Frequently Asked Questions (FAQ)
The following is a list of frequently asked questions about COHI and the Building Healthier Organizations (BHO) process. You can also suggest a question you'd like added to this page -- simply e-mail us at mail@cohi-soci.ca.
Click on a question below to link to the answer:
What are the benefits of Membership in COHI and participation in BHO?
What happens if we don't achieve full accreditation?
Who can participate in BHO?
Who are the peer reviewers?
How are review teams assigned?
Who are the review team leaders?
What happens during a BHO review?
How are clients involved in BHO?
Who will know the outcome of our review?
How can I participate?
What's our board's role?
What should we include in our response to the BHO preliminary report?
Is having a plan to do something sufficient to meet BHO requirements?
Does BHO require organizations to conduct chart audits to meet the peer review requirements?
What are the Benefits of Membership in COHI and participation in BHO?
For COHI the “accreditation” fee and “membership” fee are one and the same thing. Therefore, when an organization signs on to a three year contract and pays the annual fee, this makes it a full corporate member of COHI with the privileges and responsibilities as outlined in the bylaws. These include:
- voting at the AGM and other members’ meetings concerning elections to the Board of Directors and other matters, such as bylaw changes and increases to the membership fee
- nominating individuals associated with the member organization to stand for election to the Board of Directors
- individuals associated with the member organization may participate on COHI committees, both standing and ad hoc
Participation on the Board or various committees gives the organization a more direct opportunity, in addition to completing evaluation surveys, to contribute to the ongoing improvement of the BHO Program itself.
Organizations also find their participation in the BHO Accreditation Program is a very concrete way to demonstrate accountability and commitment to continuous quality improvement to their Boards, clients, community and funders. The Accreditation Certificate which the organization may post in a public place is very visible evidence of this. The organization is also listed in a publicly accessible part of the COHI website achieving accreditation.
Successful achievement of the BHO Mandatory Standards also provides assurance to Boards of Directors that their organization is meeting its regulatory and risk management requirements, something for which they are responsible as legal stewards of the organization. This should help the organization reduce the negative consequences of not managing risks appropriately, such as law suits and bad media coverage.
Organizations report that they use the structure of the BHO Standards to help organize their planning processes and systems within their organization, and that these cross-organizational systems help them ensure coordination across various programs, satellites and other off-site program locations, and through program expansions and amalgamations. The concrete structure of the BHO standards provides a foundation upon which the mission-related activities of member organizations may be achieved.
Finally, achieving accreditation can be a significant point of pride within the organization and a morale booster for staff, volunteers and Board, as it provides credible external feedback about the organization’s accomplishments. As such it can be used as a vehicle to motivate staff to achieve higher levels of accomplishment. It also provides a focus for teamwork by facilitating a process of setting common goals. The accreditation process and results allow an organization to compare itself to and stretch to reach established benchmarks in the sector.
Tangible Benefits:
- an external review by a team of three trained peers which provides feedback to the organization on its strengths and areas for development in relation to recognized standards in the operation of healthy service-providing non-profit organizations (the review may be conducted in either English or French)
- organizational staff may take advantage of training to become a Peer Reviewer and have the experience of being part of a BHO Review at a related organization, hence learning more about the accreditation program and about the successes and challenges of other organizations. Those involved as PRs report that this is an excellent professional development experience.
- BHO Manual and various tools which are associated with it
- presentations to the organization’s Board and staff about BHO and getting ready for BHO accreditation
- training in using the BHO Database
- access to COHI Website, including Members’ Only Section where information is provided about getting ready for accreditation
- access to Resource Library of Good Practices which lists many useful policies, procedures and other tools
- COHI office support (phone, internet) concerning questions in process of preparing for BHO
Other Benefits:
- The ability to demonstrate to stakeholders that the organization meets recognized standards (i.e., accountability).
- A structured opportunity for learning, for example, board members learning about their roles and responsibilities.
- A team building process.
- Provision of objective feedback on the organization’s functioning.
