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CET Accreditation Levels & Survey Types

General Information

ACDS' CET Standards make two levels of achievement available for community disability service providers to support continuous improvement in the provision of services to individuals. These levels flow from a primary level of service outcomes and performance, Accreditation Level 1, to an advanced level of performance achievement, Accreditation Level 2.

Accreditation Level 1

CET Accreditation Level 1 achievement tells a service provider that it is providing a quality service. The focus is balanced at this level, with Quality of Life, Quality of Service, and Organizational Framework standards being weighted quite evenly.

To achieve Accreditation Level 1, it is expected that policy (where indicated), process, and consistent and informed practice will be in place within all levels of the organization. The Accreditation Level 1 Measurement System outlines the expectations for this primary level of standards accomplishment and determinates whether an organization achieves Accreditation Level 1. Within the standards document, the individual measurement points are referred to as Accreditation Level 1 indicators. The surveyors compare the information they obtain during the evaluation process to these indicators to determine whether an individual standard is present within the organization and the services it provides.

In Alberta, a number of funding bodies have the expectation that the organizations they support will meet this primary level of standards achievement. This level is a stepping stone on the path to continuous improvement in service provision and organizational excellence.

The Requirement for Accreditation Level 1

According to the Ministry of Community and Social Services - Disabilities, Inclusions and Accessibility Division (DIAD) (formerly Persons with Developmental Disabilities [PDD]), service providers need to be evaluated according to approved standards at least once every three years. In order to be eligible to receive Ministry funding, service providers that have a current Service Agreement with a regional Community Board must be in compliance with the standards, or be actively pursuing compliance.

Therefore, all service providers funded by DIAD must either:

  1. hold current CET accreditation status;
  2. be scheduled for a Accreditation Level 1 survey; or
  3. be actively implementing an Action Plan to address all CET Standards following the receipt of the Site Survey Report, or
  4. have successfully implemented an Action Plan to address all CET Standards following the survey

Accreditation Level 1 surveys are funded by the DIAD Program.

Intent of the Accreditation Level 1 Process

The CET Survey process is intended to examine service provision:

  1. From the perspective of the individuals: How the organization, through its services, supports and facilitates Quality of Life for the individuals.
  2. From the perspective of staff: How the organization, through its staff, supports and facilitates Quality of Life for the individuals.
  3. From an organizational perspective: How the organization's policy, procedure, and infrastructure support organizational effectiveness to support the individuals' Quality of Life.

Organizations that are able to demonstrate achievement of a specified number of indicators in each of the three key areas, including the three mandatory standards on positive and restrictive procedures, are granted Accreditation Level 1. All service providers involved in the CET process are expected to address, in an Action Plan, all indicators that are not met. This is regardless of whether Accreditation Level 1 is achieved or not. ACDS will provide follow up support to service providers that do not achieve Accreditation Level 1 to ensure that this level of accreditation is achieved.

Supplemental Surveys

Organizations that have received accreditation from another accrediting body may apply for exemption from its CET survey. Although full exemption may be granted if the other accrediting body's standards have been deemed equivalent to CET, many organizations may still be required to complete a supplemental review that includes the Quality of Life and Quality of Service standards, and a select few of the Organizational Framework standards. Supplemental surveys are funded by DIAD.

Accreditation Level 2

CET Accreditation Level 2 incorporates all of the Level 1 standards and indicators, but also gives more opportunities for organizations to move forward in their service performance. The Quality of Life, Quality of Service, and Organizational Framework standards continue to play an important role in the standards review; however, to achieve Accreditation Level 2, it is expected that all Accreditation Level 1 indicators will be met at the 90% level (as per the Accreditation Level 1 Measurement System) and that written policy and procedure, and consistent, well-informed and well-understood practice will be in place at all levels of the organization and among its stakeholders. Once there is verification that Accreditation Level 1 has been met, the report will be forwarded to ACDS' Commission on Accreditation for review.

The Accreditation Level 1 portion of the survey is funded by DIAD; organizations are billed for the Accreditation Level 2 part. Seeking to achieve Accreditation Level 2 in organizational and service excellence is a major undertaking and reflects an organization's drive to be the best that it can be.

Additional Indicators

Complex Support Needs Review

Achieving the Complex Support Needs Review (CSNR) shows that service provider staff have the training, skills, knowledge, and attitude to offer specialized support to individuals with complex behavioural needs. A CSNR review can be done at the same time as either the Accreditation Level 1 or Level 2 survey.

Services for Children with Disabilities

The CET Accreditation Standards for Children with Disabilities incorporates feedback from the 2008 Children's Accreditation Standards as well as requirements for and current best practices around services to children and youth. The standards also address the needs of young individuals who are transitioning to adult services. Organizations going through CET Accreditation for their adult services can benefit from having their children's services reviewed and accredited at the same time.

Respite for Children and Adults with Disabilities

The purpose of the additional respite indicators is to provide guidelines and accreditation that

  • —is based on the specific aspects of respite services for both children and adults—
  • provides definitions for and acknowledges the typical needs of children and adults in in respite—
  • reflects the expectations for respite staff, who are often subcontractors

ACDS Head Office

160 3015-12 Street NE
Calgary, AB  T2E 7J2
Ph: (403) 250-9495
Fax: (403) 291-9864

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