257 Copyright © www.iejee.com ISSN: 1307-9298 © 2022 Published by KURA Education & Publishing. This is an open access article under the CC BY- NC- ND license. (https://creativecommons.org/ licenses/by/4.0/) International Electronic Journal of Elementary Education January 2023, Volume 15, Issue 3, 257-265 Is Accreditation, Like a Colonoscopy, Good for You? Ellie Kazemi* Abstract Introduction Accreditation is typically a voluntary process that involves a thorough evaluation of an organization’s policies, procedures, and practices. Much like a colonoscopy, the evaluation process probes deep and can be uncomfortable. With the discomfort, time, cost, and effort it takes to undergo evaluation for accreditation, the natural question is whether it is worth doing. In this paper, I will review the history of accreditation and the results of systematic literature reviews focused on the impact of accreditation. I will also discuss how accreditation may help provide quality control in behavior analysis and safeguard against service providers’ behaviors being solely shaped by funding sources, such as insurance providers. Lastly, I will provide critical questions consumers can ask to assess accrediting bodies’ transparency, objectivity, and fairness when they are seeking accreditation. Accreditation is usually a voluntary process that involves a thorough evaluation of an organization’s policies, procedures, and practices against a set of pre-established standards. Once standards are established, typically, trained, and objective external peer reviewers evaluate an organization’s compliance by comparing what they review to the pre-established standards. The process is methodical and reiterative such that as a profession matures, the standards and evaluation process are revised to keep up with the changes in the profession. Accreditation programs can be developed nationally, by the government, by independent agencies authorized to do so by governments, or by independent (for profit, nonprofit, or not-for-profit) national or international agencies contracted by health care organizations (World Health Organization [WHO], 2022). Accreditation differs from certification and/or licensure even though the aim of all these professional and regulatory organizations is consumer protection (Litvak & Sush, 2023). Certification and licensure hold individual practitioners accountable to a code of ethical conduct. They also set minimum criteria for competency to practice, usually through an examination for entry into the profession and Keywords: Accreditation, Healthcare Quality, Behavior Analysis Accreditation, Applied Behavior Analysis Quality, ABA Quality, Behavior Analysis Standards, ABA Standards Received : 22 February 2023 Revised : 10 March 2023 Accepted : 23 March 2023 DOI : 10.26822/iejee.2023.298 * Correspondance Details: Ellie Kazemi, Behavioral Health Center of Excellence, California State University, Northridge, USA. E-mail: ellie@bhcoe.org ORCID: https://orcid.org/0000-0001-8316-4112 258 January 2023, Volume 15, Issue 3, 257-265 supervised experience hours. Once certified and/or licensed, the individual practitioner must update their status by providing evidence of continued education in the required subject areas and continued adherence to legal and ethical guidelines. However, licensure and certification do not manage the behaviors of organizations. From a behavioral system perspective, the direct environmental contingencies surrounding the behavior of organizations have the most influence on organizational behaviors. With behavior analysis services, the most immediate contingencies contacted by service providers are what the insurance companies approve or deny and the corresponding insurance requirements (e.g., assessments, reporting). Additionally, many funders have compliance requirements specific to aspects of clinical practice. It then makes sense that clinical practice may be shaped by funder contingencies, which may or may not be aligned with best practice. Service providers may focus on aspects of their service delivery that influence the livelihood of their organization, such as the likelihood of future patient referrals, compliance with insurance requirements to avoid audits, and compliance with authorizations to ensure payment for services. Unfortunately, the requirements set forth by insurance providers are not necessarily in line with best practice recommendations and quality behavior analytic services. Therefore, it makes sense to have a specific set of standards and a process in place for shaping organizational behavior to adhere to best practice recommendations. Accreditation arranges contingencies for service providers to demonstrate that they adhere to standards of excellence and best practices in behavior analysis. For example, service providers are not specifically paid by insurance and funding entities to provide ongoing training to their clinical staff. What is worse is that investment in training staff may inadvertently be punished by the high staff turnover. However, the efforts and investment of organizations that