© 2015 CARF International. All rights reserved. Introduction to CARF Accreditation Michael W....

© 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


Agenda

• Welcome & Introductions• Value of Accreditation• Overview of CARF• Development, principles and

organization of the standards• Accreditation Process


What Is Accreditation?


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.


Value of Accreditation

• Business improvement• Service excellence• Competitive differentiation• Risk management• Funding access• Positive visibility• Accountability• Peer networking

Accreditation Supports:

• Innovation• Empowerment• Productivity


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


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.


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


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


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


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


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


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


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


The Accreditation Process


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.


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.


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


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


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


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


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


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


Resource Specialists

Kathy Lauerman is the Maryland Resource Specialist

[email protected](888) 231-6531 ext. 7168

mailto:[email protected]


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



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.


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

http://customerconnect.carf.org/

http://www.carf.org/



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


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



CARF invoices for the survey fee– CARF: Per surveyor per day

(includes surveyor expenses) Based on number of surveyors and days

– Scheduling begins


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


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



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.



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


Remember

The survey team is looking for a demonstration of consistency

between services, policies, procedures, and documentation.



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


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)



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)



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



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.)

http://www.carf.org/

http://www.customerconnect.carf.org/


Contact Us

Michael JohnsonManaging Director of Behavioral [email protected], ext. 7101

Kathy LauermanResource [email protected], ext. 7168

1-888-281-6531



© 2015 CARF International. All rights reserved. Introduction to CARF Accreditation Michael W....

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