Program Standards

A. Universal Standards
Universal program standards describe basic activities and structures that must be in
place as programs are developed and delivered. Universal Program Standards are
foundational – they are the building blocks for programs and services. Universal
Program Standards apply to all organizations and all human service programs.
The Universal standards address fundamental elements of service delivery.
All Universal program standards apply to ALL centres.

A.1 Service Approach
The service approach is the philosophy and values that underpin service and
program delivery at the organization. The service approach describes how the centre
meets the needs of the people it serves, how it engages them in decision-making,
and its philosophy of care. This philosophy is known and understood by the
organization and service participants alike.
*indicates a mandatory standard

Prog.
*A. 1.1 MANDATORY
The approach to service is strength-based, centered on the individual, and
considers him or her within their whole context, respecting their needs and
preferences.

Prog.
A. 1.2
The program/service and/or clinical philosophy is clearly articulated in a
written statement that is shared with stakeholders.

Prog.
A. 1.3
The centre provides opportunities for individuals to become involved in the
centre beyond the planning and review of their services.

Prog.
*A. 2.1 MANDATORY
The centre works to ensure the safety of service participants and staff
members during service provision.

Prog.
*A. 2.2 MANDATORY
The physical environment and the centre’s practices ensure confidentiality
and the privacy of individuals.

Prog.
A. 2.3
The facilities of the centre are welcoming and appropriate for the individuals
served.

Prog.
A. 2.4
Measures are in place to increase accessibility of programs and services.

Prog.
*A. 3.1 MANDATORY
Written policies and procedures define the organization’s eligibility criteria,
process for screening and admitting individuals, and the community’s
methods of accessing services.

Prog.
*A. 3.2 MANDATORY
Individuals approaching the organization are directed to the appropriate
resources in the agency or the community.

Prog.
A. 3.3
The centre has written policies and procedures regarding intake.

Prog.
A. 3.4
If there is a waiting list for service, the centre monitors its response times
and takes measures to improve access to services, where possible.

Prog.
A. 3.5
Where applicable, the centre outlines its expectations for implementation of
its intake tools (e.g., BCFPI), monitors compliance with these expectations,
and tracks data maintenance to ensure integrity and quality.

Prog.
*A. 4.1 MANDATORY
Individuals are oriented to the centre as they begin receiving an ongoing
course of treatment or service.

Prog.
*A. 4.2 MANDATORY
Individuals are oriented to how the centre uses their information, to their
rights in terms of personal and health information and access to their file.

Prog.
A. 5.1
Written agreements outline roles, responsibilities, accountabilities and
review process for programs delivered jointly with other agency(ies).

Prog.
A. 5.2
The centre carries out public education activities, such as presentations,
speaking engagements, awareness campaigns and media relations.

Prog.
A. 6.1
Processes are used to review ethical questions and support decision-making
in potentially difficult or conflictual situations.

Prog.
*B. 1.1 MANDATORY
The design of children’s mental health programs/services delivered by the
centre reflects the relevant knowledge that is currently available.

B. 1.2
The centre’s leadership fosters and supports a learning culture within the
organization.

Prog.
B. 1.3
Access to current knowledge and research literature relevant to the centre’s
programs and services is available at the centre.

Prog.
*B. 2.1 MANDATORY
A written policy directs the centre’s continuous quality improvement
process.

Prog.
*B. 2.2 MANDATORY
The centre measures the effectiveness of its programs.

Prog.
B. 2.3
The centre’s leadership has demonstrated its commitment to continuous
quality improvement in both service and administrative functions.

Prog.
B. 2.4
Quality improvement activities target key processes that the centre defines
as critical for success in a children’s mental health centre, and that have
major impact on meeting client needs.

Prog.
B. 2.5
If the centre develops its own innovative programs or if new services are
implemented for the first time, their effectiveness is measured and
analyzed.

Prog.
*B. 3.1 MANDATORY
Program evaluation is conducted ethically and with integrity.

Prog.
B. 3.2
Program evaluation is systematic and demonstrates the use of appropriate
program evaluation design and methodology.

Prog.
B. 3.3
Findings of program evaluation are communicated appropriately to
stakeholders.

Prog.
*B. 4.1 MANDATORY
Centres performing research have and adhere to a written research policy
that addresses standard principles of ethical research practices and
recognizes the potential vulnerability of research participants.

B. 4.2
The role and purpose of research is relevant to the centre’s philosophy and
mandate.

Prog.
B. 4.3
Research studies are designed and carried out by centre staff or in
partnership with external investigators with the appropriate research
expertise, experience, qualifications and capacity.