continue to provide sufficient training to their staff are acknowledged through the accreditation process. For another example, see the section on ethics, integrity, and professionalism in the Standards of Excellence (Behavioral Health Center of Excellence [BHCOE], 2022). The concept of accreditation in the United States is more than a hundred years old and emerged from concerns to protect public health and safety. Accreditation is carried out by private, not-for-profit, or nonprofit organizations designed for this specific purpose. In 1917, the "Minimum Standard for Hospitals" was developed by the American College of Surgeons (ACS). It was a set of guidelines establishing minimum standards for hospitals in the United States. To develop the guidelines, a committee of 21 surgeons, hospital administrators, laboratory workers, statisticians, and leading hospital superintendents met for two days in Chicago to formulate a set of questions that would enable them to obtain hospital data to consider a “minimum standard.” These standards were designed to ensure that hospitals were equipped and staffed to provide safe and effective care to patients. The "Minimum Standard for Hospitals" included guidelines for hospital size, equipment, and staffing levels, as well as recommendations for the types of services that hospitals should provide. The standards also established requirements for the training and education of hospital staff, including doctors, nurses, and other healthcare professionals (for more information regarding ACS’s efforts, the minimum standards, and historical images of the notes, see Wright, 2017). The "Minimum Standard for Hospitals" was a groundbreaking effort to improve healthcare quality in the United States, laying the foundation for developing more comprehensive accreditation standards. The ACS was pleased to find an immediate interest in compliance with the standards, even though compliance was entirely voluntary and sending out college staff to conduct evaluations and provide consultations was labor-intensive and costly. The immediate adoption of accreditation was likely because hospitals had an opportunity to help formulate the standards, and their competitors were doing it (Wright, 2017). Today, hospitals in the United States must meet a wide range of standards to be accredited, including standards related to patient safety, quality of care, and healthcare outcomes. The ACS hospital standardization project was an essential framework for hospitals for three decades before evolving into The Joint Commission on Accreditation of Hospitals in 1951, which was renamed The Joint Commission on Accreditation of Healthcare Organizations in 1987, and The Joint Commission in 2007. In the decades since its establishment, the Joint Commission has become one of the country's most widely recognized accrediting bodies for healthcare organizations. Other accrediting organizations have also been established over the years, including the Commission on Accreditation of Rehabilitation Facilities (CARF), Utilization Review Accreditation Commission (URAC), the National Committee for Quality Assurance (NCQA), and Council on Accreditation (COA). In healthcare, the movement toward standardization and accreditation was to question the status quo and to improve patient care (Lenaway et al., 2007). Today, accreditation for healthcare services is most often required by payers, such as insurance providers, as a condition for reimbursement. In cases when it is not required, some healthcare organizations seek accreditation to renegotiate or obtain higher reimbursement rates from funding entities. Also, some organizations choose to seek accreditation voluntarily to demonstrate their commitment to quality and to improve their own performance. In 259 Is Accreditation, Like a Colonoscopy, Good for You? / Kazemi line with this movement in healthcare, educational institutions, licensure boards, and certification bodies have all moved toward requiring accreditation as a means of quality control (Eaton, 2015; Ibrahim, 2014). The accreditation process, however, is costly, and it involves much time and effort from the accrediting body, the evaluators, and the organizations seeking accreditation. It is no wonder that accreditation evaluation can be compared to a colonoscopy because an organization must allow an objective third party to look at all its intimate parts, including its procedures, policies, and practices. The question is, does this cumbersome and costly process increase the quality of care? First, what is Healthcare Quality? Healthcare quality is a broad concept that has been defined by the National Academy of Medicine as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Centers for Medicare & Medicaid Services [CMS], 2021, What is quality improvement? section). Like the seven dimensions that define applied behavior analysis proposed by Baer et al. (1968, 1987), a physician by the name of Donabedian (1990) proposed the seven attributes of health care that define healthcare quality. These dimensions were later adapted by the Institute of Medicine (2001) and included safety, patient-centeredness, timeliness, equity, access, efficiency, and effectiveness. Accurate assessment of healthcare quality is challenging, but the CMS has proposed various frameworks for improving outcomes and conducting quality measurements (see CMS, 2022;). In the meantime, as efforts to improve measurement continues, hospital accreditation which incorporates adherence to the seven dimensions has become adopted worldwide to assess and improve healthcare service quality (Lam et al., 2018). What Has Been the Impact of Accreditation on Healthcare Quality? Accreditation methodologies vary across accrediting bodies and typically rely on the organization seeking accreditation to provide documentation of procedures and policies. Therefore, the research evidence in the published literature evaluating the effectiveness of accreditation for patient outcomes is mixed, and the results should be interpreted with some caution (Araujo et al., 2020). Additionally, accreditation takes a bird’s view of an organization; thus, it does not guarantee that best practices will be followed daily (Hinchcliff et al., 2012). One long-standing challenge to producing robust research evidence on the impact of accreditation has been the absence of patient-level data on both accreditation status and patient outcomes (Bracewell & Winchester, 2021). A more appropriate mechanism for evaluating patient outcomes seems to be value-based care (VBC) and payment models whereby service providers are incentivized to submit patient-level data for quality measurement and patient-level analyses (see Litvak, 2023). Despite the challenges in evaluating the impact of accreditation, the results of systematic literature reviews suggest that healthcare accreditation may have a positive impact on several important aspects of healthcare (see Araujo et al., 2020). In their literature review, Araujo et al. (2020) initially reviewed 943 citations from eight different databases. Araujo et al. only included 36 studies in their final review that used quantitative methods to compare accredited vs. nonaccredited hospitals on the seven healthcare quality dimensions. They found that accreditation had a positive impact on five of the seven dimensions, including efficiency, safety, effectiveness, timeliness, and patient-centeredness. Some earlier systematic literature reviews have also found that accreditation programs improve the process of care and clinical outcomes of a wide spectrum of clinical conditions (Alkhenizan & Shaw, 2011). In the field of education, the literature also suggests that accreditation of educational institutions may have a positive impact on educational services by cultivating accountability, encouraging continuous self-reflection and improvement, and increasing access to educational opportunities (e.g., Ülker, 2020). In a recent survey conducted by NORC at the University of Chicago for The Public Health Accreditation Board (PHAB), 98% of applicant health departments expected the accreditation process to increase quality improvement processes and 76% reported continued engagement in quality improvement activities four years after accreditation (Gonick et al., 2020). The World Health Organization (WHO) suggests that healthcare accreditation should be recognized as an ongoing process of quality improvement vs. simply a status (e.g., whether an organization is accredited) and thus supportive of the perpetual process to improve the quality of care provided. Furthermore, it is recommended that accreditation standards and subsequent reaccreditation processes systematically measure improvement over time (WHO, 2022). In general, the results of literature reviews and recommendations of organizations such as the WHO suggest that accreditation impacts health quality in a positive way. However, it is unclear how accreditation directly impacts the quality of care and achieves improved outcomes for patients and organizations. Some of this may be easy to infer. For example, in their review, Cabana et al. (1999) found that there were about 300 potential barriers physicians reported when asked about adherence to clinical practice guidelines. 260 January 2023, Volume 15, Issue 3, 257-265 Bracewell and Winchester (2021) suggested that one of the ways accreditation may improve outcomes is by reducing some of these types of barriers. That is, physicians’ lack of awareness of newer practice guidelines because of a fast pace evolving literature may be overcome through discussions about accreditation standards and requirements to pass. Additionally, the accreditation evaluation process itself may set the occasion for open discussions and change the focus to improvement (Hovlid et al., 2020). Outside of patient data, however, there is evidence that accreditation is valuable and pays off both financially and non-financially in terms of higher quality care, improved client outcomes, and increased compliance. In 2021, the Joint Commission contracted with the ROI Institute (see https:// roiinstitute.net/) to conduct an evaluation of a sample of behavioral health organizations