Executive Summary

Introduction, Methodology and Acronyms

Chapter 1 : The Purposes and Uses of Accreditation................................................................1

Rationale for Accreditation..........................................................................................................1 Current Oversight of Public Housing...........................................................................................2 Fundamental Accreditation Program Design Issues.....................................................................3

Chapter 2 : Accreditation Standards and Processes..................................................................1

Categories of Accreditation Standards.........................................................................................1 Accreditation Standards Development and Review.....................................................................2 Steps in the Accreditation Process...............................................................................................3 Time Required for Accreditation..................................................................................................6

Chapter 3 : Requirements for Establishing an Accrediting Organization.............................1

Process and Issues for Establishing an Accrediting Organization................................................1 Organization Budgets and Costs..................................................................................................8 Sources of Initial and Ongoing Income.........................................................................................9 Summary and Application to PHAB.........................................................................................10

Chapter 4 : The Political Feasibility of Establishing an Accrediting Organization.............1

Existing Models of Federal-Industry Accrediting Partnerships...................................................1 Key Elements of Models.............................................................................................................2 Summary and Application to PHAB...........................................................................................4

Chapter 5 : Conclusions and Recommendations.......................................................................1

Feasibility.....................................................................................................................................1 Options........................................................................................................................................1 Next Steps....................................................................................................................................2

Appendix A: Categories of Industry-Specific Accreditation Standards

Appendix B: Department of Education Requirements for Recognition of Accrediting Organizations

Appendix C: Interviewees

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The Council of Large Public Housing Authorities (CLPHA) commissioned this study to determine the feasibility of creating an accreditation board for the public housing industry. In an earlier paper prepared by CLPHA, it was recognized that now is a propitious time to consider the formation of a public housing accreditation program, as HUD continues to shrink its workforce and reforms its assessment process for public housing authorities (PHAs). After a review of the accreditation literature and some preliminary interviews with accreditation entities, CLPHA concluded that there was considerable evidence that accreditation is applicable to public housing and that such an evaluation system would offer positive benefits for the industry as a whole (see "Accreditation in Public Housing: A Call for a Study," April 1997). CLPHA argued that the next logical step in evaluating the appropriateness of accreditation was to examine the feasibility of establishing an accreditation board - in terms of both the cost and effort to start such an entity and to maintain an on-going accreditation process for public housing.

This study begins to address these feasibility issues. It reviews the history and operations of accrediting organizations in the health care, education and other industries in an effort to draw lessons from these organizations for the public housing industry. It describes the requirements for creating a new accrediting body based on these other experiences, and estimates the cost and effort that would be required for creating and operating a public housing accreditation program. Last, it reviews some of the political issues such an organization would face as it coordinates with HUD to provide effective peer review services.

The major findings of this study include:

• It is feasible to create a Public Housing Accreditation Board (PHAB) that would provide benefits for public housing managers and stakeholders in terms of performance measurement, performance enhancement, and quality assurance. The cost would be comparable to that seen in other industries for a program of similar size and scope. Such a program would require industry participants both to govern the Board and to serve as peer reviewers.
• In the health care and education industries, accrediting organizations successfully provide their services on behalf of federal agencies, provide quality assurance in keeping with industry-based standards, and reduce the need for direct federal oversight. In the public housing context, accreditation could serve as a substitute for HUD oversight although it need not do so to provide a valuable benefit to industry members and stakeholders. Finally, the study recommends that the PHAB sponsors clarify their goals regarding accreditation and gauge industry interest in supporting an accreditation program before proceeding with further study.

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Introduction

This study provides initial findings on the financial, operational and political feasibility of creating a Public Housing Accrediting Board (PHAB) that would improve the quality of public housing service provision and evaluation through a peer-driven, outcome-oriented accreditation process. Public housing professionals have expressed dissatisfaction with the focus and execution of the Public Housing Management Assessment Program (PHMAP) administered by the U.S. Department of Housing and Urban Development (HUD). The Council of Large Public Housing Authorities (CLPHA), the body that represents the nation's largest housing authorities, is exploring alternative systems to PHMAP for evaluating and demonstrating the performance of public housing. In a recent paper prepared by CLPHA and endorsed by the National Association of Housing and Redevelopment Officials (NAHRO), it was proposed that the housing industry study the accreditation of public housing as a means of addressing issues of quality, performance, deregulation and remediation. The paper points out that: HUD is reducing its staffing levels, leaving it less able to provide effective oversight to public housing authorities The principles of reinventing government argue in favor of a flexible, qualitative and outcome-oriented performance measurement system PHMAP has come under attack from internal and external agency sources as being inconsistently applied and questionably valid. * Since the CLPHA paper was prepared, HUD has proceeded with the development of new performance standards for public housing. This study responds to CLPHA's proposal. It examines the costs, operating needs, and political considerations of creating such a Public Housing Accrediting Board. The study also offers alternative structures for developing an accreditation system and concludes with recommendations for further action. The study does not offer an opinion on whether accreditation is the appropriate replacement for HUD oversight, however.

Methodology

To prepare this study, staff contracted by CLPHA reviewed current literature on the practice of accreditation and reviewed accrediting organizations' World Wide Web sites for

* "Accreditation in Public Housing: A Call for a Study," paper prepared by the Council of Large Public Housing Authorities and endorsed by the National Association of Housing and Redevelopment Officials, April 1997 5 October 1997 (rev. 3/98)

Acronyms

This paper uses the following acronyms: AALA* American Academy of Liberal Arts ACA* American Correctional Association, the accrediting organization for prisons, jails and juvenile detention facilities CALEA* Commission on Accreditation of Law Enforcement Agencies CARF* Commission on Accreditation of Rehabilitation Facilities CASFC* Council on Accreditation of Services for Families and Children CHAP* Community Health Accreditation Program, Inc., the accrediting organization for home health care CHEA* Council on Higher Education Accreditation, the industry association for the college and university accrediting organizations CLPHA* Council of Large Public Housing Authorities DoED* U.S. Department of Education HARRG* Housing Authority Risk Retention Group HCFA* Health Care Finance Administration HUD U.S. Department of Housing and Urban Development JCAHO* Joint Commission on Accreditation of Healthcare Organizations NAHRO National Association of Housing and Redevelopment Officials NCCHC* National Conference on Correctional Health Care PHA Public Housing Authority PHAB Public Housing Accrediting Board PHADA Public Housing Authority Directors Association PHMAP Public Housing Management Assessment Program

* Organizations that were interviewed for this study. See Appendix C, "Interviewees."

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The Purposes and Uses of Accreditation

This chapter introduces the arguments for accreditation in general and for the public housing industry in particular. It also introduces different models of accrediting organizations, based on their purposes and goals, and raises the question of what the PHAB's purpose should be.