Prog.
B. 4.4
Research studies are conducted in a manner that respects research
participants.

Prog.
B. 4.5
The purpose, findings, practical and theoretical implications of the research
are communicated to stakeholders and used to inform decision-making.

B. 5.1
The centre carefully selects which Evidence-Based Practices will be
implemented.

Prog.
B. 5.2
The centre develops a written plan to guide and support the implementation
of Evidence-Based Practices.

Prog.
B. 5.3
The centre promotes and supports the implementation of Evidence-Based
Practices by establishing effective and sustainable structure and resources.

Prog.
B. 5.4
The centre makes careful decisions about how Evidence-Based Practices will
be implemented, maintaining integrity and making appropriate adaptations
if needed.

Prog.
B. 5.5
The centre evaluates the implementation of Evidence-Based Practices.

C. Intervention/Treatment Standards
The children’s mental health intervention/treatment process standards outline the
essential elements of the process or methodology for delivering children’s mental
health treatment and services. They address elements of the service delivery process
that are consistent across the range of services provided, while recognizing the need
for flexibility in how process elements are applied in accordance with client needs,
the intensity and length of service, and the setting in which services are delivered.
Intervention/Treatment Process Standards are applicable to ALL children’s mental
health centres.

C.1 Multidisciplinary Process
A multidisciplinary process means that representatives of a broad range of
practitioners, clients, and families can participate together, in accordance with client
needs, in the planning and delivery of an intervention/treatment. The term
“multidisciplinary” is applied in a broad sense, encompassing those disciplines
traditionally associated with children’s mental health treatment, e.g., child and youth
work, social work, psychology, psychiatry, as well as others such as cultural
interpretation and community development. Multidisciplinary considerations are
reflected throughout all stages of the service delivery process, with involvement of
specific disciplines as required.
*indicates a mandatory standard

Prog.
*C. 1.1 MANDATORY
The centre has available, internally or externally, a multidisciplinary process
for professional input during the treatment process, including assessment,
planning, implementation, review, and case closure.

C.2 Assessment
Assessment is the process in which specific skills and tools are used by qualified
professionals working within the scope of their discipline to help identify the needs,
strengths, and protective factors of a child, youth, and/or family, or community. The
extent and nature of the assessment is appropriate to the type and seriousness of
the identified needs, and length and nature of the service request. A brief, focused
assessment is appropriate in some circumstances, e.g., crisis response. Other
circumstances, e.g., referral for residential treatment, require a more extensive and
comprehensive assessment carried out by professionals from one or more disciplines
before the development of a formulation and a treatment plan. Assessment is an
ongoing process that is implemented differentially according to the nature and
seriousness of each client’s needs and the expected intensity and duration of
services to be provided.

Prog.
C. 2.1
The centre’s assessment policy outlines the nature of assessment to be
conducted according to the intervention/treatment needs of the child or
youth and family.

Prog.
C. 2.2
The assessment identifies and evaluates the strengths, needs and resources
of the child or youth and family that are relevant to the
intervention/treatment process.

Prog.
C. 2.3
Assessment findings are communicated in a manner tailored to support the
understanding of the child or youth and family.

Prog.
C. 2.4
If the child or youth and family have received service elsewhere within the
previous two years, information, views and/or records that may be relevant
to the current assessment and service planning process are sought from
relevant service providers.

C.3 Intervention/Treatment Planning and
Implementation
Planning intervention/treatment is the process by which interventions are selected by
and for a child or youth and family, based on the assessment and building on the
client’s strengths. Centre staff and the client negotiate the goals, projected time
frame, and methods of service delivery.
*indicates a mandatory standard

Prog.
*C. 3.1 MANDATORY
The child or youth and family are informed about intervention/treatment
options and the likely benefits and risks to safety and well-being.
Prog.

*C. 3.2 MANDATORY
Each child or youth and family has a written intervention/treatment plan.
Prog.

C. 3.3
Staff and the child or youth and family negotiate and share decision-making
regarding the goals and time-frame for intervention/treatment, and the
methods and arrangements for service delivery.
Prog.

C. 3.4
If staff from the centre are providing multiple interventions/treatments to
the child or youth and family, these interventions/treatments are
coordinated, and integrated where possible.

Prog.
C. 3.5
The intervention/treatment plan is communicated in a manner tailored to
support the understanding of the child or youth and family.