to report on the ROI of accreditation. The key findings, based on 180 behavioral health organizations, were that the ROI was 623%, which is a benefit-cost ratio of 7.23. In other words, for every dollar spent, the dollar is returned plus an additional $6.23. The main areas of impact included improved competencies of staff and supervisors, reduced staff turnover, improved reimbursements, increased revenue, risk reduction, and improvements in operational efficiencies (ROI Institute, 2022). What are some Pros and Cons of Accreditation? Accreditation can be valuable in several ways. It is a process through which an organization is evaluated against a set of standards to ensure that it meets certain criteria and is adhering to best practice standards. This process is designed to help ensure that the organization is operating at a certain level of quality and demonstrates that the organization is open to being reviewed and receiving and acting upon external feedback from a third party. One of the possible benefits of accreditation is that it provides assurance to patients, parents, and other stakeholders that the accredited organization meets certain standards of quality. Second, accreditation can help an organization to improve continuously by providing a framework for self-assessment and the identification of areas for improvement. Third, accreditation can help reduce the risk of errors and improve patient safety by ensuring that organizations have processes in place to identify and mitigate potential risks. Fourth, accreditation often sets the occasion for conversations that lead to the standardization of processes, procedures, terms, and titles, which reduces redundancies and ambiguity and increases efficiency and transparency in a profession. Fifth, accreditation can promote professionalism within an organization by encouraging staff to adhere to best practices and guidelines, just as the organization sets an example by adhering to them for accreditation. Lastly, it can increase the credibility and reputation of an organization by demonstrating that it has met certain standards of quality. If the organization is an internship site or offers supervised experiences for students, accreditation can provide greater recognition that the organization meets certain standards for training and supervision, which can improve the quality of the fieldwork supervised experience for individuals accruing hours to sit for certification and/or licensure. This can be especially important for students who are seeking to gain valuable clinical experience and build their professional careers. Accreditation can also have some possible downsides. First, one of the disadvantages of accreditation is that it can be a costly process. A thorough evaluation of an organization’s policies, procedures, and practices takes time and resources from the accrediting body. Therefore, accreditation involves application fees for the organization seeking an accreditation evaluation. Additionally, the organization must invest time and resources to prepare for the accreditation process and respond to the evaluation feedback. Second, the accreditation process, like a colonoscopy, is thorough and may be uncomfortable as a third-party observes some of the most intimate parts of an organization, including internal documents, correspondences, grievance procedures, training logs, supervision materials, leadership guidelines, and more. Third, accreditation does not guarantee quality because it is a snapshot in a moment in time and may miss day-in and day-out activities for specific clients or staff. Fourth, accreditation is not always recognized by all organizations or may not be required yet, which minimizes the potential of accreditation to help establish credibility. Lastly, there is a price to standardization, especially if the standards and the accreditation evaluation process do not leave room for flexibility and clinical judgment. There is a fine balance to strike with standardization to ensure appropriate customization and person-centered, individualized care. If that balance is off, accreditation may place barriers for small and innovative organizations and tip the balance toward a one-size-fits-all approach in patient care. Just as with anything else in life, including consenting to a colonoscopy, there are always pros and cons. It is crucial that service providers and stakeholders interested in accreditation are aware of the pros and cons to help shape the accrediting bodies’ standards and evaluation process to minimize the cons and strengthen the pros. Is Accreditation Right for Applied Behavior Analysis? As previously discussed, accreditation is a process by which organizations demonstrate that they meet certain standards of quality and safety. Therefore, 261 Is Accreditation, Like a Colonoscopy, Good for You? / Kazemi it makes sense for each healthcare profession to have specialized accreditation to ensure that the organizations seeking accreditation adhere to quality care as per the specific industry regulations and the profession’s best practices. For