Achieving Quality Through
CARF Accreditation
Michael W. Johnson, M.A., C.A.P.
Managing Director of Behavioral
Health
INTRODUCTIONS
Agenda
• CARF Overview
• The Value of Accreditation
– The Value of CARF
• The Survey Process
– Preparation
– The Standards
Overview
OUR NAME
Commission on
Accreditation of
Rehabilitation Facilities
CARF’s Mission is …
To promote the quality, value and
optimal outcomes of services
through a consultative
accreditation process and
continuous improvement services
that center on enhancing the lives
of the persons served.
Core Values
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All people have the right to be treated with dignity
and respect
All people should have access to needed services
that achieve optimal outcomes
All people should be empowered to exercise
informed choice regarding their treatment options
Committed to continuous improvement of
organizational management and service delivery
Diversity and cultural competence in all CARF
activities and associations
Overview of CARF
International:
 North America
 South America
 Europe
 Africa
 Asia / Southeast Asia
Accreditation Areas
– Behavioral Health - OTP
– Child & Youth Services
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Employment & Community Services
Medical Rehabilitation
Aging Services
(Adult Day Services/Assisted Living)
Overview (continued)
• Private non-profit established in 1966.
• Recognized in approximately 48 states
under mandated or “deemed” status.
• Standards apply to small organizations in
rural areas as well as large or urban.
• 1400 volunteer surveyors in U.S. and
Canada.
• Approximately 100 CARF staff members
Where is CARF?
CARF Accredited Programs
Over 8.4 Million Persons are Served
3836
1001
792
19198
23007
975
AS
BH
CYS
ECS
MED
OTP
As of 2/5/13
• Starting in 2014, all health plans that want to
participate in health insurance Exchanges or
marketplaces must be accredited; if they offer
behavioral healthcare services through an
MBHO, contracting with accredited
organizations will help them in the
accreditation process.
•
News release July 30, 2013
Value of Accreditation
• Accreditation is an internationally recognized
evaluation process used to assess and
improve the quality, efficiency, and
effectiveness of healthcare organizations.
• It is also a way to publically recognize that a
health care organization has met external
quality standards.
Value of Accreditation
Accredited organizations enjoy:
• Assurance to the public that a neutral third-party has
reviewed the quality of programs and services
provided
• The ability to contract with a variety of payers that
require accreditation of their providers
• Better reputation among persons served and
enhances their awareness and perception of quality
of care (Greenfield, Pawsey & Braithwait, 2008)
• Increased overall satisfaction level with services (Al
Tehewy, 2009)
Value of the Process
• Although there is significant value to the
status of accreditation, the real added value
of accreditation is in the process.
• The process provides a framework to improve
quality and organizational effectiveness in
preparing for the survey, and afterwards
between surveys.
Value of the Process
• Before and after the survey, the process
stimulates sustainable quality improvement
efforts and assists programs to modify their
practices to reflect changes in knowledge of
generally accepted practices in the field.
• As knowledge and practices in the field
change, the standards change, allowing
executives to rely on the accrediting body to
assist them to design and manage a modern
and effective organization.
Evidence for
Accreditation
• Provides organization with a well-defined vision for
sustainable quality improvement initiatives (Baskind
2010)
• Strengthens interdisciplinary team effectiveness
(Pomey, Lemieux-Charles, 2010)
• Promotes sharing of policies, procedures, and best
practices among health care organizations (Davis
2007)
• Improved outcomes for the persons served (Thornlow
& Merwin, 2009)
Why CARF?
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Field driven standards continually reflect best
practices
Choice of programs to be included in survey
Multiple pathways to conformance – “nonprescriptive”, “non-inspective”
Surveyors are “peers” who work in accredited
organizations, minimum 5 years experience in direct
service delivery or administration
Process represents ongoing collaborative
partnership in quality improvement
CARF accreditation is “do-able”
Standards Manual:
Roadmap/Blueprint
CARF Standards provides organizations with:
• A means of ongoing self-evaluations and continuous
systems improvement for service delivery.
• An authoritative resource to use to prepare for a
survey and accreditation.
• Guidelines for business development and practices
and the development and delivery of new programs
and services.
• An educational resource on good business and
service practices.
The Survey
Process
Preparing for a Survey
•
Acquire the correct standards manual!
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Staff and leadership buy-in is critical to success
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Make accreditation preparation an organizationwide team effort
Use the standards manual to help write and
refine policies and procedures
 Tip: Organize P&P to reflect how you do
business (cross-walk to the standards)
Preparing for a Survey
• Attend a training (face-to-face, web)
• May want to speak with or visit other CARF
accredited organizations
• Self evaluation will establish your to-do list
• Develop time lines to have things done
• Simplify, simplify, and then simplify again
• Alert all persons served, staff, outside
stakeholders to the dates and review the process
with them - POSTER
• Consultation ?
