Accreditation is a process that takes time and effort, but with consistent follow-up and good reporting, it’s worth it. It allows you to build trust in your healthcare services by proving that you are doing what you say you are. It’s not as simple as filling out a form and submitting it though. The accreditation process takes time and effort from you and your team members. In this article, we’ll walk through the steps of becoming accredited so that you can focus on your mission: helping people feel better.

Determine organizational readiness

Accreditation ensures that your organization provides quality behavioral health services. Before you apply for accreditation, it’s important to understand the purpose of accreditation and how to determine if your organization is ready for accreditation.

Accreditation services ensures that:

  • you are providing high-quality care by evaluating your proficiency and conformance with standards set by state law
  • consumers are protected from harm due to negligence or fraud.

Select an accreditation agency

A accreditation agency or surveyor is a neutral third party who evaluates your program and gives it an overall rating. There are many different types of surveyors, such as the Council on Accreditation of Rehabilitation Facilities (CARF) and Joint Commission. You can find the right type of surveyor for your behavioral health program by asking around. Find out which organizations have been known to give high marks in the past.

Prepare for the survey

The surveyor will be looking at four broad areas of your facility: the physical location, personnel policies and procedures, records management and quality assurance. The first step towards preparing for the survey is to make sure that you have all necessary documentation in place. Check out CARF’s documentation requirements here, as an example.

You also want to train staff on the standards that will be reviewed during this process so they can answer questions as needed.

Once you’ve determined what exactly will be covered by the surveyor’s review, it’s important to prepare an appropriate response for each area being assessed. 

Do a self-audit prior to your official survey date

Before you apply for accreditation with your behavioral health program, be sure that it meets all of the requirements that apply to your kind of organization or practice (for example: if you run a hospital, then some requirements will be different than if you run a group practice). Consider purchasing the standards manual from the specific accreditation organization that you select for full guidance. 

Once you’ve identified which requirements apply, you will want to ensure that your facility has the proper policy and procedures in place and evidence that those policy and procedures are being enforced.

Make sure all staff members understand what’s expected of them including their roles and responsibilities. This rings true especially during creation or revision of policies and procedures related to behavioral health care delivery within each setting. They should be able to communicate clearly with other team members by reviewing their communication skills using a tool like SIMPLE (the Systematic Initiative for Motivational Learning Program Evaluation).

If necessary, arrange training sessions or workshops on topics such as stress management or conflict resolution, so staff members can better handle difficult situations that may arise during treatment or service delivery processes.

Submit an application to the accreditation authority

After implementing changes to become in compliance with the accreditation agency’s standards, you will be in a good position to apply. You will need to submit an application to the accreditation authority.

Once all documents have been submitted successfully with no errors made during submission processing (this process is subjectively determined). Applicants will receive notification within 6-12 months’ time frame that determines whether or not their applications were accepted by your selected agency. If so, the agency will schedule surveyor to come to your facility and do an aduit.

Survey process and outcome

When visiting a behavioral health facility, you should expect that a surveyor is carrying out an independent assessment. This means that the surveyors are not affiliated with the government and are not providing any type of service to the government or another organization. Surveyors also do not work for providers or facilities. This means that they have no incentive to say anything positive about your program, but they have every incentive to say something negative if they feel it’s warranted.

You can rest assured that this is true because all surveyors will carry identification stating their independence as well as credentials showing their training and experience in performing surveys and audits in mental health settings.

After this assessment, you will find out shortly after if you are approved for accreditation.

Accreditation is not just once and done

The accreditation process is not just a one-time event. They are an ongoing commitment to quality and work towards continuous improvement in patient care.

Accreditation puts the focus on providing the best possible experience for your patients. It means that you have met certain standards that show you are:

  • committed to treating people with respect and dignity,
  • following best practices, and
  • improving continuously on what works well and what doesn’t work so well.


Our Compliance service is a great way to ensure that you are providing high-quality treatment in a safe and effective manner. It is also an important part of demonstrating that your program meets the standards set by a national agency dedicated to improving patient care. However, this should not be your only goal. If you want your organization to last for decades, then it should strive to continually improve through ongoing self-evaluation.

Need help with the accreditation process? Our experts are here to help. Contact us.

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