BeConnected
ACCREDITATION and YOU
Version 20.15
Working Together to Maintain a
Successful Accreditation
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What is Accreditation?
• Accreditation is an ongoing process of improving
services and supports to BeConnected’s “persons
served.”
• Accreditation means meeting and exceeding
international standards determined by CARF
International.
• Accreditation means that BeConnected maintains
contracts with Government Ministries and we all
keep our jobs.
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Who is CARF?
• CARF is an international society located in
Tucson, Arizona, with offices in both
Edmonton and Ottawa.
• They research and write standards for various
programs and services and then conduct site
surveys at agencies like ours to check to see if
we are meeting the standards.
• We selected them because they are user
friendly and a good fit for our organization.
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Who is CARF?
Quiz:
“CARF” stands for:
(a) Capable Aardvarks Repairing Fences
(b) Caring And Responsible Friendships
(c) Commission on Accreditation of
Rehabilitation Facilities
(d) Canadian Accreditation of Residential
Facilities
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How Does BeConnected Get
Accredited?
• BeConnected maintains its accreditation as
the result of a SURVEY visit by 2 or 3 trained
CARF surveyors;
• Surveyors issue a report to CARF based on
their visit to BeConnected Admin Offices (2!)
and homes where they observe, review
documentation, and interview persons served,
families, employees and professionals about
the quality of services being provided;
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How Does BeConnected Get
Accredited?
• *Surveyors also provide consultation to
BeConnected personnel.
• CARF reviews the survey findings and renders
their decision. The decision can be either a
three-year, a one-year, a provisional, or a nonaccreditation.
• BeConnected earned a 1 year accreditation in
2005, a 3 year accreditation in 2006, 2009,
and 2012; and is being revisited in May or
June of 2015 for a fifth time.
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CARF Survey 2012
• BeConnected’s official CARF SURVEY REPORT
confirmed that we received NO
RECOMMENDATIONS;
• We were surprised and delighted to read that
CARF awarded BSS EXEMPLARY CONFORMANCE
in the area of RIGHTS OF PERSONS SERVED;
• A letter addressed to Rhonda, from Brian Boon,
President/CEO of CARF, stated in part, “Ms.
Connell, please also be advised that the CARF
surveyors made no recommendations… This is an
extraordinary accomplishment, as only 3 percent
of CARF surveys result in no recommendations.”
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CARF Survey 2012
Some of BeConnected’s “STRENGTHS” as
identified in our 2012 CARF Survey Report
include:
• “BSS has an extremely passionate and deep commitment
to its mission, vision, purpose, and core values; to
providing quality services; and to quality improvement. “
• “BSS has an extremely positive image and reputation in
its service delivery area and is a respected and valued
member of the community. “
• “Stakeholders express very high satisfaction with the
organization’s performance and quality of services. BSS is
held in very high regard by resource people in the
community.”
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CARF Survey 2012
• “BSS is recognized for its outstanding services
to a very difficult population.”
• “Families consistently expressed appreciation
for the opportunities afforded through the
services provided.”
• “Throughout the organization the sense of
teamwork is strong and evident in ways such
as interaction, respect, communication, and
dedication.”
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CARF Survey 2012
• “Staff members are competent, motivated,
responsive, passionate, and enthusiastic about
the services delivered.”
• “This organization is dedicated to conforming
to CARF standards and has worked very hard
to prepare for this survey. The organization
demonstrates substantial conformance to
CARF standards, and the residents benefit.”
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What Can I Do to be Part of
Accreditation?
You Can Do Many Things!
A few ideas….
• Attend staff meetings regularly;
• Offer your ideas to better improve delivery of services to
residents by talking to your Coordinator;
• Ask questions about standards BeConnected is following;
• Know and follow BeConnected’ Mission, Vision, and
Values Statements, Codes of Ethics, and Guidelines for
Practice;
• Read past Accreditation Bulletins and Quizzes
(www.BeConnectedsupport.ca);
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• Read BeConnected’s annual reports;
What Can I Do to be Part of
Accreditation?
• Know the policies and procedures that BeConnected
expects everyone to know and follow;
• Set a goal to improve your job performance as part of
your Annual Performance Appraisal ;
• Attend in-service and training sessions offered by
BeConnected ;
• Attend out-service optional workshops offered by
BeConnected;
• Join a committee – Have a voice!
• Be prepared to talk to the surveyors and answer their
questions honestly and openly
• Help prepare the folks we support for survey
What else?
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What Happens During the Survey?
Day Minus-One, aka the-day-before
• BeConnected is responsible for picking up each
surveyor as they arrive at the airport and seeing
them safely to their hotel.
