Agencies look to accreditation for accountability and change.

In the five years since the Illinois Department of Children and Family Services made headlines by attaining national accreditation, three other statewide public systems--Kentucky in 2002, Louisiana in 2003, and Arkansas in 2004--have followed suit and had their child welfare services accredited by the Council on Accreditation (COA). Washington state's Children's Administration is halfway through becoming accredited, while the Ohio Department of Job and Family Services is promoting accreditation for all of its 88 county offices.

Despite this growing interest in accreditation, the process remains mystifying and intimidating for many public human service agencies. Feasibility and cost top the list of concerns that human service leaders in the public sector have about accreditation. But organizations that have gone through the process have found that it is much more manageable than they expected, and that the long-term benefits offset the initial cost.

"It's an investment in good quality services," said Eugene Foster, undersecretary for Children and Family Services at the Kentucky Cabinet for Health and Family Services, which is in the process of being reaccredited. "Ultimately, quality care is much less expensive than poor quality care."

Currently, COA is the only accrediting body offering standards for public child welfare systems. The Joint Commission on Accreditation of Healthcare Organizations accredits publicly administered treatment foster homes, and the Commission on Accreditation of Rehabilitation Facilities has recently drafted child welfare standards. Founded in 1977 as an accrediting body for family and children's agencies, COA now accredits 38 different service areas that include close to 60 types of social and behavioral health care programs. In addition to public child welfare agencies, it also accredits public mental health service providers in North Carolina, Michigan, and Ohio.

COA accreditation appeals to public human service agencies for two reasons: it is based on a human service model of practice that reflects the way these agencies operate, and it evaluates the entire organization--from management and continuous quality improvement (CQI) practices to all services for which there are standards.

According to Chris Workman, Kentucky's COA coordinator, accreditation also brought with it valuable and much-needed ideas about best practices. "The whole point of going through accreditation is that so we don't have to spend the time, money, and energy on pulling together all the information out there on best practices," he said.

Public organizations have sought accreditation to demonstrate accountability to legislators and stakeholders, to satisfy class-action service delivery requirements, to sustain quality service delivery systems, and to ensure continued federal funding. Kentucky has built its Program Improvement Plan outcomes--part of its federal Child and Family Services Review (CFSR)--into its accreditation case record review procedures. Louisiana's Office of Community Services likewise decided to pursue accreditation to prepare for its CFSR, as well as to help document knowledge for the next generation.

After Illinois became accredited, child welfare leaders in other states began to look at accreditation as a vehicle for change and a way to affirm to stakeholders that their agencies were doing good work at a time when the child welfare system was coming under great scrutiny.

Demonstrating that accountability and outcomes has been key in persuading legislators to support accreditation. Providing resources for accreditation usually means having to provide resources for staff training, CQI processes, and other changes that are necessary in order to meet the standards.

Often, the hardest sell has been to agency staff, especially in times of financial constraints and hiring freezes. Frontline workers often see it as an additional burden and worry that they don't have the credentials required by COA's standards, while managers fear that new CQI processes will undermine their positions.

But a 2003 report by the federal Government Accountability Office noted that accredited public child welfare agencies have been able to recruit high-caliber staff and reduce turnover, two areas that have been particularly problematic for the public sector. Additionally, one of the most cited benefits of accreditation by agencies that have completed the process is that it ultimately empowers staff at all levels.

Foster noted that when a new administration came to power in Kentucky just as the decision on whether to seek reaccreditation--an accreditation cycle lasts for four years--loomed on the horizon, he was inundated with support for accreditation from field staff. In Louisiana, workers worried that the accreditation process would involve strangers pointing out their faults. Instead, according to Marsha McCall, a child welfare supervisor, accreditation gave the staff a sense of accomplishment.

Fears about caseload standards and degree requirements often turn out to be unfounded. While COA recommends master's degrees in human services for many child welfare positions, it also takes experience, training, and supervision into account. It is also open to negotiating the interpretation of its standards. According to Pat Page, assistant director of legislative analysis at the Arkansas Division of Children and Family Services, the agency at first changed its educational requirements for line supervisors, but soon found out that there were not enough qualified people in the state to hire. Consequently, the agency had to roll back its requirements while it increased recruitment.

In response, COA took into account the intensive six-month training period all staff complete and how it could meet standards on staff qualification.

COA standards are developed using a consensus-based process that--when it comes to standards for the public sector--elicits input from former commissioners and secretaries, advocacy groups, university representatives, and policymakers. "Our goal is to have standards that are relevant and grounded in the way that a public organization actually manages its human resources, risk management, and fiscal policies," said Richard Klarberg, president and chief executive officer of COA. "We are also working to ensure that--especially in light of the CFSRs public systems have been going through--our standards strongly and visibly support positive outcomes."

The accreditation process involves several discrete steps, including the completion of a self-assessment document--the Self-Study--as well as site visits and the final decision-making phase. For public organizations, the entire process takes from 18 months to three years.

Given the large size of public systems, preparation and planning have proved to be the key to a smooth and successful accreditation process. Both Arkansas and Kentucky conducted internal reviews prior to starting the accreditation process in order to determine readiness. These exercises have helped agencies anticipate potential areas of difficulty and begin addressing them early on.

