The Ontario Federation of Community Mental Health and Addiction Programs (Federation) and the Canadian Mental Health Association, Ontario Division (CMHA Ontario) have partnered to develop a toolkit to assist community mental health and addiction organizations pursue accreditation.
The resources found in the toolkit were developed from several sources:
- consultation with the Accreditation Capacity Building Advisory Committee
- tools and resources generously provided by Accreditation Canada, CARF Canada and Canadian Centre for Accreditation (formerly Community Organizational Health Inc. – COHI)
- tools and resources graciously provided by the following organizations:
- Brain Injury Services of Northern Ontario
- Brain Injury Services of Hamilton
- CMHA Durham Branch
- CMHA Kenora Branch
- Riverside Community Counselling Services
- York Support Services Network
How to use the resources in this toolkit
The goal of Canadian Mental Health Association (CMHA) Ontario and the Ontario Federation of Community Mental Health and Addiction Programs (OFCMHAP) is to provide resources, samples and tools to mental health and addiction service providers to increase the capacity of the community sector to achieve accreditation. Your organization may chose the extent to which it will use the information contained in this tool kit but are cautioned against copying and pasting sample content for use in their organization’s policies and procedures. An organization’s policies and procedures should be developed to match the organization’s mission, services, clients, structures and processes. The samples provided should be used as a starting point in the policy and procedure development process. Resources were developed to close documentation gaps identified in Accreditation Self Assessment Survey. In order to enable easy access to specific accreditation elements the content of the tool kit has been organized into the following eight sections:
1. Accreditation Organizations
This section contrasts the accreditation programs of Accreditation Canada, CARF Canada and the Canadian Centre for Accreditation (formerly Community Organizational Health Inc. – COHI).
2. Governance
These documents define the framework that the board of directors uses to define the organization’s purpose, set direction and develop plans, determine roles and responsibilities, guide decisions and to oversee and monitor the organizations operations.
3. Leadership and Planning
These documents capture the purpose and direction of the organization and ensure that direction is followed by management and staff.
4. Financial
These documents define the internal framework of control activities designed to help the organization achieve its goals while protecting the organization’s financial resources.
5. Risk Management
These documents address client and staff safety.
6. Managing Information
These documents guide the privacy and confidentiality of client records and who has access to view the information.
7. Human Resources
These documents address human resource practices, professional development and training.
8. Programs and Services
These documents support how the organization delivers programs and services.
Document Links
Accreditation Organizations
- Tool: Accreditation Programs Accreditation Canada, CARF Canada and Canadian Centre for Accreditation
- Tool: Accreditation Canada Manual for Leading Accreditation Process
- Tool: Accreditation Canada Qmentum Plans and Frameworks Guide
- Tool: Accreditation Canada Required Organizational Practices
- Tool: Accreditation Canada Accreditation Primer
Governance
- Standards: Accreditation Canada Governance Standards
- By-Laws: Sample By Laws CMHA Durham
- Tool: Board Evaluation Questionnaire
- Tool: Accreditation Canada Governance Functioning Tool
- Tool: Strategic Plan Sample
- Tool: CCA Roadmap Strategic Planning
- Policy: Board Member Recruitment
- Policy: Communication and Support to the Board
- Policy: Accountability of ED
- Policy: Delegation and Accountability of ED
Leadership and Planning
- Tool: CCA Roadmap Work-Planning
- Tool: Sample Operations Implementation Plan
- Standards: Accreditation Canada Leadership Standards
- Policy: Sample Environmental Policy
- Policy: Sample Quality Improvement Policy
- Tool: Sample Quality Plan
- Policy: Sample Annual Review of Policies and Procedures
Financial
- Policies and Procedures: CCA Sample Financial Carlington
- Policy: Sample Financial Activities Policy
- Policy: CCA Sample Financial Duties Carlington
- Policy: Sample Procurement Policy YSSN
- Policy: Sample Budget Reporting Policy YSSN
- Policy: Sample Asset Protection Policy
Risk Management
- Policy: CCA Sample Communicable Disease AAMCHC
- Policy: Sample Infection and Prevention Control Policy
- Policy: Sample Infectious and Reportable Diseases Policy
- Policy: CCA Sample Staff Safety Carlington
- Tool: Sample Home Safety Assessment for Client and Staff
- Policy: Sample Workplace Violence Prevention Policy
- Policy: Sample Consumer Self-Harm & Staff Safety Policy
- Policy: Sample On Call Support for Emergency Situations Policy
- Policy: Sample Client Consent and Capacity Policy
- Policy: Sample Client Behaviour Support Plans Policy
- Policy: CCA Sample Child Abuse Sandy Hill
- Policy: Sample Mandatory Reporting Policy
- Policy: Sample Administration of Medication Policy
- Policy: Sample Administration of Medications in Residential Services
- Policy: Sample Client Use of Alcohol and Illegal Drugs Policy
- Policy: Sample Client Transportation Owned and Leased Vehicles Policy
- Policy: Sample Driver Qualifications and Training for Agency Vehicles Policy
Managing Information
- Policy: CCA Sample Privacy Policy
- Policy: Sample Managing Client Records Policy
- Policy: Sample Client Records Security Policy
- Policy: Sample Password Protection Policy
- Policy: Sample Breach of Confidentiality Policy
Human Resources
- Tool: CCA Sample Staff Survey
- Tool: Sample Staff Survey
- Tool: Staff Request for Professional Development
- Tool: CCA Roadmap Teamwork Collaboration
- Policy: Sample Continuing Education Policy
- Policy: Sample Employee Training Policy
- Policy: Sample Trainers and Instructors Policy
- Policy: Sample Employee Performance Review Policy
- Policy: CCA Sample Conflict Resolution
- Policy: Sample Conflict Resolution YSSN
- Policy: Sample Employee Complaints Policy
Programs and Services
- Standards: Accreditation Canada Community Based Mental Health Standards
- Policy: CCA Sample Participating in Research
- Tool: CCA Roadmap Assessing Community Needs
- Tool: CCA Sample Client Record Audit
- Policy: CCA Sample Planning and Evaluation Woolwich
- Tool: Sample Client Admission Information Manual
- Tool: Sample Client Admission Contract
- Tool: Sample Client Rights and Responsibilities Brochure
- Tool: Sample Consent to Collect and Use Assessment Information Agreement
- Tool: Sample Participation Agreement for Group Services
- Policy: Sample Client Transfer Between Services Policy