2010 Canadian Accreditation Council of Human Services
A Review Process is the means by which programs are evaluated against the standards for accreditation. Voluntary Reviewers are people working in the field, who review organizational materials and policies, interview staff, contractors, volunteers and persons served on-site and gather information that becomes the report of the level of compliance of the program to the standards. The Summary of Review Findings is shared with the program at the end of the on-site and presented to the Accreditation Panel, along with the organizational response. The Accreditation Panel, also comprised of peers volunteering their time, is the body that grants accreditation status to a program.
The team consists of between 1 and 4 reviewers, from other organizations, and CAC Coordinator. Team members are most often from organizations within the same geographical region as the program under review.
Team Members
It is expected that all team members:
- Understand the intent of the standards and the accreditation process;
- Review, understand and rate the organization’s policy manual and the self-study materials;
- Participate in the pre-site meeting and all meetings throughout the review, in order to share information and clarify areas of uncertainty;
- Are accurate and professional in the completion of all assigned tasks;
- Provide support and feedback to fellow reviewers in the completion of their tasks, and
- Maintain confidentiality of information gained during the accreditation process.
Team Leader
Team Leaders complete Review and Team Leader training and have fully participated in at least two peer reviews. Team Leaders:
- Co-ordinate and chair meetings - pre-site; introduction at the beginning of the on-site and the exit interview
- Review the comments for all non-compliant findings from the pre-site meeting with the program staff;
- Ask if the program wants to receive verbal observations and recommendations that may go beyond the issues which are addressed by the standards (an observation report). If so, these observations and/or recommendations will become part of the exit meeting;
- Oversee duties and responsibilities to the team members;
- Facilitate discussion towards consensus in team decision-making and makes the final decision when consensus is not achieved;
- Share preliminary findings throughout the process and keeps the program liaison person informed of the progress;
- Speak on behalf of the team to program staff, and
- Deals with any issues arising between staff or persons served and team members.
CAC Core Support Staff
CAC staff:
- Provide administrative support and consultation to the program staff preparing for the review and to the review team;
- Ensures consistency around interpretation of the intent and/or meaning of specific standards, and
- Ensures consistency of decision making during the reviews.
Reviewers are: organization/program directors; senior management staff; supervisory staff with a minimum of 3 years experience; front line staff with a minimum of 5 years experience; and/or people with review experience and have retired or left the field within the last 3 years.
Process
Individuals interested in becoming a reviewer submit an application/resume outlining experience and education:
- Front line staff and supervisors require written endorsements from their immediate supervisor or the director of the organization. Directors and senior managers are exempt from this requirement;
- All new applicants must successfully complete reviewers’ training. If someone has not been on a review within the last 24 months, they may be required to attend refresher training;
- The final decision to accept a person as reviewer, to continue to utilize their skills as a reviewer, and/or to select someone for a particular review, rests with CAC staff; and
- A signed declaration from their organization of employ, declaring that a current criminal records check (and in Alberta a current Intervention Check), reference checks and a signed oath of confidentiality are on file.
Reviewer and Team Leader training is offered in various locations, depending upon the need for reviewers and availability to take part in the training
Conflict of Interest/Right to Veto a Team Member
While CAC staff selects the members of the review team, the organization has the right to veto having a particular person on their team because of a perceived or real conflict of interest, past history and/or personality clash.
To prevent any perceived conflict of interest and/or bias:
- Team Leaders and reviewers are prohibited from accepting a paid contract or employment from an organization that they have reviewed until the conclusion of the accreditation process, and
- It is equally prohibited for an organization under review to offer employment to any of the team members during the review or until the accreditation has been completed.
Benefits of Being a Reviewer/Team Leader
Organizations find it very useful to have their staff participate in reviews as:
- Reviewers are able to learn new ways of doing things, gain insights and/or be exposed to tools/processes that can be taken back and adapted to fit into their own programs;
- Reviewers are able to see, and be positively reinforced for the areas within which their practice is more developed than that of the program under review, and/or
- Participation sheds new light on the steps needed to prepare for their own review.
While reviewers are not given an honorarium, all of their out-of-pocket expenses are covered i.e. meals, mileage and hotels (if required).
Every effort is made to put together a team that incorporates broad experience, cultural diversity, and knowledge of the program areas. To ensure the on-going development of reviewers, new reviewers are included in reviews as part of their training.