year after year, while accrediting bodies continuously are updating and refining their standards and processes.

William Bierie, president and CEO of the Maumee Valley Guidance Center in Defiance, Ohio, reminded me that Ohio has granted deemed status to accredited organizations and that the members of the Ohio Council of Behavioral Healthcare Providers "rated accreditation as superior to state certification rules because they learned more about their organizations and continuous performance improvement.... Accreditation is a learning process and certification is only a compliance process," he said.

Ohio is one of the very few states to pioneer deemed status, and there has been little success in getting others to follow suit. Perhaps for state authorities a barrier to embracing deemed status is the potential loss of the staff dedicated to the authority's own monitoring process. It also could mean a further shift in the relationships between behavioral health organizations and state authorities. Relationships already are changing as third-party reimbursements, particularly Medicaid, replace state general fund dollars; as states look to outsource oversight responsibilities to private administrative service organizations; and as behavioral healthcare organizations flex their state and federal advocacy clout.

Despite the burden of multiple surveys and audits, members like Rick Weaver, president and CEO of Central Washington Comprehensive Mental Health in Yakima, Washington, remain committed to accreditation as a vehicle for continuously improving services:

The important message that we have consistently given our staff and Board is that accreditation is not about eliminating other audits or regulatory burdens. Instead it is about getting better and performing at peak levels…. What we have experienced is that we are constantly working at the right sorts of things rather than the paper compliance things. Our quality improvement program has become a very vibrant and integral part of everyday operations…. Certainly some staff point to accreditation as burdensome and duplicative. When discussing that with them I really focus on the improved processes or the community perception accreditation gives. We continue to fight for more effective deemed status and make small bits of headway but the true value we find is internal to our organization.

Accreditation discussions more often than not go from the issue of deemed status to a discussion of differences between states when it comes to behavioral health policies and regulations. The refrain is: No two states are alike, and accreditation is a uniform set of standards and expected organizational behaviors. And yet as you look from state to state, the issues and problems are the same, and the attempted solutions are variations on a few themes.

Could accreditation be helpful in addressing behavioral health's glaring lack of standard clinical care processes? Perhaps state authorities need to embrace deemed status and financially support accreditation, with its focus on operations and practice competencies. A Michigan member offered these final thoughts:

If anything, behavioral health lacks the successes of and the respect given to the rest of medicine because of its intentional idiosyncrasies and isolationism. We have had 40 years of state oversight of mental health services. This has produced a service system that a national commission has concluded needs not just change but transformation. Why would we believe that by continuing more of the same we would get a different result?

Linda Rosenberg, MSW, is President and CEO of the National Council for Community Behavioral Healthcare. She is also a member of Behavioral Healthcare's Editorial Board.