example, for colonoscopy, the primary accreditation bodies are the America College of Gastroenterology (ACG) and the American Society for Gastrointestinal Endoscopy (ASGE). Both accrediting bodies have the same goal of ensuring that providers meet specific standards for patient care and safety, as well as for the technical quality of the procedures. Although a general healthcare accreditation would ensure patient safety, it would not include specific best practice guidelines and the technical aspects of the field of Gastroenterology. Similarly, organizations providing behavioral healthcare can pursue general healthcare accreditation, which would help assess and improve the organization’s general patient safety and organizational policies. However, an accreditation specific to behavior analysis would also include profession-specific evaluations of best practices (e.g., use of non-harmful reinforcers, supervision caseload, care coordination, collaboration). One of the advantages of a profession-specific accreditation for behavior analysis is that it would set the occasion for discussions and agreements about profession-specific titles and terminology. Another benefit of profession- specific accreditation for behavior analysis is that stakeholders such as patients, parents/caregivers of patients, and patient advocates would be able to have a source to refer to when they are trying to identify quality service providers. Usually, accrediting bodies provide information to the public that also promotes awareness of quality service provision (e.g., https://www.bhcoe.org/parent-autism-quality- aba-providers/; BHCOE, n.d.). Lastly, stakeholders interested in evaluating best practices in behavior analytic care can review published standards, which have been developed specifically for behavior analytic services; for example, see BHCOE/ANSI 201: Standards of Excellence for Applied Behavior Analysis Services, which have been adopted by ANSI as an American National Standard (BHCOE, 2022). Also, see the Autism Commission on Quality Accreditation program Standards and Guide (version 1; https:// autismcommission.org/standards/) and Standards for Interprofessional Collaboration in Treatment of Individuals with Autism (Bowman, Suarez, & Weiss, 2021). What are Some Things to Look for in an Accreditor? Overall, it seems clear that accreditation in behavior analysis would provide oversight of behavior analytic services at the organizational level and improve patient care. However, it is important to note that not all accrediting bodies are equal. Below, I have outlined some important questions consumers should ask as they consider accreditation (for a brief summary of these questions, see https://www.bhcoe. org/2022/08/top-questions-for-aba-providers-to- ask-when-choosing-an-accreditation-program/, or https://accreditationguru.com/10-steps-to-selecting- an-accrediting-body-2/) (ANSI, 2022; BHCOE, 2022). Does the accrediting body hold accreditation or receive feedback from an independent body that reviews its performance? From a behavioral perspective, every organization that potentially has control over contingencies that shape service providers’ behaviors is at risk for abuse of power. It is important to have a checks and balances system in place to ensure that power is shared and there is oversight. For a balanced approach, it is important that the accrediting body is overseen by independent parties informed of the accreditation process and best practices in standard development and evaluations. For example, a hallmark of a credible accreditation program is that they hold accreditation by the American National Standards Institute (ANSI), which promotes transparency in how standards are developed and how public comments and feedback are incorporated (Litvak & Sush, 2023). ANSI is a private organization that administers and coordinates the U.S. system of voluntary professional standards and evaluation. Although ANSI itself is not a standard developing organization, it provides a framework for fair standard development and quality evaluation systems. ANSI safeguards the integrity of organizations that develop standards and is a neutral venue for coordinating standards and promoting collaborative efforts in standard development. In addition to including stakeholders whose lived experiences are invaluable insight for developing standards, the accrediting body must guide standard development by providing the commission with results of thorough literature reviews and best practice recommendations. Is the evaluation methodology valid? Large-scale evaluation of an organization’s procedures, processes, and practices is not an easy feat. Thankfully, there is a literature base to guide large-scale program evaluation to ensure reliability and validity regarding measurement and accreditation decisions. In fact, there are empirical journals solely dedicated to quality, comparability, and evaluation for accreditation, but many of these journals are profession specific. For example, The Journal of Accreditation and Quality Assurance provides information on all aspects