Rationale for Accreditation

Accrediting organizations offer a number of reasons for facilities* in their industry to seek accreditation. First, accreditation is both an assurance that a facility meets a certain level of quality and a tool for achieving that level: A facility can use the standards and process for accreditation as a self-improvement guide, to ensure it is meeting the level of performance that the industry as a whole has established as a minimum. During the accreditation process itself, the facility has the opportunity to identify its strengths and weaknesses and to obtain help from the accrediting organization in improving its operations. Because accreditation serves as a tool and a symbol of quality improvement, the receipt of accredited status assures consumers and stakeholders that the facility adequately meets a set of professionally-recognized quality standards. Second, accreditation can be a key to receiving public funding or regulatory relief. If an accrediting organization has created standards that sufficiently protect consumers, and a process that ensures the standards are applied objectively and fairly, regulatory bodies might deem an accredited facility eligible to carry out public purposes. For instance: The Health Care Finance Administration (HCFA) requires hospitals and health care facilities to meet certain standards before they can be eligible for Medicare and Medicaid reimbursement. HCFA allows these facilities to substitute third-party accreditation for a federal survey to prove their eligibility. The U.S. Department of Education requires colleges and universities to receive accreditation from regional or specialized accrediting organizations before they can participate in the Title IV student aid programs. Many states will allow facilities to submit industry accreditation as a substitute for state regulation. Finally, accreditation is touted as a protective measure. The Continuing Care Accreditation Commission (CCAC), which oversees continuing care facilities for the elderly, was founded to prevent a regulatory backlash against the continuing care industry caused by a series of

* For purposes of clarity, we use the term "organization" to refer to the accrediting body, and "facility" to refer to the accredited body. 1 October 1997 (rev. 3/98)

Current Oversight of Public Housing

CLPHA has cited a number of arguments in favor of accreditation for public housing. In CLPHA's view, accreditation is a qualitative, peer-driven and outcome-oriented process that can help public housing authority managers focus on the management and performance factors that matter to both the public housing industry and the communities in which the authorities are located. The U.S. Department of Housing and Urban Development currently assesses the management and performance of public housing against twelve indicators contained in the Public Housing Management Assessment Program (PHMAP). These indicators include: Vacancies 7. Annual inspection and condition of units and systems Modernization 8. Tenants accounts receivable Rents uncollected 9. Operating resources Energy consumption 10. Routine operating expenses Unit turnaround 11. Resident initiatives Outstanding work orders 12. Development The standards underlying these indicators are fairly prescriptive. For example, a public housing authority (PHA) that has a balance of rents uncollected in the immediate past fiscal year of more than 6 percent (thereby receiving a grade of "C") would have to take corrective action in this area. In the area of outstanding work orders, a PHA must have completed at least 95 percent of all emergency work orders, plus have either no more than 8 percent of non-emergency work orders outstanding at the end of the past fiscal year, or no more than 10 percent outstanding but with evidence that the time to complete maintenance work orders has been reduced over the past three years. The U.S. General Accounting Office and some public housing industry stakeholders have questioned the accuracy and the utility of the PHMAP standards. The standards provide few qualitative measures of performance. "For example, PHMAP does not include an independent on-site inspection of the condition of an authority's housing, so it does not adequately assess the quality of modernization work or routine maintenance. ..." The standards set quantitative guidelines, but not qualitative ones. Moreover, "PHMAP does not always allow for extenuating circumstances that [as a result] can lead to decisions inconsistent with good property management. For example, a housing authority can improve its PHMAP

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Fundamental Accreditation Program Design Issues

Pursuit of an accreditation strategy can lead to the results CLPHA seeks for public housing self-improvement, and a well-designed accreditation program can serve as a proxy for direct federal oversight. Thus, the benefits that the public housing industry (and HUD) will see from accreditation depend on the goals the accrediting organization is designed to achieve, and the design of the program to meet those goals. If the accreditation program ensures both good management and operational practice and compliance with federal regulations, then it could relieve HUD of the need to provide direct oversight to participating, well-run public housing authorities in a time of reduced resources. If the program focuses only on issues of internal improvement and community impact, it could strengthen the role public housing plays locally without forging a federal-industry regulatory partnership. Therefore, before examining the feasibility of creating an accrediting organization, three related questions must be answered: Will participation in the accreditation program be voluntary or mandatory? Will the accrediting organization be focused primarily toward self-improvement or self-regulation? To what degree will accreditation substitute for or support federal regulation? The decisions that CLPHA and its partners make with regard to these questions will direct the overall structure of the PHAB and the relationship it has with HUD. These questions and their impacts are discussed more fully in Chapter 3. At the outset, however, it is valuable to describe how different accrediting organizations have addressed these questions.

* U.S. General Accounting Office. "Public Housing: HUD Should Improve the Usefulness and Accuracy of its Management Assessment Program," (GAO/RCED-97-27), January 1997, p. 7. See this report for additional discussion of PHMAP. October 1997 (rev. 3/98)

• Participation: Generally, accreditation is a voluntary process. Even when an accrediting organization acts as a proxy for the federal government in determining program eligibility (e.g., JCAHO and the educational accrediting organizations-see Chapter 4), facilities that do not participate in the federal programs need not seek accreditation.
• Focus: Most accrediting organizations help members of their industry improve the quality of services they provide by offering some form of technical assistance to the facilities they accredit. Some are more consultative than others, however. The Community Health Accreditation Program (CHAP) provides consultative services or directs facilities to outside consultants, and hopes to establish a separate body to provide consulting services in the next year; NCCHC, which sponsors both an accreditation program for facilities and a certification program for individual practitioners, also provides consultation as a separate service. The Council on Accreditation of Services for Families and Children (CASFC), at the other end of the spectrum, does not provide remedial services. Unlike other accrediting organizations, however, CASFC provides accreditation on behalf of a variety of sponsoring social service agencies and is thus more separate from the facilities it accredits than other organizations.
• Regulatory Substitution: If an accrediting organization will act in lieu of a federal regulatory body, its standards must be aligned with and include the regulatory requirements currently in place, and there must be continual revision of the standards to match changes in federal law and regulations. In addition, the issue of consultation will become more complicated since an accrediting organization must be clear in its responsibilities both to the facilities it accredits and to the federal government. The balance between fostering quality improvement and protecting the use of public funds can create the perception of a conflict of interest if it appears that the point of quality improvement is only to increase facilities' access to tax dollars. JCAHO has had to respond to public and Congressional concerns on this topic many times over its history. The answers to these fundamental questions may direct the PHAB sponsors toward different levels of effort, and different designs, in pursuing the creation of an accrediting organization for public housing authorities. The following chapters explore the questions of effort and design in more depth. Chapter 2 describes the common processes that accrediting organizations take in carrying out their duties. Chapter 3 describes the process and costs of creating an accrediting organization and introduces some of the variations based on the PHAB's purpose. Chapter 4 examines the political feasibility of creating a regulatory PHAB versus a more industry-focused one by profiling two existing federal-industry accreditation partnerships and describing HUD's current approach to regulating public housing. Chapter 5 concludes this study with recommendations for further action.

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This section begins with a description of the types of standards commonly used by accrediting organizations, and the processes by which these standards are developed and reviewed. It then describes a typical process and timeline for accreditation. While different accrediting organizations develop standards and processes to fit their needs, there are many common elements that can apply to a public housing model.

