Accreditation Frequently Asked Questions

Below are answers to some of the more frequently asked questions that we receive about the Children’s Mental Health Ontario (CMHO) accreditation program.

What is Accreditation?

In essence, accreditation is a process involving the setting of standards and then verifying that those standards have been attained. Standards are the foundation of any accreditation program. Unlike licensing, which measures compliance with minimum standards, accreditation emphasizes challenging standards which define high quality services and performance.

What are the Accreditation Standards?

Standards are the heart of the accreditation process because they identify the elements that create quality services. Children's Mental Health Ontario developed its standards through a process of extensive consultation that was supported by the Ontario Trillium Foundation. As a result the standards reflect a broad consensus of the knowledge and experience about effective practices in Ontario. A standards committee continues to recommend changes.

Our accreditation standards address the four major aspects of centre operation: programming, staffing, managing and governing. Each centre must have a quality assurance and client feedback mechanism to ensure that the quality of service is monitored continuously. The centre also must meet the relevant licensing and regulatory requirements.

What are the Major Steps in the Accreditation Process?

There is a two-step verification process involving both internal and external evaluation. The internal review is called the self-study process and the independent verification that the standards are met is called the site review.

What Takes Place During the Self-Study?

Each centre applying for accreditation first participates in a self-study, which usually takes between six months and one year. During this time, the centre's management and staff measure how well they have achieved the standards using tools provided by the accreditation program. This period allows a centre to make changes and judge its readiness for accreditation before the actual review. After self-study, a centre submits a formal application for accreditation and applies for a site review.

Are Data Collected from Other Sources?

The manager of the accreditation program surveys key referral sources and the centre's board of directors about how well the centre has met relevant standards. The centre must survey the users of its services to measure their satisfaction and provide information from its quality assurance process.

What is the Accreditation Site Review?

During the site review a team of children's mental health experts visits the centre to verify that the required number of standards have been achieved. The review lasts at least two days. The actual length of time and number of reviewers varies according to the size of the centre, its volume of services, and the location of its programs.

All aspects of the centre's operation are reviewed carefully, especially services and practices. The site review team concentrates on sampling case files, interviewing front-line staff and managers, participating in case conferences, discussing the results of board and referral source surveys, and observing selected program activities. All information acquired by the review team during a site review is strictly confidential.

When Does the Centre Receive Feedback From the Site Review?

At the end of the site review, the team leader gives the centre verbal feedback about the centre's achievement of the standards, indicating strengths and weaknesses, and areas for potential improvement. After the verbal report, a detailed written report is sent to the centre's executive director, who can respond to the report before it goes to CMHO's accreditation committee.

How does Children's Mental Health Ontario Make the Decision to Award Accreditation?

The Children's Mental Health Ontario accreditation committee consists of at least two executive directors, one representative of citizen boards, one person external to Children's Mental Health Ontario who has experience in accreditation, one person with experience in children's mental health, and two non-voting ex officio members. After considering the site review report, the centre's reply to the report, and supporting materials, the accreditation committee submits its recommendation to Children's Mental Health Ontario's board of directors, which makes the actual award.

What Types of Accreditation Awards Does Children's Mental Health Ontario Grant?

Standards are divided into Mandatory and Defining standards. The Mandatory standards ensure that centres meet legal requirements and address issues of safety and risk. The Defining standards are those which provide a common base for high quality services yet permit centres to respond flexibly to community needs. There are two categories: Accreditation for four years and Accreditation Pending. Accreditation is awarded to centres that reach 100% of the Mandatory and 80% of the Defining standards. The second category, Accreditation Pending, means that 1) the centre has not had its first site review, or 2) the centre has met less than 100% of the Mandatory Standards and/or less than 80% of the Defining Standards. Accreditation is valid for four years.

What are the Costs and Benefits of Accreditation?

The operating costs of the accreditation program are covered by the annual dues of the association's members. The centre applying for accreditation also pays the cost of its site review.

Accredited centres consistently report that the self-study process helps improve the quality of services. Accreditation also helps to build an ethic of continuous improvement into the organization and strengthen the identity of children's mental health centres. In short, accreditation benefits service providers and consumers alike by facilitating and developing high quality and responsive mental health services for children and families in Ontario.