Review of Children s Mental Health Ontario s Accreditation Program Standards Final Report Submitted by: Children s Mental Health Ontario 40 St. Clair Avenue East, Suite 309 Toronto, ON M4T 1M9 Gordon Floyd Executive Director and CEO February 15, 2007 Note of Thanks: This project would not have been possible without the support and assistance of individuals in our CMHO member organizations as well as in our partner agencies working in children s mental health. Dozens of such individuals participated in reference groups and interviews, reviewed draft materials and provided invaluable feedback into the standards and indicators. Thanks to the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO for financial support.
Review of Children s Mental Health Ontario s Accreditation Program Standards Final Report, January 25, 2007 Children s Mental Health Ontario (CMHO), which represents 82 community-based children s mental health centres throughout the province of Ontario, broke new ground in 1988 with the development of its Accreditation Program. The Accreditation Program defines best-practice standards that cover every aspect of children s mental health centre operations, from programming and management through to staffing and accountability. Because all CMHO member agencies must undergo accreditation every four years, the more than half a million Ontario children and youth under the age of 19 who suffer from mental health problems can be assured of receiving service that meets the highest standards. As a result of CMHO s initiative, Ontario is the only province in Canada in which child and youth mental health stand alone as an area of specialty. Accreditation promotes best practice in day-to-day operations by providing a template of excellence for all aspects of an agency s work. Children s mental health centres that have gone through the rigorous accreditation process report that accreditation is a key driver in continuous quality assurance and that by giving them the means to demonstrate how they measure up against empirically based standards as evaluated by objective reviewers, accreditation has made them more accountable to their clients and to the community. This review of CMHO s accreditation Program Standards has become necessary because of new advances and new developments in the field of children s mental health. Specifically: Research on children s mental health that has led to new, evidence-based understanding of how best to treat mental health problems among children and youth. The current standards were developed at a time when residential treatment, day treatment, and outpatient counselling were the norm in service delivery. They do not cover many new, innovative, and effective methods of delivery. To meet the demands of extensive waiting lists, many centres have developed briefer therapy models and group treatments, many of which are not covered by existing standards. Many children s mental health centres have moved into new program areas, such as treatment foster care, supervised access of children during visitation between separated couples, school suspension programs, and programs involving youth in the criminal justice system. These are not covered by existing standards. Increasingly, children s mental health centres are partnering with other childinvolved organizations, such as child welfare agencies, schools, and community centres. Standards are needed to cover these new ways of working. 2
The review identified gaps in the existing Standards and best practices in light of new evidence-based research and new ways of delivering treatment. Incorporating these new best-practice standards into the Accreditation Program that all of CMHO s member agencies are required to undergo, will ensure that these standards are implemented in children s mental health centres throughout the province, and that they become part of ongoing quality improvement programs within children s mental health centres. 3
Accreditation Program Standards Review: Objectives The review of CMHO accreditation program standards was conducted in order that the standards meet the following objectives: 1. Reflect current best practices in children s mental health services. Extensive consultation with children s mental health service providers, parents, youth, experts in specific content areas, accreditation experts, and review of relevant documentation took place to ensure that the revised Program Standards reflect current best practices. 2. Apply to a broad range of children s mental health services. The revised Program Standards now address a number of areas of children s mental health service that were not dealt with by the previous standards. These include: new standards that apply to mental health promotion; group services; consultation; timelimited treatments; implementation of evidence-based practices; home and communitybased services; treatment foster care; child care, early learning and school-based services. 3. Drive continuous quality improvements and raise the bar for service excellence. This was accomplished in a variety of ways. Many new standards were developed to address areas where there previously had been gaps in the standards. The number of Mandatory Standards within the Program Standards area was increased from four to nineteen. Within the CMHO Accreditation Program, an organization must meet 100% of the Mandatory Standards and at least 80% of the Defining Standards to become accredited. 4. Define the unique role and specialized expertise of children s mental health centres. Evidence of this objective is seen within the revised standards, across various areas of service delivery. Definitions of service areas and activities were revised and updated. 5. Advance the field in light of new evidence-based research, new ways of delivering services, and a desire to promote innovation. The Knowledge and Learning Standards reflect considerable expansion beyond the previous standards that were limited to research and service evaluation, and quality assurance. The revised standards now include a section on Knowledge Uptake and Exchange, and Implementation of Evidence-Based Practices, as well as revisions and 4
updates on Research, Program Evaluation and Quality Improvement. As noted previously, a number of new service areas are also addressed within the revised Program Standards. 6. Link strongly and clearly with a set of values that permeate children s mental health. The CMHO Accreditation Program Values were reviewed and revised, based on extensive consultation within the field. Standards were developed to reflect these values. 7. Correspond to varying levels of treatment and other children s services on dimensions of length, intensity and severity of client need. The revised Intervention/Treatment Process Standards have been developed to allow for greater flexibility than was in place previously. The new standards recognize that different levels of intervention/treatment may vary based on the length of service, intensity of service and the severity of client need. 8. Comprise the fewest number of standards possible that reflect the most crucial elements for measuring and promoting quality. The revised Program Standards were developed with the intent of reducing duplication of standards, while still ensuring the essence of quality is not lost. There are a total of 164 Program Standards in the previous model, and there are now 90 Program Standards. 9. Eliminate the need to grant program exemptions from the accreditation process. The ability of the revised Program Standards to meet this objective cannot be fully assessed until the new process is fully implemented. It is anticipated that the need for program exemptions will be significantly reduced, if not fully eliminated, once the new standards are fully implemented. 10. Provide maximum flexibility with a minimum degree of repetition As noted previously, flexibility within the new standards has been increased. A careful analysis of the previous standards was completed with respect to the degree of repetition contained within the standards. The design of the new standards significantly reduced repetition. In some cases, crucial issues relating to safety and privacy are addressed in more than one of the new standards, as a means of ensuring consistent attention to these issues across multiple service areas. 11. Ensure a holistic approach to the organization and all its components. The creation of the Universal Standards was undertaken to meet this objective. The Universal Standards are applicable to all human services delivered by an organization. 5