Categories of Accreditation Standards

Accrediting organizations' standards can be separated into two general groups. The first group broadly addresses effective governance and administration, and it includes precepts that cut across industries. Such standards include: Mission and Purpose: Does the facility have a clearly defined objective and does it focus all tasks on fulfilling this mission? Is the mission understood at all levels of the facility? Adherence to this standard can be verified through interviews with staff and a review of operational policies against the facility's documented mission. Governing Board: Most facilities have a board of trustees or directors. Does the board enforce the facility's mission? Do board processes and procedures allow for fair representation among the membership, rules for the transfer of power, and participation among board members? Adherence to this standard may be verified by a review of bylaws, examination of recent board minutes, or an interview with board members about their activities. Strategic Planning: Is the facility looking to the future? Most accrediting organizations look for proof that applicants for accreditation understand their current situation, perhaps by employing a management information system (as required by CASFC) or a methodical evaluation of the current environment (as required by CCAC). Then, the organizations look for plans that set goals for several years ahead and describe the steps the facility will take to achieve those goals. Financial Management: This often is the set of standards that bears the most weight for the accrediting organization. Is there evidence of short-term and long-term financial stability? Does the facility have the financial resources needed to carry out its mission? Are there prudent fiscal policies and controls in place? To verify adherence to these standards, many accrediting organizations review accounting records, budgets, income statements, and supporting documentation, or they require an independent audit of the facility. Administration/Organization: Does the facility have a personnel manual stating its policies and describing how employees may access facility information and resources? Are channels of communication open? Are roles and responsibilities defined? Is there a October 1997 (rev. 3/98)

• Human Resources: Often the largest single block of standards, human resources spans many functional areas, including: recruitment, hiring, orientation, training, benefits, payroll, and professional development. Are there adequate resources to provide services to employees, and evidence that employees are taking advantage of them? While general standards are commonly shared, the programmatic standards are specific to the industry served. This group of standards ensures services are adequately delivered to the consumers. The details of these standards depend on the specific business being accredited. For example:
• The American Correctional Association (ACA) which accredits correctional facilities, has quality standards for inmate health and education programs
• The Commission on Accreditation of Rehabilitation Facilities (CARF), which accredits rehabilitation facilitates, requires facilities to demonstrate how their programs empower people with disabilities as part of their accreditation standards
• CCAC, which accredits residential communities for the elderly, evaluates the facility's residential health care and wellness program. Specific standards from the accrediting organizations interviewed are included in Appendix A. The PHAB reasonably would incorporate some of the general governance and administration standards into its own standards for public housing authorities. These standards reflect appropriate practices for any organization. With regard to public housing-specific standards, however, the PHAB might include categories such as:
• Physical environment, maintenance and asset management, to reflect the housing authority's role as a housing provider
• Quality and outcomes of tenant programs (including coordination with welfare programs), to reflect the housing authority's role as a service provider
• Participation in community issues, to reflect the housing authority's role in and contribution to community health
• Management systems for assuring compliance with federal requirements, to reflect the housing authority's role as a partner with the federal government.

Accreditation Standards Development and Review

In developing standards for accreditation, an organization must use a process that wins broad acceptance of those standards by the industry to be accredited and its stakeholders. Such a process ensures that the standards have validity to the consumers of accreditation and to the audience that accreditation is meant to assure. CCAC and CALEA's histories provide two models for creating standards in this manner. In one case, the standards were created with

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Steps in the Accreditation Process

Most organizations have established a process similar to the seven-step process described below for accrediting facilities. These steps are depicted in Exhibit II-1 and they include: Application for Accreditation: The facility applies to begin the accreditation process. The accrediting organization will determine a facility's eligibility for accreditation based on shared goals, mission, and other requirements that the accreditation organization has defined. If the accrediting organization decides the facility is an appropriate candidate for accreditation, it sends application materials and, if mandated by the organization's procedures, a self-evaluation guide for the facility to complete in advance of the accrediting organization's site visit. Most October 1997 (rev. 3/98)

2. Self-Evaluation: The self-evaluation is an opportunity for the facility to compare itself to the stated principles and standards of the accrediting organization. The evaluation lists each standard by which the facility will be graded, as well as a guide for how to demonstrate adherence to those standards. Supporting documentation is defined, guide questions offered, and sometimes the grading process is given. Many accrediting organizations recommend that facilities undergoing the self-evaluation establish a steering committee that includes management, staff, and customers as appropriate, to guide them through this process. When the facility feel it meets the standards and is ready to receive accreditation, it returns the completed self-evaluation and supporting documentation to the accrediting organization which reviews the material.
3. Selection of Site Surveyors: After receiving and reviewing the self-evaluation documents, the accrediting organization selects a team of surveyors to visit the facility. The team members also review the self-evaluation before visiting the facility. The size of the survey team varies according to the size of the facility and the detail investigated by the accrediting organization. In choosing the team, the accrediting organizations generally ensure several conditions: that there is no conflict of interest between the surveyors and the facility; that the surveyors have complementary skills to create a balanced team; and that the surveyors come from organizations similar in scope to the subject facility so they can evaluate the facility fairly and appropriately. Most organizations have a procedure to designate one team member as the lead reviewer with responsibility to set the agenda before the visit, be the primary contact with the facility during the visit, and write the report afterwards. Where the surveyors receive a fee for conducting the visit, the lead reviewer's fee is slightly higher to reflect the extra responsibility involved.
4. Site Visit: The purpose of the site visit is to verify the self-evaluation, ensure accreditation standards are met, and provide helpful feedback to the facility. Many accrediting organizations stress that the site visit is not an adversarial process but a chance for professionals in the industry to view and comment on the performance of the facility. The site surveyors have a dual role when visiting the facility. First, as representatives of the accrediting organization, they need to validate the self-evaluation report on compliance with accreditation standards and policies. Second, as peer reviewers, they have the opportunity to point out weaknesses in the facility's programs and provide consultative services. With few exceptions, the site survey is arranged with the facility in advance, although CHAP makes its visits to Medicare home health facilities unannounced. Most site reviews follow a similar pattern:

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• Before arriving, the surveyors schedule various meetings and arrange for the facility to provide the documents they will need to examine.
• Upon arrival, the surveyor team meets with the facility's general staff to introduce themselves, explain the purpose of the visit, and describe what assistance they may require.
• Throughout the rest of the visit, the survey team - Reviews documents such as administrative manuals, newsletters, meeting minutes, and policy statements. Financial documents may be viewed on site but frequently are sent to a finance expert who does not make the trip. - Conducts interviews with various stakeholders including board members, staff and customers (residents, patients, students, etc.) either in focus groups or individually to learn their perception of the facility. - Tours the facility to meet with managers, staff and customers, inspect the facility, and investigate the services offered by the facility. In the CHAP visit to home health care providers, the survey team also visits patient homes (after obtaining the patient's consent) to observe services there.
• The survey team usually meets among themselves once per day to discuss what they have observed.
• At the end of the visit, the surveyors hold an exit interview to share their observations with the facility management and obtain their feedback.
• Site Visit Report: After the site visit, the lead surveyor writes a report of the team's findings. The lead surveyor passes the report to the other team members and to the facility so they may check for factual errors. The facility has the opportunity to respond to any aspect of the report, and its comments may be included in the final report.
• Accreditation Determination: The accrediting organization's board (or a committee) meets and considers the information from the self-evaluation, the site survey and the facility response in deciding the accreditation status. In some programs, this process is public and the facility is allowed to address the board, with the lead reviewer acting as an advocate for the facility; other times the decision is made behind closed doors. Nearly all of the accrediting organizations have different levels of accreditation ranging from full accreditation (unconditional) to denial of accreditation. Denial (or revocation if the candidate is applying for reaccreditation) is rare and follows a facility's demotion through intermediate stages. Between these extremes, a facility may receive conditional or provisional accreditation, meaning areas were identified as needing improvement but the facility is sound overall; the facility also may receive recommendations on those areas and direction for obtaining technical assistance. In these situations, the facility must correct the deficiencies within a specified time frame. Probational accreditation means the facility had been accredited but now is in danger of losing its status.

