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Accreditation Process Summary
Revised June 2002
INTRODUCTION:
The responsibility of the COMISS Commission on Accreditation of Pastoral Services (formerly JCAPS) is to assess and evaluate the quality of pastoral services to patients, clients, families, and employees of an organization. Accreditation of an organization's pastoral services by CCAPS is a voluntary procedure for consultation and evaluation of the organization. CCAPS will examine the ability of an organization to meet the Standards for Accreditation of Pastoral Services approved by the COMISS Network October, 2000.
THE COMMISSION:
CCAPS commissioners are nominated by member organizations of the COMISS Network. Nominations of new commissioners are ratified by the COMISS Network Leadership. Two additional persons will serve as at-large public members and will be nominated by CCAPS and ratified by the COMISS Network Leadership.
Members will serve three-year terms and may not serve more than two terms, or six consecutive years on the Commission. Officers will be a Chair, Chair-elect, and Secretary.
The Commission reviews the Standards on an on-going basis. It will make formal recommendations for Standard(s) revisions to the COMISS Network Leadership.
ACCREDITATION PROCESS:
The accreditation process has three phases:
I. ASSESSMENT AND EVALUATION (A & E)
II. ACCREDITATION (A)
III. PERIODIC ACCREDITATION REVIEW (PAR)
The accreditation process begins with a letter and the completion of a formal application under the signature of the CEO and the submission of the appropriate fee. The letter is addressed to the Chair of CCAPS. This correspondence should go directly to the CCAPS office.
I. ASSESSMENT AND EVALUATION
Assessment and Evaluation is designed to assist an organization’s preparation of its pastoral program in light of the COMISS Network Standards. Members of a site visit team perform the major evaluative work. The organization must submit the following material in order to make A & E an effective experience:
1. Pastoral services goals and outcomes/objectives for the last five years.
2. Pastoral services budget for the last five years.
3. Job descriptions and curricula vitae for all current employees and job descriptions for any vacant positions.
4. Pastoral services policies and procedures.
5. A summary and raw data from surveys with
a) Nurses employed by organization
b) Physicians affiliated with organization
6. Description of the organization including a mission statement.
7. History of pastoral services department including any previous accreditation documents.
8. Organizational chart of facility/organization and pastoral services department.
9. Narrative description of pastoral services program including Scope of Service and Scope of Practice documents.
10. Description of pastoral services evaluation program/process improvement program.
11. Organizations that have had pastoral services programs operating for 5-plus consecutive years may feel satisfied with their ability to meet CCAPS Standards for Accreditation during this phase. These organizations should also include a description of how the organization meets each CCAPS Standard. Please note that submission of this material does not guarantee by-passing phase I, the Assessment and Evaluation phase.
The Chair of CCAPS will name a site team chair, a reviewer, and members of the site team sufficient for a comprehensive review. These individuals will be identified to the organization in advance of the site visit. A typical single organization site visit is three people/two days, but will vary according to the size/complexity of the organization.
All material should be sent to the CCAPS Chair, the CCAPS reviewer and each site visitor six weeks prior to the date of the site visit. The one exception is that the raw data from the surveys in No. 5 may be given to the site visitors upon arrival.
The Chair of the site team will negotiate the site visit schedule with the facility for the site visit. The site visitors will generally meet with the following people: Chief Executive Officer; Administrative Officers responsible for Nursing, Education, Social Services, Medical Staff, Ethics Committee Chair; representative of community clergy, pastoral services staff (individually and/or in group); designated ancillary personnel to be determined by site visit team; and other people as may be requested. The site visit will include a tour of the physical plant.
The purpose of the A&E site visit is to evaluate the organization’s potential to meet the Standards and to offer consultation for the organization to address any deficiencies.
The site visit will conclude with an exit interview to provide an immediate verbal report of impressions and recommendations formulated at that time. A complete written report will be sent to the CEO and Director of Pastoral Services within one month of the site visit. This report will also be forwarded to the CCAPS Reviewer whose purpose is quality assurance.
The site visit report will describe the findings of the site visitors. It will identify strengths and limitations of the organization in relation to its pastoral services. It will also note areas of compliance, partial compliance, or non-compliance with the COMISS Network Standards.
The organization will respond to the report within four weeks of its receipt. Copies of the response will be sent by the organization to the CCAPS Reviewer and each member of the site team.
The site team will make a written recommendation to CCAPS and CCAPS will provide timely notification of its deliberations with the organization's CEO and pastoral services director.
In those instances where an organization has significant work required to substantially meet the COMISS Network Standards, an accreditation review will be set to occur not more than two years from the date the organization is reviewed by CCAPS.