of quality, transparency, and reliability of measurement results in chemical and biological sciences. The journal also includes fields such as nutrition, consumer protection, pharmacy, forensics, and laboratory medicine. Science and Engineering Ethics focuses on education, research, and practice in engineering. Quality Assurance in Education focuses on education 262 January 2023, Volume 15, Issue 3, 257-265 at all levels (e.g., primary, higher, professional). Joint Commission Journal on Quality and Patient Safety focuses on the quality and safety of healthcare. Taken together across the literature, commonalities exist in what is considered good measurement science and program evaluation. Some best practice recommendations include employing leadership services with experience in quality assurance and evaluation methodology. With the evaluation process itself, it is important to involve all stakeholders (e.g., patients, technicians, supervisors, and leadership) and to incorporate all voices using a multi-informant approach. Furthermore, a multi-dimensional approach to evaluation helps increase assessment validity (Cumming & Miller, 2019; Shryock & Reed, 2009). For example, an accreditation evaluation based on self-assessment and self-report is much more limited than an evaluation based on self-assessment, direct observations of therapy/treatment, open-ended interviews, and surveys. The multi-dimensional approach to assessment increases the acceptability of the accreditation decision, thereby increasing the validity of the results when there is reliability across dimensions and informants. At a minimum, it is best to include both direct and indirect assessment methods for evaluating if an organization’s practices, policies, and procedures adhere to the profession’s standards. Lastly, there are many key players within accrediting bodies, it is essential that the individual(s) responsible for overseeing the accreditation program, including but not limited to standard development and maintenance, evaluation methodology, compliance, procedures, and processes, have educational and professional experience in quality assurance, quality measurement, and evaluation methodology. Is the accreditor an independent neutral entity, which helps make the accreditation decision fair? In any profession, there are a limited number of professionals, and it is difficult to develop neutrality and independence when the limited number of professionals shift and change positions in their careers. However, it is imperative for accrediting bodies to be neutral, objective third parties that do not personally benefit from setting the professions’ standards and accreditation evaluation methodology. To have credibility, the accrediting body should not be owned or operated by an organization representing a specific group of stakeholders such as payors, service providers, or patients. Furthermore, the evaluators cannot be employees from other organizations who provide services to the same population or work for a competitor. Such practices protect the evaluation process and limit any influence of potential biases and conflicts of interest. Lastly, it is crucial for the accrediting body not to have dual relationships or organizational biases toward certain trade organizations, certification or licensing bodies, or professional associations. How long has the accreditor been evaluating organizations? It is important for the accrediting body to have demonstrated a history of viability for continued successful operation and stability. Any reader who has taken some time to develop tools for measuring behavior can relate to the time and experience it takes to develop a behavior measurement system that is reliable and valid. Developing evaluation tools for accreditation, similarly, requires time and experience in large-scale evaluations. Additionally, developing tools that enable trained evaluators to reliably make high stake decisions of pass/not pass requires piloting and obtaining a representative sample, several revisions to tools based on the results, and revisions to the tools and/or methodology based on stakeholder feedback. It can take years to develop reliable evaluation tools that are informative, fair, and socially acceptable. Organizations should ensure that accrediting bodies have spent years developing and self-assessing and revising their tools. Does the accreditor have an independent disciplinary review or compliance committee? When a credentialed clinician does not adhere to the credentialing board’s code of ethics, the witness of the violation can submit a formal complaint outlining the clinician’s behaviors alleged to violate the code of ethics, documentation for the alleged violation, and documentation of attempts to bring the issue to the clinician (for example see https://www.bacb.com/ ethics-information/reporting-to-ethics-department/; Reporting To The Ethics Department, 2023). What about when the violation is conducted by individuals who are not clinicians or credentialed? Who oversees grievances or complaints against service organizations, sometimes