© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Introduction to CARF Accreditation
Michael W. Johnson, M.A., C.A.P.Managing Director, Behavioral Health
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Agenda
• Welcome & Introductions• Value of Accreditation• Overview of CARF• Development, principles and
organization of the standards• Accreditation Process
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
What Is Accreditation?
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CARF Accreditation Is...
A continuous improvement process where peers apply internationally
recognized standards to an organization’s programs/services
through a consultative on-site survey to address stakeholder needs around accountability in efficiency, results or outcomes of services, and
satisfaction with services and the organization.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Value of Accreditation
• Business improvement• Service excellence• Competitive differentiation• Risk management• Funding access• Positive visibility• Accountability• Peer networking
Accreditation Supports:
• Innovation• Empowerment• Productivity
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Value of Accreditation
• Business strategy• Communication
system• Management tool• Quality strategy• Prompts
development and use of outcome measures and the management of outcomes
• Establishes baseline of quality for an industry
• Refocuses business on person served/resident
• Establishes and re-establishes relationships with stakeholders
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Mission of CARF
The mission of CARF 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
persons served.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Core Values
• 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/service delivery
• Diversity/cultural competence
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Overview of CARF• Independent, nonprofit, international accreditation
and standards setting organization founded in 1966
• CARF International is a group of companies that includes CARF, CARF Canada, and CARF Europe
• Fields served:– Aging Services– Behavioral Health, includes Business and Service Management
Networks– Child and Youth Services– Durable Medical Equipment Prosthetic Orthotics and Supplies
(DMEPOS)– Employment and Community Services– Medical Rehabilitation– Opioid Treatment Program– Vision Rehabilitation Services
• Recognized in approximately 48 states under mandated or deemed status
• Over 1,300 surveyors and approximately 100 staff members
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
CARF Accredited Programs Over 8 Million Persons Served
Annually
896
25031
1166
18201
3992 1066
AS BH CYS ECS MED OTP
More than 6,800 service providers with more than 50,000 accredited programs and services at 23,000
locations on 5 continents
As of 4/5/15
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Why CARF?
• Field-driven standards continually reflect best practices
• Choice of programs to be included in survey
• Non-prescriptive and 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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
CARF Process
• Person-centered• Quality framework
(ISO, Baldrige, Six Sigma, LEAN – crosswalk with CARF)
• Emphasis on performance improvement in business and service delivery
• Consultative peer-review survey• Assistance throughout the
journey
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Principles of the Standards
• Worded to describe what end needs to be achieved, allows flexibility to meet the standards
Non-prescriptive
• Grounded in day-to-day world of service delivery
Practical
• Makes sense to those who receive, pay for, and deliver the services
Relevant
• Reflect current knowledge in the field and emphasize best practices
State-of- the-
art
• Benchmarks that can be achieved by competent providers
Achievable
• Reflect field consensus
Consensus-
based
• CARF controls cost of standards development
Efficient
• Positive relationship between cost to implement and the resulting improvement
Cost effectiv
e
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
How Standards are Organized:
Process and Outcome Focus
Section 1 Business Practice Standards
Practices common to all providers
Optional specialized services
Section 2 Care Process for Person Served Standards
Entry, transition, exit and processes for services
Section 3 Program Specific Standards Practices most unique for persons in a setting
Section 4
Specialty ProgramStandards
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
The Accreditation Process
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Accreditation Conditions
1. For a minimum of six months prior to the site survey, each program/services for which the organization is seeking accreditation must demonstrate:a. The use and implementation of CARF’s
organizational and service standards applicable to the service.
b. The direct provision of services to the persons served.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Conditions
2. The organization must provide such records, reports, and other information as requested by CARF.
3. A Quality Improvement Plan (QIP) must be submitted within 90 days following notice of accreditation. This plan shall address all areas for improvement identified in the report.
4. An organization that achieves a Three-Year Accreditation must submit a signed Annual Conformance to Quality Report (ACQR). The report is submitted in each of the two years following the Three-Year Accreditation award.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Steps to Accreditation STEP
PROCESS TIME
1 Consult with CARF resource specialist 1 year prior to survey
2 Conduct a self-evaluation 6–9 months prior to survey
3 Submit survey application 3–6 months prior to survey
4 CARF invoices fee After application is received
5 Survey team selected 30 days before survey
6 Survey
7 Outcome rendered 6–8 weeks after survey
8 QIP submitted 90 days after outcome
9 ACQR submitted Anniversary date
10 Maintain contact Ongoing
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Some Firsts
• Relax—Most of this is good business and common sense and a reflection of what you do on a daily basis
• Be prepared for resistance• Be aware of change mechanisms
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Know your capabilities
• Factors affecting what you can and cannot do– Environment– Resources– Strategies and tactics– Values
• Does the organization have what it takes to succeed?