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7. Follow-up: If a facility receives conditional or probational accreditation, it is required to prepare and implement a corrective action plan, document implementation of that plan, and be reviewed at the next board meeting. In addition, most accrediting organizations require all accredited facilities to submit an annual report during accreditation cycles to ensure they maintain compliance with the standards or to identify incipient problems before they develop.

Time Required for Accreditation

The average time required to complete the entire process of accreditation, from application to acceptance, is 16 months for the organizations surveyed in this study. This actual time needed depends on two variables. The single largest time-driver is the self-evaluation. Completion of this step indicates the candidate is ready to be evaluated by the appropriate organization. If the candidate is far from compliant with the accreditation standards, completion of the self-evaluation can require years of work. On the other hand, if the candidate is already well run, this step could require only a few months or even be as short as one day (as for some NCCHC-accredited facilities). On average, the time needed to complete a self-evaluation was six months. A second time-driver is the frequency with which the accreditation review board meets to consider candidates. Most boards convene between three and six times annually. If a site visit and subsequent report is not ready for a particular board review, the candidate must wait until the next one.

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This chapter describes the requirements, in terms of process and cost, for establishing an accrediting organization for public housing authorities. In describing the process, it considers the financial and human resource needs experienced by other accrediting organizations. The chapter concludes with a summary that highlights the costs that could be faced by individual public housing authorities participating in the program.

Process and Issues for Establishing an Accrediting Organization

The process of creating an accrediting organization can be set out in eight steps, from the establishment of the organization's purpose to the solicitation and training of surveyors to conduct the accreditation reviews. Some of these steps are fundamental to any start-up organization, but others are particular to the establishment of an accrediting organization, and the cost and time required for them will depend on the organization's stated purpose.

As discussed in Chapter 1, the PHAB sponsors should be clear about the purpose of the accrediting organization: whether accreditation should be mandatory or voluntary, whether the accrediting organization will serve as a consultative body or more of an "arm's length" oversight one, whether accreditation status is meant to substitute for federal regulation or coexist with it, and, subsequently, which aspects of a facility's operations and management accreditation should address. The answers to these questions should be consistent, i.e. If accreditation is to substitute for federal regulation, or the accrediting organization serve as an agent for the federal government, it should be mandatory to ensure complete coverage of the industry, designed to encompass the aspects subject to regulation, and arm's length to ensure the integrity of the procedure. If accreditation is to serve as an internal management tool coexisting with federal regulation, it may be voluntary and focused toward whatever areas the sponsors wish it to be, and the organization may offer more consultative services. JCAHO is an illustration of this first option-it is sponsored by a number of trade organizations (e.g., the American Medical Association) but is not specifically allied with them. NCCHC, on the other hand, represents for correctional health care facilities and offers accreditation in addition to other services. October 1997 (rev. 3/98)

Accrediting organizations are governed by Boards of Directors (or Commissioners, Trustees, etc.). The Board's responsibility is to set general policy and direction for the organization. It approves standards and either makes decisions on accreditation or delegates this responsibility to a smaller committee of board members and professionals. The answers to the questions in step 1 will set the framework for the governance structure. Important issues to address here include: Size: The boards of the accrediting organizations we interviewed range in size from 9 to In some cases, the board is a particular size because it includes members from the organization's sponsoring agencies; in other cases, it is a size that is considered "manageable." Generally, a board should be of a size to reflect the concerns of the organization's constituencies fairly. Some organizations, such as CARF and JCAHO, reserve board seats for their sponsoring organizations; thus, the more sponsors there are, the larger the board is. There is less of a correspondence between the size of the board and the number of facilities accredited, however: CCAC, CHAP and NCCHC each have 10-12 members on their boards, but the number of facilities they accredit ranges from 130 to 410. Composition: The appropriate composition of the board will depend on the organization's purpose, as decided above: an organization that focuses on regulatory compliance (either on behalf of the government or for the industry alone) should have a board with a greater proportion of public members than an organization that simply provides management improvement services to its industry. Of the organizations interviewed for this study, anywhere from half to all of their board members come from the industry and any remaining members come from the public. Related to the issue of composition is the issue of how board members are to be elected and what qualifications they must have. For example: - If members are to come from the public, who will nominate them? Should HUD have a role in identifying them and selecting them? Should HUD have a voting or ex oficio seat on the board? - Should the organization reserve one or more seats for specific industry and stakeholder groups such as (for example) CLPHA, public housing tenants' organizations, the National Academy of Public Administrators, the Institute of Real

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A broader range of non-PHA representatives in these key roles will increase the public's perception of the PHAB's independence from the public housing industry.

• Independence: The PHAB sponsors should decide early in the process how clearly separate the PHAB board must be from the boards of CLPHA or other industry stakeholders. While the PHAB board must contain expertise in the area of public housing, to the extent that there are overlapping memberships on the boards the appearance of the PHAB's objectivity could be called into question. For example, CHAP's board is appointed by the board of the National League of Nursing, its parent organization, which suggests a close relationship between the two bodies. The American Academy of Liberal Arts (AALA), on the other hand, excludes the institutions it accredits from membership on its Board of Directors; this enables it to more easily avoid the appearance of conflict of interest. Table III-A describes the board structure of some of the organizations interviewed for this report.

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The budget needed for the organization will depend in large part on the purpose decided upon by the sponsors, as well as the extent to which public housing authorities participate in the accreditation program. A program that is meant to supplant federal regulation might require a full-time external affairs staff to promote accreditation, whereas a program with a more limited scope might need fewer staff. Similarly, the organization will need more staff if all 160 large public housing authorities participate from the outset than if only a handful of PHAs participate. Information provided by other organizations suggests that a new accrediting organization will need approximately $250,000-350,000 to pay for a minimal staff and the costs of standards development. For example: AALA had an initial budget of $350,000 which covered up to four salaries, rent, travel and the development of standards and handbooks, as well the creation of by-laws and a Board of Trustees. CCAC required $200,000 in start-up funding in 1985. These costs included 1.5 staff persons' salaries and the expenses for developing standards and procedures. We were unable to obtain data on start-up costs from the other organizations interviewed, as many were begun too long ago for them to provide accurate estimates.* The PHAB sponsors and/or Board might seek funding from a number of sources, including foundations, public housing authorities, and Congress. The more non-governmental sources the PHAB obtains, the more it will appear to the public as a body independent of both HUD and the industry: the fact that CCAC was subsidized by its sponsoring organization, the American Association of Homes and Services for the Aging, places it in a different relationship to its industry than CASFC, which receives funding from a number of different sponsors.

* It may be useful to note that the Housing Authority Risk Retention Group (HARRG), the public housing authorities' insurance carrier, required approximately $200,000-250,000 for start-up costs in 1985.

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Other accrediting organizations' hiring practices suggest that the organization director and other high-ranking staff should have substantial experience in the public housing industry and/or accreditation programs. If the director will be hired as the Board is being formed, then the PHAB sponsors should establish the hiring criteria; otherwise, this should be left to the Board of Directors. The sponsors or Board may conduct the search themselves or use the services of a recruitment agency. According to the "Certification Communications Compensation Report," the majority of certification program executive officers (62 percent) receive a salary of $60,000 or more, depending on experience and education.* We will assume a base salary of $65,000, plus benefits estimated at 33 percent of salary, for a total director's salary of $86,500.