owned or operated by leadership who are not certified or licensed behavior analysts? The role of the disciplinary review or compliance committee of an accrediting body is to process compliance concerns received from the general public, patients, parents/caregivers, and staff to assist accredited organizations to remedy any problem areas as well as provide continued support to allow for growth and quality improvement. Although it may not be at the forefront when choosing an accreditation program, it is essential that the accrediting body has a committee to oversee organizations’ adherence to the standards under which they have been evaluated. As noted before, accreditation evaluation only provides a birds- eye view from a mere snapshot in time; therefore, a compliance review department enables the accrediting body to promote accountability and adherence to the standards across time (for example, see https://www.bhcoe.org/become-a-bhcoe/ report-a-compliance-concern/; BHCOE, 2022). 263 Is Accreditation, Like a Colonoscopy, Good for You? / Kazemi Does the accreditor demonstrate good customer service? It may not seem important initially, but good customer service is crucial. The organization undergoing the accreditation process may have questions or concerns throughout the evaluation. It is important that they can receive answers promptly. It is also important for customer service personnel to consist of standards experts, a support team, resources, specific examples, and someone who oversees their account. Another key component to an accrediting body demonstrating good customer service is a modality for organizations to be able to provide ongoing feedback throughout and following the evaluation process. Furthermore, it is crucial that the accreditor not only solicits and encourages feedback but also can demonstrate how the feedback has been utilized to promote improvements. Has the accreditor been considered or approved by federal and/or local/state authorities? Lastly, organizations should seek out an accreditation body whose standards align with their applicable federal, state, and local mandates in the regions that they operate to ensure compliance and consistency with both mandates and best practices. Summary and Conclusions The answer to the question of, “is accreditation, like a colonoscopy, good for you?”, is yes, absolutely! Accreditation will provide a contingency for organizational behavior and allow the profession of behavior analysis to shape the quality-of- service delivery instead of funding organizations. Accreditation will also catapult discussions between behavior analysts to standardize terms and come to some consensus regarding how they reference common procedures, much like the BCBA Task List from Behavior Analyst Certification Board (Behavior Analyst Certification Board [BACB], 2017). Accreditation will also provide transparency into the profession and what the profession itself considers best practice. Ultimately, transparency regarding best practices in service delivery will influence patient outcomes and quality of care. Currently, there is no way for a consumer, or a funding agency, to differentiate between service providers outside of personal relationships and anecdotal data (e.g., testimonials, word of mouth). However, just as an accrediting body can hold service organizations accountable, it is equally important that service providers hold the accrediting bodies to standards of excellence to mitigate potential negligence and abuse of power. In conclusion, like a colonoscopy, accreditation allows for the assessment and identification of problems, which can prevent the widespread growth of problems through intervention. Most organizations providing behavior-analytic care are highly patient- centered and focused on delivering excellent treatment. However, the rare bad seeds influence the public’s perception of behavior analysis and cultivate widespread criticism. Unfortunately, bad news and reports of poor behavior spread quickly, like cancer, undermining the efforts of organizations that provide excellent services. Although undergoing accreditation may not feel pleasant, it can prevent the spread of cancer, and I would argue that it is good for the profession of behavior analysis and its future vitality. Author Note Statements and Declarations: Ellie Kazemi serves as the Chief Science Officer at the Behavioral Health Center of Excellence (BHCOE), which has provided financial support for writing this manuscript. References Alkhenizan, A., & Shaw, C. (2011). Impact of accreditation on the quality of healthcare services: A systematic review of the literature. Annals of Saudi medicine, 31(4), 407-416. https:// doi.org/10.4103/0256-4947.83204 ANSI National Accreditation Board. (2022). Tips For Selecting A Certification Body. https://anab. ansi.org/management-systems-accreditation/ certification-bodies/how-to-select Araujo, C. A. S., Siqueira, M. M., & Malik, A. M. (2020). Hospital accreditation impact on healthcare quality dimensions: A systematic review. 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