• Not instinctive if all is going well
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
A Team Approach
• Involve governance partners at the beginning
• Orient all staff that this is about improving service quality not passing the survey
• Involve all departments• Identify core workgroup and leader• Use the strengths/interests of staff to work
on pieces, e.g., Health & Safety, outcomes• Develop system(s) for tasks, e.g.,
calendars• Communicate: newsletters, internal and
external; workgroups; regular meetings
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 1
Consult with a designated CARF resource specialist
– Make contact early– Access to Customer Connect– Identify and order standards manual– Ongoing contact for assistance
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Resource Specialists
• Experts in CARF process• Interpret standards• Discuss time lines and fees• Assist you select appropriate standards
manual and program(s)/service(s) for accreditation
• Set up Customer Connect account– Secure online web portal available 24/7– Designed specifically for CARF contacts at
accredited organizations or those seeking accreditation
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Resource Specialists
Kathy Lauerman is the Maryland Resource Specialist
[email protected](888) 231-6531 ext. 7168
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Budget for the Costs
• Publications – go to www.carf.org/catalog– Accreditation Sourcebook– Standards Manual– Survey Preparation Workbook– Standards Conformance Checklist
• Application fee• Survey fee• Staff time
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 2
Conduct a self-evaluation (internal process)
– Use standards manual– Use survey preparation workbook– Use standards conformance
checklist– Use spreadsheets or project
planning tools
Accreditation is an ongoing process, not a one-time event.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Tips for Success
• Identify where your activities fit and satisfy the standards
• Allow adequate preparation time and resources
• Use a team approach to prepare• Use preparation as a management tool
and quality strategy• Use CARF resources
– Resource Specialist– customerconnect.carf.org – www.carf.org
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 3
Submit survey application– Via Customer Connect– Indicates desire for survey and
agreement of terms
– Includes detailed information about leadership and demographics
– Size, number, and distances of locations of the organization (to establish survey team)
– Required supporting documents– Application fee
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Survey Time FramesPreferred Time
FrameApplication Due 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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 4
CARF invoices for the survey fee– CARF: Per surveyor per day
(includes surveyor expenses) Based on number of surveyors and days
– Scheduling begins
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
CARF Fee Structure*
• Application Fee: $995.00– Non-refundable
• Survey Fee: $1,590.00 per surveyor per day– Based on number of surveyors and days
needed to complete the survey– Includes all surveyor expenses
* USD
Average Survey
2 surveyors/2 days
$6,360.00
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
What if Something Changes?
• Notify CARF if something changes after you have submitted your survey application
• Especially stay aware of the time frame you have requested for the survey
• If you have been notified of the survey dates and then want to change, there
is a cancellation/rescheduling fee plus nonrefundable travel expenses
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 5
CARF selects the survey team– Selected by matching surveyor
expertise with organization programs/services
– Letter of survey date(s) and names of surveyor(s) sent to the organization at least 30-day prior
Alert all persons served, staff, and outside stakeholders to the survey dates — display survey notice poster.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 6
Survey team conducts the survey– Determines conformance to
standards• Tour• Observations• Interviews• Review of documentation
– Provides consultation– Shares findings with organization– Submits findings to CARF
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Remember
The survey team is looking for a demonstration of consistency
between services, policies, procedures, and documentation.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 7
CARF renders accreditation decision– Review of survey team findings– Decision 6–8 weeks after survey– Survey report (emailed)
– Documented recognition for observed excellence and strengths
– Consultative suggestions based on collective experience
– Recommendations for areas of improvement
– Certificate awarded
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Outcomes
Three-Year Accreditation – Substantial conformance to the standards. Demonstrated ongoing quality improvement and continuous conformance from any previous period of CARF accreditation.
One-Year Accreditation – Areas of deficiency, but evidence of capability and commitment to progress toward their correction.
Provisional Accreditation – After a One-Year accreditation, awarded if organization is still functioning at the same level. Only awarded once for a period of one year.
Nonaccreditation – Major deficiencies in several areas. Serious questions as to the benefits of service or the health, welfare, or safety of those served. Or if failed to satisfy one or more Accreditation Conditions.
(Cannot achieve a Three-Year Accreditation following a Provisional Accreditation)
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 8
Submit Quality Improvement Plan (QIP)
– Due 90 days following receipt of survey report
– Outlines actions taken or to be taken
– Be sure to address all recommendations
– Reviewed by CARF staff– Included for surveyor’s review and
use in the next survey
(If you are unsure about any of the recommendations, call your Resource
Specialist)
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 9
Submit annual quality reports– Annual Conformance to Quality
(ACQR) submitted on accreditation anniversary in each year following award• CARF send information 10 weeks in
advance• Confirms ongoing conformance
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Process — Step 10
CARF maintains contact with the organization
– Ongoing resource throughout tenure of accreditation• Publications• Seminars and conferences• Websites (www.carf.org and customerconnect.carf.org)
Organization provides timely information to CARF regarding administrative changes and significant
events (changes in leadership, mergers, allegations, compliance inspections, etc.)
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Contact Us
Michael JohnsonManaging Director of Behavioral [email protected], ext. 7101
Kathy LauermanResource [email protected], ext. 7168
1-888-281-6531