Organizations requesting consideration for the use of the A and E visit to serve as an Accreditation visit should identify that request in advance. In such instances, action will be taken in accordance with the procedure for Accreditation site visits.
II. ACCREDITATION
Centers embarking on the Accreditation Phase of the process should begin by sending a written request to the CCAPS office along with the appropriate fee no less than six months prior to an anticipated site visit date. This correspondence should be directed to the Chair of CCAPS.
In preparation for Accreditation, the organization shall prepare a Self-Assessment Report. The report will be compiled in a collaborative effort of the people who provided input at the time of A&E site visit. The report will include the following: (Refer to I. Assessment and Evaluation)
1. Description of how the organization meets COMISS Network Standards.
2. Current budget for pastoral services.
3. Current goals and objectives for pastoral services.
4. Revised policy and procedure statements.
5. Updated description and history of organization.
6. Current organizational chart of facility/organization and department.
7. All information requested by CCAPS in light of A&E decisions.
The Chair of CCAPS will name a site team chair, a reviewer, and members of the site team sufficient for a comprehensive review. These individuals will be identified to the organization in advance of the site visit. Whenever possible, members of the A and E visit will also serve as members of the Accreditation site visit. A typical single organization site visit is three people/two days, but will vary according to the size and complexity of the organization.
All material should be sent to the CCAPS Chair, the CCAPS reviewer and each site visitor six weeks prior to the date of the site visit. The one exception is that the raw data from the surveys in No. 5 may be given to the site visitors upon arrival.
The Chair of the site team will negotiate the site visit schedule with the facility for the site visit. The site visitors will generally meet with the following people: Chief Executive Officer; Administrative Officers responsible for Nursing, Education, Social Services, Medical Staff, Ethics Committee Chair; representative of community clergy, pastoral services staff (individually and/or in group); designated ancillary personnel to be determined by site visit team; and other people as may be requested. The site visit may include a tour of the physical plant.
The purpose of the Accreditation site visit is to evaluate the organization’s compliance with the COMISS Network Standards.
he site visit will conclude with an exit interview to provide an immediate verbal report of impressions and recommendations formulated at that time. A complete written report will be sent to the CEO and Director of Pastoral Services within one month of the site visit. This report will also be forwarded to the CCAPS Reviewer whose purpose is quality assurance.
The site visit report will describe the findings of the site visitors. It will identify strengths and limitations of the organization in relation to its pastoral services. It will also note areas of compliance, partial compliance, or non-compliance with the COMISS Network Standards.
The organization will respond to the report within four weeks of its receipt. Copies of the response will be sent by the organization to the CCAPS Reviewer and each member of the site team.
The site visit team will make a written recommendation to CCAPS and CCAPS will provide timely notification of its deliberations with the organization's CEO and pastoral services director.
COMMISSION ACTION
CCAPS will review the organization file for the purpose of accreditation of the pastoral services according to the COMISS Network Standards. CCAPS may make one of several recommendations to the COMISS Network Leadership:
1. Accredit the organization and its pastoral services.
2. Accredit the organization and its pastoral services with notations of the organization's partial or non-compliance with Standards. Organizations will be given up to one year to become in full compliance.
3. Defer accreditation with notations identifying those Standards requiring compliance in order to be accredited. CCAPS may require an additional site visit if the organization's non-compliance with Standards is significant.
4. Deny accreditation in those cases where compliance with Standards is wholly inadequate.
Upon granting of accreditation by the COMISS Network, CCAPS will set the date for the Periodic Accreditation Review. The review date means the year in which the organization must be reviewed by CCAPS. Organizations will be expected to report to CCAPS any significant changes in key personnel or programming in between accreditation review dates.
III. PERIODIC ACCREDITATION REVIEW
Once an organization's pastoral services have been accredited, that organization may maintain accredited membership through a PERIODIC ACCREDITATION REVIEW every five years.
The material required for the Periodic Review is the same as that required for Accreditation.
The procedure for a Periodic Review is the same as that required for Accreditation.
CCAPS and COMISS Network processes following a Periodic Review are the same as those at the time of Accreditation.
A three person team who will spend two days at the organization will make the Periodic Review site visit. They will meet with people described in the A&E and Accreditation site visits.
COST:
Organization cost for:
CCAPS Assessment and Evaluation - $3,000.00
CCAPS Accreditation - $1,500.00
CCAPS Periodic Review - $3,000.00
The organization will be responsible for all site team expenses, i.e. travel, lodging, and
meals per site visit.
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