• We will have dropped off a “welcome package”
including boxes full of non-confidential
information for them to review prior to Day One
(policies, procedures, handbooks, reports for the
last three years, etc.). The surveyors will review
all of these materials PRIOR TO commencing
survey in the morning.
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What Happens During the Survey?
Day One
• 8:00am – Introduction of Surveyors to
BeConnected at Orientation Conference…
Leadership, Admin, HC’s and stakeholders.
• 9:00am – Survey Begins (Admin Offices and
Program Locations)
• 5:00pm – The survey team returns to their hotel
to review findings relative to conformance to the
standards. *Because BeConnected provides
residential services, it may be the case that the
program surveyors choose to visit some homes
into the evening.
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What Happens During the Survey?
Day Two
• …more of the same…
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What Happens During the Survey?
Day Three
• 8:00am: The survey team returns to head office to
make specific requests for evidence of conformance to
standards – things they haven’t already noted
conformance to.
• 11:00’ish – The survey team meets to compile its
findings. A “pre-exit meeting” is an option with
BeConnected Leadership and surveyors if we request it.
• 2:00’ish – The Exit Conference, which is approximately
one hour in length, is conducted by the survey team
with those invited by BeConnected (we open this one
up). Exiting conference consists of…
• Celebrate!
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What the Surveyors will ask to see?
• Care Plans and Person Centred Plans; GOALS and goal
boards
• Program Emergency Information
• Resident binders and files (home and at admin offices)
• Household Comm Books
• Emergency and First Aid Kits
• Van Safety Kit and Documentation
• Accessibility Issues (getting around the site safely –
entrances and exits)
• Health and Safety Minutes and Staff Meeting Minutes
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What the Surveyors will ask to see?
• A safe and clean environment – a well cared for home
• Personalized rooms showing the residents choice,
interests and culture
• Policy and Procedure Binder and all Manuals
• Personnel Files
• Financial Records
• Confidentiality of resident and personnel records
(locked filing cabinets, office doors, etc)
• Medications are kept in a secured and locked cabinet
• Access to cleaning products are kept under lock and
key
What else?
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What Happens After the Survey?
• 2 months after survey we will receive our final report
including recommendations and the official status of
BeConnected’s 2015 accreditation result (1 or 3 years, no
accreditation…).
• Then, Kristen submits to CARF a Quality Improvement Plan
(QIP) outlining the actions that have been or will be taken
in response to the recommendations made in the survey
report.
• Ongoing quality improvements to services offered to
persons served and our systems.
• Assuming we are accredited for another three years, we
issue an annual report to CARF of conformance to new
standards on the anniversary date of our accreditation
survey… and continue preparation for next survey…2018!
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…and Finally
Congratulate…
…personnel, persons served, families,
stakeholders, YOU!...on a job well done!
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BUT…?
If we met standards enough to receive the
highest award in 2012, and we are doing the
same things now as we were then, wouldn’t
we get the same award in 2015 as we did in
2012???
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No.
The whole point of accreditation is
CONTINUOUS QUALITY IMPROVEMENT. If we’re
the same, then we haven’t improved. If we
haven’t improved, then we will not be
successful at meeting the standards. We need
to DEMONSTRATE improvements across all
categories of standards.
If we do not, BeConnected is at risk because our
funders (CLBC and MCFD) require us to be
accredited in order to do business.
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What else is really really important?...
This.
“…where the agency has multiple
programs being surveyed (I.E., our
group homes), the accreditation
decision reflects conformance at the
weakest program, site or service.”
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The…
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1A) Leadership
(just examples, non-exclusive)
•
•
•
•
leadership structure
responsibilities
vision/mission…
code of ethics and what happens when one
violates the Code…
• cultural competency
• contractual relationships
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1C) Strategic Integrated Planning
• “the loop, “the machine:” _____
• strategic planning/strategic plan
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1D) Input from Persons Served
• “…input is obtained…on an ongoing
basis…from all stakeholders…using a variety of
mechanisms…”
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1E)
Legal Requirements
• complies with legal and regulatory requirements for:
– rights (HR, LL)
– privacy and confidentiality
– contractual requirements (what we are
contractually required to abide by)
– licensing
– employment practices (CA)
– “all others as applicable”
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1F) Financial Planning and Management
1G) Risk Management
• individual and agency risk
• insurances
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1H) Health and Safety
• OHS; H&S; EP
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1I) Human Resources
•
•
•
•
•
•
•
•
cascade of in-hire requirements
recruitment activities
retention activities
trending (internal re. turnover and external)
competency-based training
performance evals and goal-setting
students & volunteers
personnel policies
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1J)
Technology
• plans and report
1L)
Accessibility
• plans and report; RA
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1K)
RIGHTS of Person Served
• “…communicated in a way that is
meaningful…prior to the beginning of service
delivery…at least annually thereafter…available at
all times.”
