CQL Accreditation
What should a provider look for in choosing an accrediting body?
The organization's leaders 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 rather a collaboration and ongoing relationship.
How do the Personal Outcome Measures® fit into the Quality Measures 2005® 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®.
What about the Quality Measures 2005® 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.
How many on-site visits are conducted? When? What is reviewed?
CQL conducts three on-site visits over the course of four years. Visit One includes a review of Shared Values, Basic Assurances® and Personal Outcome Measures®. The on-site visit contributes 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. Visit Two takes place approximately 12 months after Visit One. This visit focuses primarily on measures related to Responsive Services® and Community Life®. Visit Three takes place approximately 18 months after Visit Two and focuses on a review of the organization's intergrated quality management system.
How does CQL look at health issues?
Our focus on health issues is grounded in the people receiving services from the organization.
CQL uses the Personal Outcome Measures® interviews 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.
What if an organization wants to only have Basic Assurances® reviewed?
An organization may want to request a review or assessment using the Basic Assurances®. By reviewing only Basic Assurances®, an organization could earn a Basic Assurances® Certification for a period of two years.
This would not, however, 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 separate sites or programs. We will visit a representative sample of sites/cities/states and when determine whether the entire agency is either accredited or not.
What if the agency provides additional services beyond the Intellectual and Developmental Disabilities field (such as children's services)?
For the initial visit, 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 visits, 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.
Does CQL allow a organizations to do some of the individual Personal Outcomes interviews themselves?
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.
How do you determine the accreditation review team size?
The size of the review team is based on several factors. Each review 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 as part of the on-site visits.
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 views affiliated providers as a network. During the review, we will visit homes or sites of each participating agency. At the end of the visit, the network either meets the accreditation criteria or not. Creating an artificial network for the purpose of accreditation might not be advisable.
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, fund raising, 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 organization 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 rights. CQL would look at how the organization is responding to/advocating for an individual.
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 x102 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 review. A visit will be scheduled and tailored to your organization.
What is the turnaround time from receipt of application to first on-site visit?
Plan on at least six months ahead. In other words, apply six months in advance of when you would like to schedule your first on-site visit.
How far in advance of an on-site visit can we expect to hear from the lead reviewer?
You can expect to hear from the lead reviewer approximately 3 to 4 weeks prior to the on-site visit.
What are the criteria for accreditation?
The criteria for accreditation are: 100% (46 indicators) of the Basic Assurances® indicators are present; Personal Outcome Measures® have an average of 11 outcomes and 11 supports present (out of a total of 21).
If an organization does not meet these criteria but has at least 34 Basic Assurances® indicators present, accreditation may be awarded for a period of 1 year to the organization to allow additional time to work on system enhancements and implement the necessary practices.
What is expected to maintain CQL Accreditation over the four year term?
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 both systems and practice. After the first year, the organization is expected to continue to meet the first year criteria, plus address targeted areas in Responsive Services® and Community Life® and demonstrated commitment to integrate Community Life® 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 CQL 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 analysis and more.
When do we receive our sample interview selection?
Approximately 2 to 3 weeks in advance of your on-site visit.
Is there a difference in standards for non-Medicaid Waiver providers?
No, all providers have to meet the same CQL criteria.
Does 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?
There is no single answer to this question. There are many options available. Some organizations 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®. Others 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.
From the documents list, how many months of information need to be available?
Prepare from 6 to 12 months of data, where requested.
Regarding the Self-Assessments, does the supporting evidence referenced need to be submitted?
No, but it should be easily accessible if reviewers request to see it while on-site.
Can we send the roster of people served/supported in another format?
Yes, as long as all of the requested information in included. You may use your own spreadsheet/database if it has the required information, but please delete any additional information you may have in that file.
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 just about spending more money, but using those resources wisely.
How is the cost for accreditation 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.
Back to Top