Calvin Wilbon, the COA coordinator for Arkansas DCFS, established 15 working groups shortly after the agency applied for accreditation. Each group--from all levels and service regions--was charged with one of the 10 organizational standards and five service standards under which DCFS was going to be reviewed.

A challenge for COA and public child welfare systems has been how to integrate the accreditation process with the federal CFSRs and Program Improvement Plans. Most agency leaders have found the two processes to be complementary. Others see the relationship between the two as a work in progress. The piece tying it all together is CQI. Like the Program Improvement Plan, accreditation requires that an organization has a process and plan in place for long-term improvement.

Prior to accreditation, Kentucky had no formal CQI system in place. Implementing one has helped to transform the culture of the agency. "There is much more ownership by direct care workers," said Foster. "Workers monitor their own outcomes, and because of that they focus on results rather than the process--and that results in a higher level of services."

Through CQI, agencies can also ensure that they are including input from external stakeholders in their decision-making process. "We have seen a shift to providing the best and most consistent services, and working more with the family on case planning rather than telling families what their case plan will be," noted McCall, the Louisiana supervisor.

RELATED ARTICLE: Does accreditation lead to best practice? Maybe.

The mandatory accreditation wave is gaining momentum. The U.S. Department of State recently issued proposed regulations to implement an international treaty that standardizes and streamlines international adoptions. The Intercountry Adoption Act establishes a protocol that should ensure greater accountability and simplicity for adoptive families who seek to adopt children from other countries. Among other things, the proposed regulations call for adoption agencies to be accredited to provide intercountry adoption services. On a state-by-state basis, other human service functions are targets for accreditation, including child and family services, behavioral health care services, and employee assistance programs.

The United States has no centralized governmental body that exercises control over child welfare agencies. The states, counties, and cities assume varying degrees of oversight over these services, but overall, child welfare agencies operate with considerable autonomy. As a result, they vary widely in character and quality.

In order to ensure a basic level of quality, accreditation began as a means of conducting non-governmental, peer evaluation. The goal of accreditation is to ensure that services provided by child welfare agencies meet acceptable levels of quality. Accreditation is a voluntary peer review process that involves a comprehensive evaluation of professional practice. It is based on research-based national standards developed with input by all sectors of the child welfare profession. Using nationally recognized standards, a group of voluntary reviewers conducts an on-site visit and evaluates the agency's capacity to effectively deliver its programs.

There are numerous reasons why agencies seek and earn accreditation:

* Accreditation represents quality. Organizations aspire to communicate their commitment to excellence. In the child welfare services community, accreditation shows that an agency is serious about setting and achieving high standards for services. Nationally, accreditation is recognized as a symbol of quality.

* Accreditation demonstrates accountability. Although accreditation is voluntary, it demonstrates a desire to go beyond the minimum requirements of the law. It informs the public that the agency is committed to responsible practice and promotes the development and implementation of measures that can point to quality improvement over time.

* Accreditation is a recruiting tool. Accredited agencies market their accreditation as a recruiting tool to attract the best workers. Highly qualified professionals look for high-quality programs; accreditation assures prospective employees that an agency is dedicated to achieving the highest standards.

* Accreditation impresses funding sources. Many donors recommend that grantees be accredited.

* Accreditation ensures confidential peer review. Accreditation requires an agency to perform its own self-evaluation.

* Accreditation demonstrates flexibility. The accreditation process validates that the agency can be responsive to ongoing changes in federal and state regulations.

* Accreditation shows commitment. Accreditation shows the public that an agency is serious about its commitment to quality human services and is not afraid of measuring itself against national benchmarks.

At this time, there are several models of accreditation that are relevant for a wide range of functions carried out by child welfare agencies. These models address legal services, protective services, foster care services, adoption services as well as services to families. Of critical importance in accreditation is ensuring that the particular model of accreditation actually ensures that child welfare agencies are meeting acceptable levels of quality across the spectrum of their activities.

There are also reasons why an agency may not wish to be accredited. Unfortunately, there is little evidence that the models being used result in measurable improvements in the quality of services. Indeed, there may be some real drawbacks to attempting accreditation. They include: the time required to complete the accreditation process; the cost of undergoing the accreditation; staff who are reluctant or have no need to compare themselves with their peers; the implied need to continuously keep pace with rapid changes that may or may not make sense for the agency and its clients; and the feeling of agency administrators and staff that the good service the agency provides speaks for itself and there is no need to get someone else's seal of approval.

Accreditation is an intensive, procedurally inclined endeavor. It hopes that good outcomes will follow from good inputs, though accreditation does not purport to directly evaluate outcomes. Nonetheless, there is a tendency to believe that an accredited program is a quality program. But if we are not empirically measuring results, how can we distinguish success from failure? And if we are not assured of success, why should we attempt to replicate program models?

Accreditation is a good start and a noble endeavor. Its principal drawback is that it doesn't focus sufficiently on outcomes. This is where the critical future work of accreditation lies.

Daniel Pollack is a lawyer and professor at Yeshiva University's Wurzweiler School of Social Work and a senior fellow at the Center for Adoption Research, University of Massachusetts Medical School. He can be reached at [e-mail]

Bojana Stoparic is a public relations associate at the Council on Accreditation.