• freedom from _____ and right to _____
• complaints procedure and review
• informed consent
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The Standards:
SECTION 1 – BUSINESS PRACTICES
1M) Information Measurement and Management
• “outcomes” (…that individuals are supported to
achieve their goals)
• Reliability, validity, completeness, accuracy
• demographics
*1N) Performance Improvement
• just the loop. this is what it’s all about.
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The Standards:
SECTION 2 – QUALITY INDIVIDUALIZED
SERVICES AND SUPPORTS
2A) Program/Service Structure
• service delivery model/map (intake)
• transition and exit
• records of persons
• informed consent
• behaviour planning (positive, restrictive)
• rights restrictions
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The Standards:
SECTION 2 – QUALITY INDIVIDUALIZED
SERVICES AND SUPPORTS
2B) Individual-Centred Service Planning, Design,
Delivery
• PCP and Goals!
• SNAP and culture
• resident files
• assistive technology and RA’s
• risk assessment
• referrals
• exit and exit summary
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The Standards:
SECTION 2 – QUALITY INDIVIDUALIZED
SERVICES AND SUPPORTS
2C) Medication Monitoring and Management
• …storage…safe handling…labeling…training…
documentation…disposal…and a whole lot
more.
• DROPPED PILL!
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The Standards:
SECTION 2 – QUALITY INDIVIDUALIZED
SERVICES AND SUPPORTS
2F) Community Services Principle Standards
• matching/input into support persons
• community inclusion
• social networks
• “the organization is a proactive force in their
community…”
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The Standards:
SECTION 2 – QUALITY INDIVIDUALIZED
SERVICES AND SUPPORTS
2G) Children and Adolescents Specific
Population Designation
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The Standards:
SECTION 3 – COMMUNITY SERVICES
3K) Community Housing (aka our group
homes)
• privacy & security; personalized setting
• meals and snacks
• community activities, integration
• spiritual, cultural, social, recreational,
employment, self advocacy, self-help activities
& transportation to get there
• visitors & guests
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The Standards:
SECTION 3 – COMMUNITY
SERVICES
3K) Community Housing (continued)
•
•
•
•
•
•
•
•
•
risk
Abuse + neglect
opportunities to make changes in living environment
transitioning
skill development
Personnel are trained
24/7 emerg response
Transportation
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Maintenance of residence during temp leaves
The Standards:
SECTION 3 – COMMUNITY SERVICES
3J)
Host Family Services (HFS)
3L)
Supported Living (SL/SIL)
3M) Respite Services (RS)
• SNAP of family and of person served
• medications
• communication
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Questions?
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Let’s Play…
Surveyor Says!
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Surveyor Says!
(1) Proper handling procedures for a “dropped pill”
include (choose all that apply):
a) 5 second rule
b) Flush it
c) A replacement dose should be ordered from the
Pharmacy
d) Tape it back into the bubble pack
e) A dose from the highest numbered pouch
containing medication should be used until the
replacement dose is received from pharmacy
f) The medication must be returned to the dispensing
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pharmacy for proper disposal
Surveyor Says!
(2) BSS’s Abuse and Reporting Abuse Policies state that “…All
employees and volunteers are responsible and obligated
to reporting any/all situations of abuse or neglect,
observed or suspected, without delay or hesitation; with
no time intervening, to their Coordinator.” In the event
personnel suspects, or it is reported to him or her, a
situation of possible neglect or abuse, he or she must:
a) Sleep on it
b) Talk about it with other staff members, practicum
students, residents, parents of residents, neighbours,
anyone who listen, to get their opinion
c) Report the situation, without delay or hesitation; with no
time intervening, to their Coordinator
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Surveyor Says!
(3) The term “stakeholder” refers to (choose all
that apply):
(a) Persons served and their family members
(b) CLBC social workers
(c) Dan at the dance
(d) Employees and Contractors of
BeConnected
(e) Community partners [Such as DDMHT]
(f) Keg Steakhouse kitchen staff
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Surveyor Says!
(4) A person’s Planning is based upon his or her
SNAP. What does SNAP refer to?
(a) Social Night Away Partying
(b) Strengths Needs Abilities Preferences
(c) Silly Neurosis Affecting Personality
(d) Supplying Needs And Personal Care
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Surveyor Says!
(5) BeConnected’s Vision states:
(a) “The sky is the limit!”
(b) “Over 50 billion served”
(c) “Where everybody knows your name”
(d):___________________________________
_____________________________________
_____________________________________
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