C.4 Review of Intervention/Treatment
Review of intervention/treatment is the process by which intervention/treatment is
monitored, facilitating adjustment of the intervention/treatment plan as required.
Intervention/treatment is reviewed on a regular basis in partnership by staff and the
client in a manner suitable to the nature of the service provided and in accordance
with the centre’s policy and procedures.

Prog.
C. 4.1
Intervention/treatment is reviewed and recorded in the file on a regular
basis as set by centre policy, but at least every six months.

Prog.
C. 4.2
The child or youth and family are involved in reviewing
intervention/treatment.

Prog.
C. 4.3
The review of intervention/treatment is used to modify the
intervention/treatment plan, if necessary.

C.5 Service Coordination
Service coordination occurs when more than one service provider is involved in the
intervention/treatment process. On behalf of the client, the intervention/treatment
plan is coordinated between the centre and any external service providers, and
integrated within the centre when multiple internal services are involved.
Prog.

C. 5.1
When the centre takes a lead or substantive role in a community
intervention/treatment plan involving multiple agencies, services are
coordinated, and integrated where possible.

C.6 Case Closure
Case closure is the point in the intervention/treatment process where there is a
decision to stop service. The time for case closure might be set in advance as part of
the intervention/treatment plan, or it might occur when goals have been met, or
simply when it has been agreed that there is no need to continue. Case closure
involves a review and documentation of successes achieved, ongoing or anticipated
client needs, and suggestions for future support/services.
Please note: There are more specific program discharge standards relevant to day
treatment and residential services in those sections of the standards.

Prog.
C. 6.1
When case closure is a planned process, centre staff and the child or youth
and family negotiate a plan for case closure that takes into consideration
successes achieved, ongoing or anticipated client needs, resources
available, and the preferences of the child or youth and family.

Prog.
C. 6.2
Where case closure is unplanned, efforts are made to invite the child or
youth and family to contact the centre in future as needed, or to provide
suggestions of alternate services.

Prog.
C. 6.3
There is a written closing report for each child, youth and/or their family,
with details appropriate to the nature of service provided.

D. Service-Specific Standards
Service-Specific Standards outline the special requirements related to a particular
type of services. These include: Public Education and Mental Health Promotion,
Prevention, Groups, Consultation and Respite. Other types of services are covered by
the Treatment/Intervention Process Standards and/or Setting-Specific Standards.

D.1 Public Education and Mental Health Promotion
Public education efforts raise awareness and understanding of children’s mental
health, increase a group or community’s knowledge of an issue, and ensure that
services related to children’s mental health issues and problems are known and
supported.
Mental Health Promotion empowers people and communities to interact with their
environments in ways that enhance emotional and spiritual strength. It is an
approach that fosters individual resilience and promotes socially supportive
environments. Mental health promotion also works to challenge discrimination
against those with mental health problems. Respect for culture, equity, social justice,
interconnections and personal dignity is essential for promoting mental health for
everyone.

Prog.
D. 1.1
The centre has a public education, prevention and mental health promotion
strategy that is based on community and clients’ needs as well as
organizational priorities.

Prog.
D. 1.2
The centre is involved in advocacy efforts/campaigns to build a healthy
children’s mental health policy, strengthen services, and contribute to
advancing the children’s mental health agenda.
Prevention seeks to avert mental health problems through interventions. These
interventions include activities geared toward reducing factors leading to mental
health problems; activities involving the early detection of, and intervention in, the
potential development or occurrence of a health problem; and activities focusing on
the treatment of health problems and the prevention of further deterioration and
recurrence. Prevention can be universal or targeted. Universal prevention programs
are applicable to whole populations such as elementary school-aged children while
targeted are delivered to a specific population at increased risk of developing mental
health problems (e.g., parenting groups for teenage mothers). The prevention
program standards apply to both types of prevention programs.

D. 2.1
When Prevention programs are offered, they are designed to address
specific individual and/or community needs with appropriate goals and
activities.

Prog.
D. 2.2
Prevention programs are evaluated and improvements are made, if
required.

D.3 Groups
Group programs include treatment groups for children or youth, and targeted
prevention, psycho-educational and support group programs for children, youth or
families.
Each treatment group participant is a client of the centre and has a client file that
reflects group involvement. In keeping with the intervention/treatment process
accreditation standards, group involvement is reflected in the client’s treatment
planning and review processes.
Targeted prevention, psycho-educational and support groups serve at-risk children,
youth and parents. These groups may include clients, non-clients, or a combination
of the two. While involvement of clients in any group is addressed by the
intervention/treatment process standards, involvement of non-clients is addressed
only by the Service-Specific standard for groups.