- Validation of the good work the organization has accomplished.
- Motivation to put systems, policies and procedures in place which benefit the organization.
What does it mean to be accredited?
Organizations are accredited when they demonstrate that they meet all of the Standards of Mandatory Practice and the required number of Standards of Good Practice in each module in BHO. Organizations that are accredited provide their funders, clients, community, staff and board with assurances that they meet recognized standards across the BHO modules. Accredited organizations receive accreditation certificates that they can post to advertise their achievement.
What happens if we don’t achieve full accreditation?
Organizations which are granted a conditional accreditation have six months from the date of the conditional accreditation decision to address any outstanding accreditation requirements. The BHO final report includes an appendix which details the indicators of achievement the review team will use to verify that the accreditation requirements have been met at the end of the six months. Organizations that are not accredited can apply for another BHO review one year after the previous BHO review. Organizations that are not accredited can appeal the decision if they wish. The appeal must be filed within 30 days of receipt of the accreditation decision using the COHI appeal application form.
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Who can participate in BHO?
BHO is designed to be used by community-based not-for-profit health and social service organizations. More more information, please contact COHI.
Who are the peer reviewers?
BHO reviews are conducted by peer reviewers who are executive directors, managers, staff, board or committee members of organizations participating in BHO. Peer reviewers are carefully selected and receive special training.
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How are review teams assigned?
Review teams are generally made up of three peer reviewers, one of whom is the team leader. COHI carefully considers the composition of each review team, endeavouring to bring together individuals with complementary knowledge, skills and experiences. Efforts are made to ensure neither the organization nor the peer reviewers have any conflict of interest which would prevent an objective review.
Who are the review team leaders?
Each review team has a team leader with special training in BHO. Team leaders are consultants contracted by COHI or are COHI staff members.
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What happens during a BHO review?
Prior to a BHO review, the review team reads the documents submitted by the organization in the BHO Database and makes decisions about the extent to which the BHO standards have been met based on documents alone. During the on-site review the BHO team collects information by conducting interviews and observing aspects of the organization’s work. Interviews are held with staff, board members and the executive director. The team also reads the results of the community and educational partners surveys conducted on the organization’s behalf by COHI. All of this information is used to assess whether the organization has met the BHO standards contained in the BHO Manual.
How are clients involved in BHO?
Client feedback is included in the results of client satisfaction surveys and program evaluations the organization shares with the review team. This approach was taken to ensure that clients are not over-surveyed and to minimize the amount of work BHO creates for organizations being reviewed.
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Who will know the outcome of our review?
All those involved in BHO reviews (i.e., peer reviewers, team leaders, COHI staff and board members) sign oaths of confidentiality. Maintaining confidentiality is a high priority for COHI and is important for the integrity of the review process. COHI does not release review reports or information about reviews without the written consent of the organization which has been reviewed. COHI does annually publish a list of currently accredited centres (this is a part of the written agreement between participating organizations and COHI).
How can I participate?
There are many ways to participate in BHO:
· help your organization prepare for BHO
· participate in a BHO interview during the on-site review
· apply to be a peer reviewer
· stand as a candidate for election to the COHI board
· volunteer to participate in mock interviews at peer reviewer training.
If you would like more information, please contact the COHI office at 416-239-2448 or mail@cohi-soci.ca.
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What’s our board’s role?
The board makes the decision to participate in BHO which leads to the organization signing a BHO contract. Board members assist in preparing for BHO and participate in the board interview during the on-site review. The preliminary and final reports are sent to the board chair with a copy to the executive director.
What should we include in our response to the BHO preliminary report?
Centres have 45 working days to respond to the preliminary report of the BHO review. COHI encourages organizations to offer additional information, ask questions and suggest a different point of view in response to this initial report. Here are some additional guidelines for writing this response:
• If you can demonstrate that you have met an indicator of achievement required for accreditation (either because of work already completed at the time of the review or based on work completed since the review) document this.
