Survey Gap Analysis for Initial Accreditation

Are you a behavioral healthcare organization seeking initial accreditation from TJC, ACHC, DNV, CARF, CMS, CIHQ, TJC, AAAHC or COA? Although the accreditation process can present numerous challenges, our team of experts can help simplify the process.

Behavioral Health Survey Gap Analysis: Foundation for Accreditation

Barrins & Associates conducts a comprehensive gap analysis for behavioral healthcare organizations seeking initial accreditation. This gap analysis forms the foundation for achieving accreditation. It identifies the specific actions you need to take in order to achieve full compliance with accreditation standards, so your organization can achieve successful outcomes.

Initial Behavioral Health Accreditation Gap Analysis Process

Our gap analysis provides a baseline evaluation of your current state of compliance with accreditation and regulatory standards. Using our structured gap analysis approach , customized to your organization, ensures we move forward with the approach that best fits your specific needs.

These are the steps we take to implement the process:

• Identify the specific requirements applicable to your organization based on your scope of service, client population, and setting. This saves you the time and trouble of trying to figure out exactly which standards apply to you.
• Provide a Documents List of the specific policies, plans, and other documents we’ll review onsite. You’re clear on exactly what you need to have ready for the consultation.
• Conduct a conference call to plan the agenda and the attendees for the various sessions. You get the right staff involved for the right survey activities so nobody’s time is wasted.
• Educate your staff on the key standards that your organization needs to earn accreditation through a series of interactions with our expert consultant.
• Review the following components of your operation:
  • Policies and procedures
  • Organizational plans (Infection Control, Environment of Care, etc.)
  • Clinical records
  • Performance Improvement data
  • Medication management processes
  • Human Resources files
  • Credentialing files
  • Physical plant
• Provide immediate feedback, identifying which areas are compliant and which ones need further work to achieve full compliance. Your managers and staff are clear on next steps.
• Share samples of compliant policies, plans, and tools. Your team gets help from us to customize these to your setting.
• Conduct an exit conference with your leadership team. Your leaders are briefed on the key compliance issues and next steps from our accreditation consultants.
• Report our findings and recommendations for achieving full compliance within five business days of our onsite meetings.
• Follow-up to review the report to clarify any questions about the report and how to move forward.

Why Choose Barrins & Associates for Initial Accreditation

Barrins & Associates excels at helping psychiatric hospitals and community behavioral health or human services providers achieve a successful survey outcome. Using survey gap analysis and other tools, we have assisted over 300 behavioral health organizations successfully achieve accreditation.

To learn more about how we can help you, contact us online or call us at 1-888-742-4621.