Prog.
D. 3.1
The centre plans, provides and evaluates group programs to clients and the
community for purposes of treatment and/or prevention.
Prog.
D. 3.2
Treatment group involvement is coordinated with the client’s overall
treatment plan.

D.4 Consultation
Consultation involves the provision of advice or direction in the diagnosis, prognosis,
and treatment of a particular children’s mental health case or issue. The consultant
does not assume ownership of the case, but assists others in their service provision.
Different types of consultations may occur, depending on the specificity of the
question on which the children’s mental health provider has been asked to consult:
• Client-specific consultation is focused on the needs or problems of a specific
child or youth;
• Issue-specific consultation is when someone from an organization provides
advice and direction about a children’s mental health issue (e.g.,
understanding Asperger’s syndrome) to a team or group within an
organization (but not specific to any one child or youth).
• Program-specific consultation is the provision of broader advice or direction
about a program or service so that it takes a children’s mental health
perspective into consideration in its design and implementation.

Prog.
D. 4.1
The centre provides formal client-specific consultation to its community
partners on the issues of a specific child or youth.

D. 4.2
The centre provides issue and/or program-specific consultation on
children’s mental health issues to teams, groups and organizations.

D.5 Respite
Respite services provide temporary family relief from caring for children or youth.
The primary purpose of respite is support for families, including foster families, and
kinship care. Respite services play a crucial role in helping to keep families together
or to avoid placement breakdown. Children or youth participating in respite do not
necessarily have a mental health problem. Although respite could be one component
of a child or youth’s treatment plan or of a community’s plan for the family’s services
(e.g., wraparound), the focus of the respite service is not treatment and these
services are not change-oriented. The respite service provider is not necessarily
responsible for the development or review of the child or youth’s overall service plan,
of which respite may be one component. Respite services may take many forms, and
could be residential, after school, or day programs. Respite may be offered in a
variety of settings, such as recreation-based settings, community centres, agency
settings, and family care settings. Respite providers may be centre staff, volunteers
or family care providers. Respite services may be offered on a planned or crisis basis.

Prog.
D. 5.1
Respite services are accessible, flexible, family-centred, strength-based,
and promote resiliency.

Prog.
D. 5.2
The centre maintains brief written records of the respite services provided
and reviews the family’s respite plan regularly.
plans.

Prog.
D. 5.3
The centre provides appropriate organizational supports that are applicable
to the type of respite program, population served, and the setting.

E. Setting-Specific Standards
Setting-Specific Standards address the requirements of a particular service delivery
setting. Children’s mental health intervention/treatment takes place in a variety of
settings appropriate to children (e.g., home, school, residential). Standards reflect
the specific requirements that an organization must satisfy depending on the types
of settings in which it operates.

E.1 Home and Community-Based
Home and community-based services take place in the home of the child or youth
and family, and/or community settings. These settings can provide excellent
opportunities to intervene in ways that are not possible in agency based settings.
Home and Community-based services provide support and modeling in these
settings.
Providing services in the home and community presents unique challenges for
children’s mental health providers because it is more difficult to control the
environment, particularly when unpredictable situations arise. Centres that provide
these services must take extra measures to recognize and respond to significant
levels of potential risk inherent in home-based settings. The success of these
services depends on a highly collaborative, strength-based approach that respects
the preferences, privacy and unique circumstances of the child or youth and family.
*indicates a mandatory standard

Prog.
*E. 1.1 MANDATORY
The centre takes measures to address safety issues specific to home and
community-based services.

Prog.
E. 1.2
Home and community-based services are flexible, collaborative and
responsive to the unique circumstances of the family, child or youth.

Prog.
E. 1.3
Home and community-based services link with other community resources
to develop and enhance social support systems for families, children and
youth.

E.2 School, Early Learning or Child Care Centre
School, early learning or child care services allow for ready and convenient access for
most pre-school and school-aged children and youth. Many different mental health
interventions, ranging from prevention through intensive treatment can be delivered
in these settings. Some services are delivered in partnership with educators and
other professionals, while others are offered solely by the children’s mental health
centre staff. In most cases, children or youth are the direct recipients of services, but
some school, early learning or child care-based programs may focus more on
enhancing the knowledge and skill level of educators or other professionals regarding
mental health issues.
School-based services include, but are not limited to, programs that have been
commonly referred to as “day treatment”. Day treatment frequently describes a
program where there is a collaborative, contractual service between a school board
and a children’s mental health centre to provide treatment and education in a small
classroom setting. Early childhood education settings that have a treatment
component are also considered to be day treatment. Day treatment programs may
be housed in a community school, at a children’s mental health centre, hospital, child
care centre, or other setting, and can be offered to children and youth living at home
or in the community, or to residential clients of a children’s mental health centre.