In general, there are two ways for the PHAB to establish standards and procedures. The PHAB director can develop the standards and procedures, based on existing industry sources, HUD (PHMAP) and other federal reports, and models drawn from other accrediting organizations, then disseminate them to the industry for comment, and finally field test them. The director can convene industry and stakeholder panels to help draft the standards and procedures, disseminate them for comment, and then field-test the standards in a representative sample of PHAs. In both cases, the Board of Directors would approve the final version of the standards and procedures. The first option will enable the PHAB to start operations most quickly while still obtaining industry concurrence on the standards. The second option will require more time but it will help create greater stakeholder buy-in. The time needed to develop (and test) the standards also will depend on the PHAB's scope: if the program is meant to replace federal regulation, the organization will have to spend more time working with HUD and OMB in crafting the initial standards.

* "Certification Communications Compensation Report." National Certification Commission of the National Certification Association. Undated fax sent to CLPHA on September 3, 1997. October 1997 (rev. 3/98)

The basic positions for accrediting organizations (in addition to the director) include a program/training manager, scheduling coordinator, and administrative support staff. All organizations require managerial staff to have responsible experience either with the industry being reviewed or with other accreditation programs. Total organization size appears to be correlated to both the number of facilities it accredits and the number of services it provides (such as training or publications). In a small organization, the director and staff likely will assume multiple roles-e.g., governmental relations, marketing, surveyor training and evaluation, relations with facilities, publications, and administrative functions. As the organization grows, it may need to hire specialists in each of these areas; CCAC, for example, hired staff as needed during the first two years while it was developing and testing its accreditation standards. Table III-B displays staffing structures of other accrediting organizations.

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If only a few public housing authorities will participate in the program at the outset, a staff of 3-4 may be sufficient, particularly if the organization does not expand into areas such as publishing technical assistance documents or providing extensive surveyor training. We estimate that the PHAB staff base salaries will range between $85,000 and $105,000, depending on the scope of staff responsibilities, experience and education.* With benefits again at 33 percent of salary, the total staff salaries (not including the director's salary) range from approximately $113,000 to $139,500. Thus, in combination with the director's salary and benefits, total personnel costs will range from approximately $200,000 to $226,000.

An accrediting organization would need the typical office supplies and furnishings. In Washington, DC, office space, furnishings and supplies (including telephone and postage) will cost approximately $100,000 for the first year. The PHAB may be housed in office space provided by a sponsoring organization (e.g., CLPHA) in its early years to reduce organizational start-up costs. Co-location of the PHAB with a public housing industry representative will reduce the appearance of third-party independence, however.

* "Certification Communications Compensation Report."

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As with earlier steps, the decision that the PHAB sponsors make on the purpose of the Board will inform the decisions made about surveyors. Although all accrediting organizations use peer surveyors, an "arm's length" organization might include representatives from other multifamily housing industry groups, smaller PHAs not seeking accreditation, academics, private real estate managers, or HUD field offices to demonstrate an appropriate level of objectivity. Surveyors generally have at least 5 years of responsible experience in the industry and are nominated or solicited from the facilities and then interviewed by the organization. Most are volunteers or receive a small stipend, although CHAP uses paid outside professionals to conduct the site reviews when it cannot find appropriate peer surveyors. In addition, not all organizations require surveyors to come from accredited facilities. Their pools of surveyors range from 100 to 900, depending in part on the size of the industry itself. Accrediting organizations provide at least some form of training to their surveyors. Some limit the training to a half-day session during the organization board meeting, and rely on the surveyors' own experience and on written materials to provide sufficient guidance; others develop and offer a multiple-day, intensive training regimen. Only CARF was able to assign a cost to its training program, which was $1,500 per person for a five-day course. We assume that the cost of developing the training would be included in the salaries of the director and program/training manager, and that development would require one month of staff time.

Organization Budgets and Costs

There is a rough correlation between the size of the organizations' operating budgets, on one hand, and a combination of staff size and number of site reviews the organization conducts on the other. Five of the seven organizations identified personnel as one of the largest cost drivers, and four of these also identified travel costs associated with the site reviews as a large cost driver. We could not quantify other contributing factors to the overall budget. See Table III-C. Note that the surveyors' travel expenses are included in these budget figures because the organizations provide the reimbursement to the surveyors, even though the funds are collected paid from the facility fees.

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Sources of Initial and Ongoing Income

In some cases, accrediting organizations' operations were subsidized by a parent organization. Other organizations received grant funding in their early years: CALEA was funded with a Law Enforcement Act grant, for example, while CASFC received $1 million in grant funding from the Department of Health and Human Services and private foundations, and AALA received private foundation funds. The organizations' operating budgets are financed through fees paid by facilities for accreditation applications and site visits, as well as from profits from the sale of publications. Facilities applying for accreditation pay applications fees, annual fees where they are required, and fees for the site survey visit. Application fees for accreditation range from a low of $250 to a high of $16,000. Annual fees, where they are charged, range from $2,800 to more than $23,000. In some cases, the fees are standard regardless of size; in others, it is based on facility revenues or facility size. The site visit costs range widely, depending on the number of surveyor-days required and the size of the honorarium (if any) paid to surveyors.* On average, the cost appears to be approximately $1,000 per surveyor-day; of this, $1,500-$2,000 total is reimbursable to the surveyor as travel expenses and an honorarium if any; the remainder goes to the organization to cover operating expenses. See Table III-D.

* Generally, facilities will conduct a self-assessment prior to receiving an site visit. Apart from the cost of purchasing materials, there is no direct cost estimated with this activity. From the facilities' point of view, there is a cost attributable to staff time, document copying, etc., but most accrediting organizations view this as an inherent cost for good management practice rather than as a separable activity cost. October 1997 (rev. 3/98)

Summary and Application to PHAB

Based on the above discussion, we estimate that the first year organizational costs for the PHAB will start at $180,000, assuming the $50,000 cost of recruiting a director, $86,500 for the director's first-year salary and benefits, $10,000 for travel costs and approximately $30,000 for printing, supplies, postage and telephone attributable to the project. We assume that office space and infrastructure will be donated for the first year. The estimated first-year cost does not include charges for the sponsors' staff time, legal costs for incorporation or other activities, PHAB staff hired mid-year, nor any travel costs needed for the Board meetings or for standards development. The process could take as little as two years, or as many as four. Table III-E on the following page displays an estimate of the PHAB's operating budget once the organization is established. Based on other accrediting organizations' experience as well as CLPHA's own operating budget, we estimate that the PHAB's annual operating costs will run approximately $420,000 for salaries and benefits, office rent and supplies, publications, Board meeting expenses, professional services and miscellaneous costs. In addition, we estimate that the PHAB will incur a cost of $1,500-2,000 per surveyor per site visit based on

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As a new organization, provided that not all 160 large PHAs seek accreditation in the first year, the PHAB will be able to operate on a smaller staff that will begin scheduling visits, reviewing PHAs' documentation and self-evaluation reports, and enlist and train surveyors. As interest in the accreditation program grows, the PHAB may need to hire more staff who will have more specialized duties, such as finance, training or publications production; alternately, the PHAB may choose to organize itself by geographic region rather than special function (as ACA is organized, and similar to CARF's organization by type of rehabilitation facility). For the PHAB to be self-supporting, its revenues will have to come primarily from application fees and annual fees, as well as the difference between the fee for the site review and its actual expense, as noted above. It is here that the issues of feasibility and participation intersect, since the size of the application and annual fees will depend on the number of public housing authorities that participate in accreditation. The more PHAs there are to cover the organization's expenses, the lower the fees may be. Exhibit III-1 displays the annualized fees each PHA will have to pay to support the PHAB, assuming different levels of participation and a five-year accreditation cycle. If only 32 (one- fifth) of the large PHAs participate in the program, each PHA will have to pay some combination of application, annual and site visit fees totaling approximately $74,000 over the accreditation cycle (i.e., $12,000 every five years for the site visit plus a total of $62,000 in some combination of application and annual fees). If all 160 large PHAs participate, the average total fee can be as low as $21,100 over the accreditation cycle (i.e., $12,000 every five

* The PHA pays the PHAB for the cost of the site visit and the PHAB reimburses the surveyors for their actual expenses and honoraria as required. The difference between the PHA's cost and the PHAB's cost supports general operating expenses. October 1997 (rev. 3/98)

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The Political Feasibility of Establishing an Accrediting Organization

This chapter considers the feasibility of establishing an accrediting organization from the political perspective-that is, whether other models of government-industry partnership on accreditation and HUD's current posture suggest that a PHAB would meet its sponsors' goals.