Steps to Accreditation
STEP
PROCESS
TIME
1
Consult with CARF resource
specialist
1½ - 1 year prior to survey
2
Conduct a self-evaluation
6 months (suggest 9-12)
3
Submit Intent to Survey
4 months (suggest 6)
4
CARF invoices fee
After application is
received
5
Survey team selected
30 days before survey
6
Survey
7
Outcome rendered (email report)
6-8 weeks after
8
QIP Submitted
90 days after award
9
ACQR (3 year only)
Anniversary date
10
Maintaining contact
Ongoing
Resource Specialist
• Resource Specialists are your:
– Guides
– Experts in interpretation of the standards
and CARF process
• Resource Specialists help with:
– Selection of appropriate field categories
(BH) and programs.
– Time lines for submission of pre-survey
documentation and fees.
• Resource Specialists will set you up in
Customer Connect.
CARF Contact for New Hampshire
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6951 E. Southpoint
Rd Tucson, AZ
85756
888-281-6531
Kathy Lauerman,
ext.7168
klauerman@carf.org
www.carf.org
Time Frame at a Glance
Preferred Time
Frame
Intent Due to CARF
Expiration Month
*Jul/Aug
Feb 28
Aug
*Jul/Aug
March 31
Sept
Aug/Sept
Apr 30
Oct
Sept/Oct
May 31
Nov
Oct/Nov
June 30
Dec
Nov/Dec
July 31
Jan
Dec/Jan
Aug 31
Feb
Jan/Feb
Sept 30
Mar
Feb/Mar
Oct 31
Apr
Mar/Apr
Nov 30
May
Apr/May or May/June
Dec 31
June
Accreditation Outcomes
 Three-year accreditation – substantial conformance to
the standards. Demonstrated improvement from
previous periods of CARF accreditation.
 One-year accreditation – areas of deficiency, but
evidence of capability and commitment
 Provisional accreditation – one year, awarded only
once, after one year accreditation.
 Non-accreditation – numerous and/or major
deficiencies in many areas. Serious questions about
program benefits, health welfare or safety. (Inability to
achieve a Three Year Accreditation following a Provisional
Accreditation)
The Standards
The Standards
Principles of the
Standards
Achievable
• benchmarks that can be achieved by
competent providers
Consensual
• reflect field consensus
Cost Effective
Non-prescriptive
• positive relationship between development
and implementation
• leaves the organization free to meet the
standards in its own manner
Practical
• grounded in day-to-day world of service
delivery
Relevant
• makes sense to those who implement the
standards
State-of-the-Art
• reflect current knowledge in the field and
emphasize best practices
A “Typical” Standard
Standard (bold)
1.I.2. The organization
implements an
accessibility plan that
includes, for all
identified barriers:
a. Actions to be taken.
b. Time Lines.
Check the Glossary
Intent Statement
There may be barriers identified that
the organization does not have the
authority or resources to remove:
effective accommodations may be
the appropriate action to be taken in
those circumstances.
Examples
Written documentation of potential
barriers to services exists. When
identifying potential barriers to
services, the org. considers various
barriers which may include attitudes
of staff members toward persons
with disabilities and how this will
impact initial and ongoing access to
services.
Key Definitions
Policy: Written course of action; guidelines
adopted by the leadership
Procedure: A “how to” description of actionsto-be-taken. Not written unless specified
Written procedure: Requirement that the
procedure is described in writing
Plan: Written future direction that is action
oriented and related to a specific project or
defined goal.
Section 1
ASPIRE to Excellence®
ASSESS THE ENVIRONMENT
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Leadership
Governance
SET STRATEGY

Strategic Planning
PERSONS SERVED & OTHER STAKEHOLDERS –
OBTAIN INPUT
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Input from Person Served and Other Stakeholders
IMPLEMENT THE PLAN
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Legal Requirements
Financial Planning and Management
Risk Management
Health and Safety
Human Resources
Technology
Rights of Persons Served
Accessibility
REVIEW RESULTS
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Performance Measurement and Management
EFFECT CHANGE
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Performance Improvement
Section 2 – BH / CYS
General Program Standards
A
Program Service Structure
B
Screening and Access to Services
C
Individual Plan
D
Transition / Discharge
E
Medication Use
F
Non-Violent Practices
G
Records
H
Quality Reviews
Program Standards
Sections 3, 4, 5
BH:
3. Core Program Standards
4. Specific Population Designation Standards
Addictions
Pharmacotherapy
Child and
Adolescent
Consumer Run
Eating Disorder
Criminal Justice
Juvenile Justice
Medically Complex
5. Community & Employment Services
Questions