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Haven and Hope

Compliance and Accreditation

Too often, “compliance” and “accreditation” are dirty words in the field of non-profits – including the world of residential treatment and education. While there is a clear understanding why there’s a need for regulating agencies – especially given the vulnerability of the populations with whom we work – there is often push-back against placing compliance and accreditation processes at the center of a school’s culture or ethos.

Many organizations believe that an emphasis on compliance or accreditation tends to distract staff members from focusing on the client – or student. This assumption is understandable. Often times these processes – whether driven by public licensing or private accreditation requirements – are all-encompassing and can overwhelm the bandwidth of any organization, making it hard to focus on the day-to-day logistics (and minor/major crises!) that need to be priorities.

Maintaining public licensing (from a specific state department or board of education) is a required part of running many non-profits, including both residential treatment centers and schools. The Sonia Shankman Orthogenic School (O-School) is licensed – in the State of Illinois – by the Illinois Department of Children and Family Services, the Illinois Department of Healthcare and Family Services, and the Illinois State Board of Education. The first two agencies oversee our residential program (and some of our students’ public funding) – while ISBE licenses our educational program. Each of these agencies requires regular documentation and site visits – to ensure compliance. Privately, the O-School’s residential program is accredited by the Council on Accreditation (COA), a renowned and respected private accrediting agency that operates in the world of human and social services. COA requires an extensive process of self-study – followed by a site visit – every four years. Our educational program is accredited privately by Cognia, formerly known as AdvancEd, which provides best practice standards for schools nationwide. Cognia requires a self-assessment and site visit every five years.

Cumulatively, these processes do require a lot of work from our staff members and, to be honest, they’re not always thrilled to participate. From what I’ve experienced, we’re not the only organization that’s experienced that type of resistance. It’s not hard to understand why! Working in education, mental health, and social services is exhausting on a good day! There is always something left undone, always something pulling the team’s focus, always a metaphorical fire to put out somewhere in the program. It’s hard to ask staff members – who are already putting in so much – to add processes of compliance and accreditation to their workload.

Even though, at the O-School, we’ve been through multiple rounds of self-studies and site visits – we are still working to overcome this resistance ourselves. Here are some pointers, however, that might help improve staff buy-in and make compliance and accreditation productive and positive experiences organization-wide.

1. Don’t let it feel too perfunctory – give it purpose.

Reading pages and pages of standards can get boring quickly! Think of ways to align this process with your organization’s mission and culture. Even ways to make it fun! Remind your team that, separate from the sometimes frustrating self-study/site visit process, you are focused on improving your organization – and objective self-assessment is a big part of that. At the end of the day, compliance is about striving for best practice and improving services for your clients – and that should remain the focus throughout, even when people feel like they’re just jumping through meaningless hoops – which can sometimes happen. The more meaning you can embed in the process up front, the more buy-in you’ll get, organization-wide.

2. Remind everyone that the process is not a “witch hunt.”

Remember that your staff members might have had bad experiences with compliance or accreditation in the past, and they may be nervous that the process will be used to target or blame employees if standards are not met. At the start of the process, let your staff members know that this is NOT the case – and make sure you keep that promise. The accreditation process should be both collaborative and strength-based – with a focus on making your team feel proud of the great work they’re doing AND identifying how to improve – organizationally – in areas of relative weakness.

3. Find accreditors that match your organization’s approach, culture, and mission.

One of the reasons that organizations dread compliance and accreditation processes is that they don’t connect with the standards or approach. While you might not have much choice regarding who licenses you (as that’s determined by state regulations), you may have some say in who privately accredits you. Take the time to work with your team and find the right match. This accrediting body will likely be in your organization’s life for a while – so make sure you have the right chemistry! Does their process reflect what you prioritize in your organizational culture? For example, the O-School has enjoyed working with COA and Cognia because they both focus on growth, learning, and continuous change – which align closely with our mission and organizational goals. Their reviews never have a “gotcha” approach, and we leave our experiences with them both proud of all we’re accomplishing – and focused on ways in which we can learn and improve moving forward. Different agencies provide different approaches – so find one that works well for you and keeps you striving for best practices.

4. Work to embed these processes into the daily life of your organization.

This one isn’t easy. Too often, no one is thinking about the organization’s licensing or accrediting agencies until the email arrives in your inbox saying something like, “your annual accreditation cycle is beginning this month!” Then, of course, everyone jumps into action. Schedule a meeting! Make a plan! What do those standards say again?! We’ve all been there! At the O-School, we are learning, year by year, how to incorporate and embed these standards and processes into our daily work. How do we ensure staff members at all levels and layers have familiarity with the standards that most affect their work (and are acting in full compliance with said standards)? How do we build organizational policies, procedures, and trainings around the best practice standards laid out by our compliance and accrediting agencies? Obviously, there is no easy answer to these questions. It takes a concentrated and concerted effort – to include compliance and accreditation (often through quality improvement processes) in every meeting, in every department. It takes a level of determination to ensure these topics don’t fall off the organizational radar – which can happen easily, as there is so much to balance. Creating a “Compliance Committee” – with representatives across different departments – to stay up-to-date on all things compliance and plan upcoming engagement strategies/meeting agendas – is always a great place to begin.

Again, none of this is easy, but making the effort to embrace these sometimes dry, yet almost always useful processes will inevitably increase adherence to best practices and, thus, is in any organization’s best interest.

Author Ellie Badesch, MUPP, serves as Director of Compliance and Special Projects for the O-School. To learn more about the O-School’s residential and day programs, please visit our website. If you have a child or loved one who you believe may benefit from the O-School’s or BWC’s services, please visit our contact page or call our Director of Admissions, Kristin Friesen, at 773-420-2891.

  • Residential treatment
  • accreditation
  • compliance
  • mental health treatment


Haven and Hope is a destination for professionals, educators, and parents to learn from O-School experts about the issues facing children and adolescents with a variety of social-emotional challenges and/or autism, and how various aspects of the School’s 21st century therapeutic milieu provides a safe haven and a path to hope for those in need.

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