Existing Models of Federal-Industry Accrediting Partnerships

The two largest federal government-industry partnerships in accreditation are in health care, represented by the partnership between the Health Care Finance Administration (HCFA) and the Joint Commission on Accreditation of Health Care Organizations (JCAHO), and in education, represented by the partnership between the U.S. Department of Education (DoED) and six regional accrediting bodies for higher education (referred to here as the "regional bodies"). CLPHA already has described these models thoroughly in its paper "Accreditation in Public Housing: A Call for a Study"; this section summarizes their key aspects. The Health Care Model: HCFA reimburses hospitals and other health care facilities for services provided under the Medicare and Medicaid programs. HCFA requires each participating facility to meet certain standards as a condition of participating in the programs. Since the creation of the Medicare program in 1965, HCFA has relied on JCAHO accreditation as a substitute for its own survey. JCAHO was created in 1951 to improve the quality of care provided to the public through the provision of health care accreditation. JCAHO accredits hospitals and other health care institutions that meet certain professionally-established standards of patient care. When the Medicare program was created, HCFA incorporated JCAHO's accreditation process and standards into its survey requirement and deemed JCAHO accreditation to qualify a facility as eligible to receive Medicare and Medicaid reimbursement. JCAHO accredits 90-95 percent of the hospitals receiving federal payments through Medicare and Medicaid. HCFA evaluates the remaining hospitals itself but also validates JCAHO's work, and the equivalence of JCAHO's standards with its own, through an independent survey of JCAHO-accredited hospitals. Thus, the relationship between HCFA and JCAHO is one in which HCFA sets minimum standards for program participation and then evaluates JCAHO against its compliance to these standards. The Educational Model: There are six regional accrediting organizations for institutions of higher education as well as a number of accrediting organizations for specialized education. These six regional bodies have accredited institutions of higher learning based on the quality of their educational services through much of the 20th century. With the passage of the Higher Education Act in 1965, DoED enlisted them-much as HCFA enlisted JCAHO-to deem colleges and universities eligible to participate in the Title IV 1 October 1997 (rev. 3/98)

There are important differences between the Health Care model and the Educational model. First, educational institutions themselves are accountable to a "triad" of bodies: DoED for fiscal responsibility relative to participation in the Title IV program and to a regional body for quality assurance (also required for participation in the Title IV program), as well as to state review boards for licensure. In other words, an institution's eligibility for Title IV participation is subject to review by DoED both directly and through the regional body's accreditation. Second, the regional bodies must receive recognition not only from DoED but also from their own industry as represented by the Council on Higher Education Accreditation (CHEA). CHEA is a non-profit organization of colleges and universities that provides accountability in the academic accreditation industry. Whereas DoED's review serves to recognize those accrediting organizations which meet the government's threshold standards of quality for participating in federal programs, CHEA serves as an external judge of the quality of the regional bodies' accreditation practices and an advocate for best practices in accreditation. See Exhibit IV-1 for an illustration of this difference. Exhibit IV-1: Health Care and Educational Models

Key Elements of Models

Given the variety of goals that have been forwarded for the PHAB, it is instructive to see whether these other federal-industry accrediting partnerships foster the use of outcome-based standards and reduced direct federal oversight of the accredited facilities. In summary, it appears that neither HCFA nor DoED focus directly on outcomes, but they allow the

October 1997 (rev. 3/98) 2

* For a PHA and PHMAP, an analogy might be a focus on addressing uncollected rents in a timely and appropriate manner rather than a measurement strictly of the percentage of rents uncollected. + North Central Association of Colleges and Schools Commission on Institutions of Higher Education. "Accreditation of Higher Education Institutions: An Overview" (undated brochure). October 1997 (rev. 3/98)

Summary and Application to PHAB

The relationship between JCAHO and HCFA is closer and more collaborative than that between the regional bodies and DoED in all respects: verification of accreditation results, on-going exchange of information, or participation on committees. This difference appears to be a result of the tighter regulation over health care, as well as the specialization inherent in health care that requires private-sector expertise for successful oversight. It may be that

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JCAHO's expertise enables it to change the government's thinking about appropriate performance measures. In contrast, DoED's focus on controls over Title IV funding appears to provide fewer incentives for a collaborative relationship on standard-setting.

It already is clear that a PHAB could provide a valuable service for public housing authorities apart from playing any regulatory role. The PHAB standards could be fully oriented toward outcomes and could be developed with local, state or federal input. Insofar as the industry is willing to operate under both a PHAB accreditation system and a HUD regulatory system, there is no apparent political obstacle to creating the system, and much to be gained in terms of offering management improvement opportunities.

The Health Care and Educational models suggest that, under certain circumstances, private accrediting organizations can collaborate with federal regulatory agencies and reduce the need for direct federal oversight, provided that the accrediting organizations uphold high standards for industry performance. Accrediting organizations and government agencies can share oversight duties, working in partnership to address different aspects of an institution's operation (as the regional accrediting bodies and DoED do, with DoED responsible for an institution's Title IV fiscal compliance and the regional body responsible for quality assurance). However, HUD's own efforts in revising its role in public housing regulation suggest that, at best, PHAB would operate in parallel with HUD rather than as an agent for HUD in any oversight area, based on three current factors:

1. Unlike the PHAB, both JCAHO and the educational accreditation organizations existed prior to the programs they oversee on behalf of the federal government. The government used these existing bodies as alternative to regulation. Since HUD currently regulates public housing authorities, it may recognize few incentives to cede any of its responsibilities.
2. HUD already has proposed the development of a Secretary-appointed Public Housing Performance Evaluation Board in its Public Housing Management Reform Act of
1997.  
3. HUD is in the process of creating new housing review centers under its Management Reform Plan. These include a Real Estate Assessment Center to evaluate fiscal and property management of public and assisted housing; an Enforcement Center to take action where assessments identify problems; and two Troubled Agency Recovery Centers to help severely distressed public housing improve their performance. HUD also is developing a new set of performance measures for public housing authorities with limited industry input. In short, HUD is strongly vested in overseeing and assisting public housing authorities. HUD's reorganization consequently has not presented the public housing industry with the opportunity for self-regulation that the creation of the Medicare and Title IV programs created for the health care and educational industries in 1965.

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This chapter summarizes the findings of this study and offers next steps for action.