In this way, there is assurance that organizations that deliver multiple services that go beyond the scope of children s mental health, such as adult programs, will undergo a review that encompasses all of the human services provided. 6
Accreditation Program Standards Review Process: Steps and Timelines The focus of this final report is on progress since the Interim Report was submitted to the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO, on March 31, 2006. At that time, Phase One, the Review of Accreditation Values and Definitions had been completed. Phase Two: Review and Revision of Program Standards: Recruited representatives from children s mental health centres of varying sizes and with diverse range of services to participate in a focus group, held May 4, 2006 regarding the draft framework and model. Identified 9 reference groups to advise on specific Program Standard areas: universal standards, knowledge and learning, treatment process, health promotion, time-limited interventions, home-based services, school-based services, residential and treatment foster care services. Approximately 50 children s mental health service providers participated in these reference groups from June-July 2006. Completed an analysis of current standards. Completed a draft set of new Program Standards, July-August 2006. Circulated a revised framework and model and a first draft of Program Standards to centres in September, 2006. Surveyed member centres for their feedback, October 2006. Consulted with various content experts and a group of critical readers on the new draft Program Standards, October 2006. Consulted with a focus group of parents and a focus group of youth on the draft Program Standards, October 21 & 24, 2006. Revised Standards based on consultations & document review, and circulated to CMHO member centres, November 23, 2006. Held a consultation session with members and other stakeholders at the CMHO Conference, November 28, 2006. Revisions to the Program Standards as well as some additional revisions to the values, model and framework document incorporating the November 28 th feedback were reviewed by the Program Standards Committee on December 18, 2006. Final revisions made to the two key documents, Values, Model & Framework and Program Standards completed December 22, 2006. (See Appendix A and B). Distribution of the two documents took place January 11, 2007. Next Steps Note: Phases Three and Four will be undertaken by CMHO but are beyond the scope of the current grant. Phase Three: Pilot Testing and Final Program Standards Revision Selected three pilot sites for testing new Program Standards, approved by the CMHO Accreditation Committee, October/November 2006. 7
Recruitment & selection of site reviewers to conduct the pilot site reviews completed in early January, 2007. On-site visits to the three pilot site agencies for orientation regarding the new Program Standards and assistance in developing their preparation work plans were completed by January 16, 2007. Development of a centre-to-centre support network between the three pilot site agencies initiated, and a first joint meeting will be held February 21, 2007. Training for site reviewers that will conduct the pilot site reviews to be held in March, 2007. Pilot test Standards in selected centres: three site reviews to pilot test the new Program Standards are scheduled between April 17-27 th, 2007. Feedback from and evaluation of the pilot process to take place in May 2007. Further revisions, based on pilot test process, will be completed by early June 2007. Phase Four: Dissemination & Full Implementation: Revise CMHO Accreditation Manual- June-July 2007. Translate revised Accreditation Manual into French- August 2007. Distribute Accreditation Manuals to children s mental health centers- September 2007. Conduct training of CMHO member centres and Site Reviewers throughout 2007/08. 8
Conclusion & Summary The process for undertaking this review of the accreditation Program Standards has involved several stages of consultation, eliciting feedback from numerous CMHO member centres and several other stakeholders. Expertise from other accreditation organizations was generously provided, and greatly enhanced our work. Key informant interviews with experts in specific content areas added depth and validation to the revised Standards. The input from parents and from youth who are currently engaged with the children s mental health system provided a tremendously useful perspective that could not have been obtained from any other source. The active participation of children s mental health centres throughout this process has confirmed their commitment to accreditation as one component of ongoing quality improvement efforts. See Appendix C for summary of participants in the process. In addition to the revised Program Standards themselves, the process of undertaking this review led to other valuable outcomes for the CMHO accreditation program. In order to begin the review process, an in-depth review of the values that lay the groundwork for the standards was conducted. While there had been a previous set of values in the accreditation program, there was not a strong and visible connection to them within the actual standards. Additionally, they had not been reviewed since 1997. A second unexpected benefit of this project was that the format and structure of Standards was significantly improved. The new Program Standards now include specific Indicators, which were not present before. This new structure and inclusion of Indicators will be used when CMHO undertakes a review of the standards for staffing, governance and management, which are beyond the scope of this project. The revised Program Standards will provide CMHO accredited centres with a template to guide and measure quality improvement in service delivery. A major benefit of the new approach to Program Standards is the assurance that all human service program components in the organizations will have undergone an appropriate level of examination in the accreditation process. The new Program Standards focus on the importance of incorporating knowledge and learning into practice, with a section on implementation of evidence-based practices, which we believe to be unique to the CMHO accreditation process. The process for reviewing the program area of our accreditation standards, and the resulting product will serve as a model for CMHO as we move forward to review the standards for staffing, governance and management areas at a future date. CMHO greatly appreciates the opportunity to complete this work through the support of the Provincial Centre of Excellence for Child and Youth Mental Health at CHEO. 9
Appendices A. CMHO Accreditation Program Values, Model and Framework, December 22, 2006. B. CMHO Accreditation Program- Program Standards, December 22, 2006. C. Summary of Participation in the Program Standards Review Process. D. Financial Report. 10