Prog.
E. 2.1
Staff delivering children’s mental health services in schools, early learning
or child care centres adapt to the distinct culture of each setting, while
maintaining their role and expertise in children’s mental health services.

Prog.
E. 2.2
If services are school-based, the centre ensures that the children or youth
who require it have access to ongoing mental health support during
extended school breaks.

Prog.
E. 2.3
When day treatment programs are provided, the program will approximate,
as closely as possible, the normal daily routine of children or youth, and
provide a range of educational and therapeutic activities appropriate to the
learning style and achievement level of the children and youth served.

Prog.
E. 2.4
When Day Treatment is offered, staff make active use of interpersonal
relationships and events that arise to produce change.

Prog.
E. 2.5
In Day Treatment Programs, whenever possible, admission takes place on a
planned basis to facilitate the child or youth’s transition to the day
treatment program, and to provide day treatment staff with relevant
information about the child or youth.

Prog.
E. 2. 6
Where day treatment is offered, the staff and educators function as a team,
both within the school setting and with the broader multidisciplinary team.

Prog.
E. 2.7
The organization provides resources that promote day treatment staff’s
participation in ongoing learning, skill development and job support.

Prog.
E. 2.8
Whenever feasible, planning discharge from day treatment begins as early
as possible, involving the child, youth and parents/caregivers, to support a
successful transition to the school placement.

E.3 Treatment Foster Care
Treatment foster care programs provide a family-based treatment approach for
children and youth requiring mental health intervention. The treatment foster family
serves as the primary treatment setting, and plays a central role in the child or
youth’s care and treatment. A team approach is an essential element, where
treatment foster parents work together with other multidisciplinary professionals and
with the families of the children or youth to meet client needs. Treatment Foster
Care programs differ from group-based residential services by offering a very small
number of children or youth a family-based setting in which new behaviours, skills
and experiences can be developed.
*indicates a mandatory standard

Prog.
*E. 3.1 MANDATORY
Treatment foster parents are trained to understand and meet the treatment
needs of the children or youth served.

Prog.
E. 3.2
The program promotes the provision of organizational and clinical support
for treatment foster parents.

Prog.
E. 3.3
The treatment foster care program has the capacity to meet the treatment
needs of the children or youth served and their families.

E. 3.4
Crucial transitions for children or youth are planned and managed with
sensitivity and attention to individual needs.

E.4 Residential
Residential services have a unique role in the children’s mental health continuum of
services due to the level of care provided, and because the residence replaces the
child or youth’s usual living situation for a period of time. Residential service
providers are charged with the responsibility of acting in the role of alternative
caregivers on a 24-hour basis. Children’s mental health centres most frequently
provide residential services where the primary objective is mental health treatment;
however, other residential services may be provided with a different primary focus
such as shelter/housing, transition to independent living, youth justice/custody, crisis
intervention and stabilization. In these circumstances, some of the Residential
Standards are not applicable, as indicated.
*indicates a mandatory standard

Prog.
*E. 4.1 MANDATORY
The organization has a comprehensive system to promote the use of
positive, safe methods to intervene in crisis situations with children or
youth at high risk in residence.

Prog.
E. 4.2
The residential program provides a supportive milieu that is designed to
meet the needs of the children or youth served.

Prog.
E. 4.3
Residential staff make active use of interpersonal relationships and events
that arise to produce change.

Prog.
E. 4.4
Whenever possible, admission takes place on a planned basis to facilitate
the child or youth’s transition to the residence, and to provide residential
staff with relevant information about the child or youth.

Prog.
E. 4.5
Residential staff function as a team both within the residential unit and as
active members of the multidisciplinary process.

Prog.
E. 4.6
Stability of staff is promoted to provide the opportunity for each resident to
form a consistent interpersonal relationship with staff.

Prog.
E. 4.7
The organization provides resources that promote residential staff’s
participation in ongoing learning, skill development and job support.

E. 4.8
Whenever feasible, planning discharge from residence begins as early as
possible, involving the child, youth and parents/caregivers, to support a
successful transition to the new living situation.