Feasibility

We have estimated that the PHAB's sponsors will need a budget of at least $180,000 in the first year to create the organization (not including legal, travel, or additional staff or sponsor staff time) and then approximately $675,000 per year to accredit all of the nation's 160 large public housing authorities over a five-year period. Provided that the PHAs are willing to support the ongoing costs through fee contributions of at least $4,200 per year (depending on the number of participating PHAs, as shown on page 3-11), and that the sponsors can obtain the start-up funds needed, a Public Housing Accrediting Board is affordable. The PHAB sponsors also should be able to find appropriate personnel to direct and staff the organization. The greater question is whether it can assemble a large enough team of qualified surveyors to conduct the necessary site visits that play an critical part in the accreditation process. In our interviews with two CLPHA board members and receivers of large public housing authorities, we received contradictory answers: one PHA director was very willing to make 2-3 trips each year to help other housing authorities, while the other expressed concerns that neither he nor his staff would be able to devote the time to conducting site visits. An answer to the question of whether the PHAB will achieve all of its sponsors' goals is less clear. An accrediting organization can provide the support for operational and managerial improvement that the sponsors seek. HUD's current political actions suggest that the Department is not interested in transferring any of its regulatory powers to an independent accreditation organization, however, so PHAB accreditation might coexist with some form of PHMAP exercise.

Options

CLPHA has a number of options available to it for meeting the goals of an accreditation process. If it seeks to pursue the accreditation route, it may develop an independent accrediting organization. Alternately, it may sponsor an existing accrediting organization to accredit public housing authorities; or the PHAB may be created as an independent organization but contract the work out to an existing accrediting organization. Both of these latter options could strengthen the appearance of third-party objectivity. These options are illustrated in Exhibit V-1 on the following page. The HCFA representative identified a number of legislative and regulatory issues for CLPHA to consider if it decides to pursue establishing an accrediting organization that apply under any of these scenarios. If the role of an accrediting organization needs to be written into statute or regulation, CLPHA should consider: October 1997 (rev. 3/98)

Next Steps

The above discussion suggests that CLPHA should take the following steps before proceeding further with its investigation of accreditation.

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• Decide whether a public housing authority accreditation program should serve in support of HUD oversight, or whether it is primarily an internal management tool
• Determine whether an accreditation program could be operated by an existing organization or whether a new organization should be created
• Determine the scope of interest among its entire membership under the various scenarios and options presented in this study, given the effort and cost that could go into the entire process
• Determine whether it can create a large-enough pool of peer surveyors to visit PHAs each year without creating an undue burden on existing staff
• Identify potential funding sources for the PHAB if members are sufficiently interested. It is clear that many service providers have found accreditation to be a valuable and cost- justifiable tool for monitoring the quality of their industry overall. It also is clear that, under certain conditions and within certain windows of opportunity, the federal government is willing to look to accreditation to substitute for some aspects of regulatory oversight. The creation of a PHAB is not a quick process, however, and it will require concerted support.

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American Correctional Association

ACA's standards cover five areas:

1. Administration and management
2. Inmate programs
3. Institutional operations
4. Institutional services
5. Physical plant

Commission on Accreditation of Law Enforcement Agencies

From CALEA's Internet web site http://www.calea.org/apstand.htm: "In the Commission's view, the standards reflect the best professional requirements and practices for a law enforcement agency. The requirements in each standard provide a description of 'WHAT' must be accomplished by the applicant agency, but allows that agency wide latitude in determining 'HOW' it will achieve its compliance with each applicable standard. This approach allows independence and is the key to understanding the universal nature and flexibility of the standards approved by the Commission for this manual. Compliance should never be limited to a single means of achievement. Consequently, compliance is always attainable."

CALEA's accreditation standards address six areas of law enforcement agency operations:

1. Role, responsibilities, and relationships with other agencies a) Law enforcement role and authority b) Agency jurisdiction and mutual aid c) Contractual agreements for law enforcement services
2. Organization, management and administration a) Organization b) Direction c) General management d) Planning and research e) Crime analysis f) Allocation and distribution of personnel and personnel alternatives g) Fiscal management and agency-owned property
3. Personnel administration a) Classification and delineation of duties and responsibilities b) Compensation, benefits, and condition of work c) Collective bargaining

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Council on Accreditation of Services for Families and Children

CASFC evaluates facilities against both generic, cross-industry standards and service-specific standards. The generic standards include:

1. Organization purpose and relationship to the community a) Purpose of the organization

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3 October 1997 (rev. 3/98)

6. Financial and risk management a) Alignment of financing with mission b) Financial planning c) Cost accounting and financial information d) Risk management e) Fiscal management system f) Financial accountability g) Payroll h) Contractual relationships and provider alliances i) Contracting practices of organizations under public auspices
7. Professional practices a) Codes of conduct b) Confidentiality and privacy protections for persons served c) Sources of information d) Case records e) Access by persons served to case records f) Security of case records g) Research protections for persons served h) Grievance procedures for persons served Program-specific standards for Group Home/Transitional Residence Services and Residential Centers (as one example) include:
1. Access to services
2. Service elements: a) Group living environment b) Continuum of services c) Safety of persons served

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3. Human resources
4. Outcomes

Continuing Care Accreditation Commission

CCAC evaluation areas include two management areas and two programmatic areas.

1. Governance and Administration a) Mission and purpose b) Governing board c) Planning and evaluation d) Administration and personnel e) Marketing and promotional materials
2. Financial Resources and Disclosure a) Short-term financial resources b) Long-term financial resources c) Financial information, management and disclosure
3. Resident Life and Services a) Resident quality of life b) Resident services c) Physical environment d) Resident admissions and contract
4. Resident Health Care and Wellness program a) Health care philosophy b) Health care programs and services c) Health care continuum

Community Health Accreditation Program, Inc.

CHAP evaluates facilities along four lines:

5 October 1997 (rev. 3/98)

1. The organization's structure and function consistently support its consumer-oriented philosophy and purpose a) Purpose b) Organization c) Administration d) Support of purpose
2. The organization consistently provides high quality services and products. a) Accessibility b) Coordination c) Clinical policies and procedures d) Clinical records e) Quality improvement and client outcomes f) Infection control and safety
3. The organization has adequate human, financial, and physical resources effectively organized to accomplish its stated purpose. a) Human b) Financial c) Physical
4. The organization is positioned for long-term viability. a) Planning b) Evaluation c) Risk Management d) Marketing e) Accountability f) Expansion of knowledge g) Innovation

National Conference on Correctional Health Care

NCCHC's standards cover nine areas:

1. Facility governance and administration (interaction, meetings, quality improvement, emergency preparedness)
2. Managing a safe and healthy environment (sanitation, first aid)
3. Personnel and training (credentials, training, staff levels, orientation)
4. Health care service support (pharmacy, equipment)
5. Inmate care and treatment (health care screening, evaluating conditions)
6. Health promotion and disease prevention (hygiene, diet, exercise)

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7. Special inmate needs and services (treatment plans, pre-natal care)
8. Health records (confidentiality, record keeping, document storage)
9. Medical legal issues (informed consent, physical restraint, use of force)

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Criteria for Secretarial Recognition

Criteria similar to the following might be reasonably applied to the PHAB, and could serve as a model of HUD's regulation over the accreditation process. See 34 CFR 602 for complete requirements.