• Use the BHO report Appendix B to comment on issues which impact accreditation. Label attachments clearly to indicate what BHO Indicator they relate to and limit attachments to documentation which clearly helps to address a BHO Indicator.
• BHO isn’t simply about having pieces of paper such as policies and procedures. It is intended to evaluate how organizations put into practice what they have written in terms of mission, beliefs, plans, policies, etc. If you are going to develop new policies, plans or other documents within the 45-day period, you must also be able to demonstrate that you have involved stakeholders in their development, have followed appropriate approval processes and have oriented everyone affected. Borrowing policies and procedures from other organizations makes a lot of sense – centres must, however, demonstrate that they have tailored such policies to their own setting. These steps will help to ensure that these are living documents. The same expectations exist for work conducted during the six month period granted conditional accreditations.
• Limit your comments on Standards of Good Practice to items where you believe there are errors of fact or where you disagree with the review team’s point of view. New work to achieve Standards of Good Practice should not be completed within the 45-day period nor the six-month conditional period unless they impact the accreditation outcome.
• COHI asks that organizations send one hard copy of the response to the preliminary report to COHI as well as an electronic version to mail@cohi-soci.ca.
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Is having a plan to do something sufficient to meet BHO requirements?
Generally, having a plan to do something is not sufficient to meet BHO requirements. BHO review teams look for evidence of a track record (i.e., a record of regular or ongoing activity) as a way of affirming that organizations fulfill many of the BHO Standards. When preparing for BHO, it is useful for centres to prepare with the idea of demonstrating track record in mind.
In the past few years team leaders and peer reviewers have worked on improving consistency of decision-making across BHO review teams. As part of these discussions about consistency we’ve recognized that many BHO Standards include the idea that a specific practice or process in an organization is something that happens in a regular (often periodic) or ongoing way.
In some cases the expectations regarding the frequency of the practice are detailed in the BHO Indicator (e.g., BHO Indicator 1.2.2.6: Board minutes document the review of financial statements at least on a quarterly basis). In considering this Indicator, the BHO review team will look at board minutes to see if there is a pattern of quarterly review at your organization.
In other cases, the BHO Indicator simply indicates that the practice or process should occur on a regular basis (e.g., BHO Indicator 1.4.3.3: Policies and procedures are reviewed regularly according to a review schedule established by the organization.) In these cases, the organization is left to decide how often it will interpret “regular” to be and make this case. BHO review teams look for a planned approach and periodic activities as evidence of regular activity.
These Indicators are not just about yesterday or today, but about something that is regular or ongoing. They are not about plans to take action on a regular basis, but about evidence that action has been taken.
On occasion organizations preparing for BHO or striving to respond to a conditional accreditation have submitted plans that demonstrate their intention to take action on a regular basis. For example, an organization may submit a board calendar that demonstrates that the board has scheduled quarterly reviews of financial statements over the next year. In the interests of fairness and consistency, COHI has directed reviewers that a plan is not sufficient evidence of regular or habitual activity. Evidence of the activity itself is required, and also evidence that there is some kind of pattern of regular activity – say two or more quarterly reviews of financial reports in the example cited.
When there are accreditation issues for a specific centre, review teams try to establish indicators of achievement that can realistically be met within the conditional period. These indicators are identified at the preliminary report stage, which gives the organization as much as eight months to establish a pattern of activity before it must submit evidence that it has completed its action plan. In its response to the preliminary report, the centre has a chance to comment on these indicators, clarify (by calling COHI) anything that may be confusing, and assess its capacity to satisfy these indicators.
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Does BHO require organizations to conduct client record audits?
Yes, the latest version of BHO requires that organizations that deliver service to clients on an individual basis (e.g., medical or counselling services) conduct administrative client record audits (see BHO Standard 2.5.1) and quality of service client record audits (see BHO Standard 2.5.2). These are Standards of Mandatory Practice and as such, must be met for accreditation. In addition, BHO includes Standard of Good Practice 2.5.3 which addresses having a quality of service client record audit tool and process that evaluates services based on best practice.
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