Behavioral Health Standard 1.I – Workforce Development and Management


The organization documents the composition of its workforce, including all human resources involved in the delivery, oversight, and support of the programs/services seeking accreditation.

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Workforce development and management practices reflect the organizations:

  1. Mission.
  2. Culture.
  3. Person-centered philosophy.
  4. Performance measurement and management system.
  5. Risk management plan.
  6. Strategic planning.
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Ongoing workforce planning includes:

  1. Workforce analysis.
  2. Written job descriptions.
  3. Review and update of written job descriptions in accordance with organizational needs and / or the requirements of external entities.
  4. Recruitment.
  5. Selection.
  6. Retention.
  7. Succession planning.
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The organization implements written procedures that address:

  1. Verification of:
    1. Backgrounds of the workforce in the following areas, if required:
      1. Criminal checks.
      2. Immunizations.
      3. Fingerprinting.
      4. Drug testing.
      5. Vulnerable population.
      6. Driving records.
    2. The credentials of all applicable workforce (including licensure, certification, registration, and education):
      1. With primary sources.
      2. When applicable, in all states / provinces or other jurisdictions where the workforce will deliver services.
    3. Fitness for duty, if required.
  2. Actions can be taken in response to the information received concerning:
    1. Background checks.
    2. Credentials verification.
    3. Fitness for duty.
  3. Time frames for verification of backgrounds, credentials, and fitness for duty, including:
    1. Prior to the delivery of services to the persons served or to the organization.
    2. Throughout employment.
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Onboarding and engagement activities include:

  1. Orientation that addresses the organization’s:
    1. Mission.
    2. Culture.
    3. Person-centered philosophy.
    4. Performance measurement and management system.
    5. Risk management plan.
    6. Strategic plan.
    7. Workforce policies and procedures.
  2. On-the-Job training.
  3. Position roles and responsibility.
  4. Position performance expectations.
  5. Communication systems and expectations.
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The organization promotes engagement through respect for all individuals in the workforce, including:

  1. Open communication.
  2. A value driven focus.
  3. Initiatives that address:
    1. Recognition.
    2. Compensation.
    3. Benefits.
  4. Policies and written procedures that:
    1. Address at a minimum:
      1. Mechanisms to provide favorable and constructive feedback.
      2. Mechanisms to address concerns.
      3. Job postings.
      4. Promotion.
      5. Disciplinary action.
      6. Separation.
      7. Labor relations, if applicable.
      8. Prevention of harassment.
    2. Are accessible to the workforce.
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Workforce development activities include:

  1. Identification of competencies:
    1. To support the organization in the accomplishment of its mission and goals.
    2. To meet the needs of the persons served.
  2. Assessment of competencies.
  3. Identification of time frames / frequencies related to the competency assessment process.
  4. Competency development, including the provision of resources.
  5. Performance appraisal.
  6. Education and training.
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The organization implements written procedures for performance appraisal that address:

  1. The identified workforce.
  2. The criteria against which people are being appraised.
  3. Involvement of the person being appraised.
  4. Documentation requirements.
  5. Time frames / frequencies related to the performance appraisal process.
  6. Measurable goals.
  7. Sources of input.
  8. Opportunities for development.
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There is an adequate workforce to:

  1. Implement the plans of the persons served.
  2. Ensure the safety of the persons served.
  3. manage unplanned absences.
  4. Meet the performance expectations of the organization.
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As applicable, the organization demonstrates a process to address the provision of services by the workforce consistent with relevant:

  1. Regulatory requirements.
  2. Licensure requirements.
  3. Registration requirements.
  4. Certification requirements.
  5. Professional degrees.
  6. Training to maintain established competency levels.
  7. ON-the-Job training requirements.
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The organizations succession planning addresses, at a minimum:

  1. Its future workforce needs.
  2. Identification of key positions.
  3. Identification of the competencies required by key positions.
  4. Review of talent in the current workforce.
  5. Identification of workforce readiness.
  6. Gap analysis.
  7. Strategic development.
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