* * *

To be listed by the Secretary as a nationally recognized accrediting agency, an accrediting agency must demonstrate to the Secretary that:

1. It is separate and independent of any related, associated or affiliated trade associations or membership organizations, has at least one public member on the decision-making body for every six non-public members, has conflict of interest guidelines, receives dues separate from those paid to any related, associated or affiliated organization, and has a budget that is developed and determined without review or consultation with any other entity or organization. ('602.3)
2. It has the administrative and fiscal capability to carry out its accreditation activities in light of its requested scope of recognition, i.e. it has ('602.21): a) Adequate administrative staff to carry out its accrediting responsibilities effectively and manage its finances effectively b) Competent and knowledgeable individuals, qualified by experience and training, responsible for site evaluation, policy-making, and decision-making regarding accreditation and preaccreditation status c) Representation on its evaluation, policy, and decision-making bodies of both academic and administrative personnel d) Representation of the public on all decision-making bodies e) Clear and effective controls against conflicts of interest or the appearance of conflicts of interest by the agency's board members, commissioners, evaluation team members, consultants, administrative staff, and other agency representatives f) Adequate financial resources to carry out its accrediting responsibilities, taking into account the funds required to conduct the range of accrediting activities specified in the requested scope of recognition and the income necessary to meet the anticipated costs of its activities in the future g) Complete and accurate records of its last two full accreditation or preaccreditation reviews of each institution or program, all preaccreditation and accreditation decisions, including all adverse actions.

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3. It has adequate experience in accrediting institutions, programs, or both, i.e. it has ('602.22): a) Granted accreditation or preaccreditation status to institutions or programs in the geographical area for which it seeks recognition b) Conducted accreditation activities covering the range of the specific degrees, certificates, and programs for which it seeks recognition including granting status and providing technical assistance related to accreditation c) Established policies, evaluative criteria, and procedures, and made evaluative decisions, that are accepted throughout the United States by educators and educational institutions.
4. It consistently applies and enforces written standards that ensure that the education or training offered by an institution or program is of sufficient quality to achieve, for the duration of any accreditation period granted by the agency, the stated objective for which it is offered, i.e., ('602.23): a) The agency's written standards and procedures for accreditation and preaccreditation, if that latter status is offered, comply with the requirements of this part b) The agency's preaccreditation standards, if offered, are appropriately related to the agency's accreditation standards, with a limit on preaccreditation status of no more than five years for any institution or program c) The agency's organizations, functions, and procedures include effective controls against the inconsistent application of its criteria and standards d) The agency bases its decisions regarding accreditation or preaccreditation on its published criteria e) The agency maintains a systematic program of review designed to ensure that its criteria and standards are valid and reliable indicators of the quality of the education or training provided by the institutions or programs it accredits and are relevant to the education or training needs of affected students f) The agency demonstrates to the Secretary that, as a result of its program of review ... each of its standards provides a valid measure of the aspects of educational quality it is intended to measure; and a consistent basis for determining the educational quality of different institutions and programs.
5. It has effective mechanisms for evaluating compliance with its standards and that those mechanisms cover the full range of an institution's or program's offerings, including those offerings conducted at branch campuses and additional locations, i.e., ('602.24): a) In determining whether to grant initial or renewed accreditation, the accrediting agency evaluates whether an institution or program: i) maintains clearly specified educational objectives consistent with its mission and appropriate ...

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b) In reaching its determination to grant initial or renewed accreditation, the accrediting agency: i) requires an in-depth self-study by each institution or program, in accordance with guidance provided by the agency, that includes the assessment of educational quality and the institution's or program's continuing efforts to improve educational quality ii) Conducts at least one site review of the institution or program at which the agency obtains sufficient information to enable it to determine if the institution or program complies with the agency's criteria iii) Conducts its own analyses and evaluations of the self-study and supporting documentation furnished by the institution or program, and any other appropriate information from other sources, to determine whether the institution or program complies with the agency's standards iv) Provides to the institution or program a detailed written report on its review assessing the institution's or program's compliance with the agency's standards, including areas needing improvement ... c) The accrediting agency monitors institutions or programs throughout the accreditation or preaccreditation period to ensure continuing compliance with the agency's standards or criteria; and conducts special evaluations, site visits, or both, as necessary d) The accrediting agency regularly reevaluates institutions or programs that have been granted accreditation or preaccreditation.

6. It maintains adequate substantive change policies that ensure that any substantive change to the educational mission or program(s) of an institution after the agency has granted accreditation or preaccreditation to the institution does not adversely affect the capacity of the institution to continue to meet the agency's standards ('602.25).
7. Its accreditation or preaccreditation standards, or both, are sufficiently rigorous to ensure that the agency is a reliable authority as to the quality of the education or training provided by the institutions or programs it accredits, i.e., it has standards addressing the quality of the institution in the following areas ('602.26): a) Curricula b) Faculty c) Facilities, equipment, and supplies d) Fiscal and administrative capacity as appropriate to the specified scale of operations

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An accrediting agency shall take appropriate action if its review of an institution or program under any standard indicates that the institution or program is not in compliance with that standard. If the agency believes that the institution or program is not in compliance with the standards, the agency shall take prompt adverse action against the institution or program; or require the institution or program to take appropriate action to bring itself into compliance with the agency's standards within a time frame specified by the agency. If the institution or program does not bring itself into compliance [within the specified period], the agency must take adverse action unless the agency extends the period for achieving compliance for good cause. An accrediting agency that has established and applies the standards of this section may establish any additional accreditation standards as it deems appropriate. The agency ('602.28) a) Maintains and makes publicly available written materials describing: i) Each type of accreditation and preaccreditation granted by the agency ii) Its procedures for applying for accreditation or preaccreditation iii) The criteria and procedures used by the agency for determining whether to grant, reaffirm, reinstate, deny, restrict, revoke, or take any other action related to each type of accreditation and preaccreditation that the agency grants iv) The names, academic and professional qualifications, and relevant employment and organizational affiliations of the members of the agency's policy and decision- making bodies as well as the agency's principal administrative staff v) The institutions or programs that the agency currently accredits or preaccredits and the date when the agency will review or reconsider the accreditation or preaccreditation of each institution or program. b) In accordance with agency policy, publishes the year when an institution or program subject to its jurisdiction is being considered for accreditation or preaccreditation and

October 1997 (rev. 3/98) B-4

c) Provides advance public notice of proposed new or revised criteria, giving interested parties adequate opportunity to comment on these proposals prior to their adoption d) Reviews any complaint it receives against an accredited institution or program, or the agency itself, that is related to the agency's standards, criteria, or procedures, and resolves the complaint in a timely, fair, and equitable manner.

9. The procedures the agency uses throughout the accrediting process satisfies due process requirements, i.e. ('602.28): a) The agency sets forth in writing its procedures governing its accreditation or preaccreditation processes b) The agency's procedures afford an institution or program a reasonable period of time to comply with agency requests for information and documents c) The agency notifies the institution or program in writing of any adverse accrediting action d) The agency's notice details the basis for any adverse accrediting action e) The agency permits the institution or program the opportunity to appeal an adverse accrediting action, and the right to representation by counsel during an appeal ... f) The agency notifies the appellant in writing of the result of the appeal and the basis for that result.
10. The agency has written policies, procedures, and practices that require it to notify the Secretary, the appropriate State postsecondary review entity, the appropriate accrediting agencies, and the public of the following types of decisions, no later than 30 days after a decision is made ('602.28): a) A decision by the agency to award initial accreditation or preaccreditation to an institution or program b) A final decision by the agency to take adverse action against an institution or program c) A decision by the agency to place an institution or program on probation d) A decision by an accredited institution or program to withdraw voluntarily from accreditation or formal preaccreditation status e) A decision by an accredited institution or program to let its accreditation or preaccreditation lapse.

5 October 1997 (rev. 3/98)

October 1997 (rev. 3/98) B-6