CARF - University of Pittsburgh · HFAP DNV COA URAC ACHC CARF. Why Get Accredited? ... meets or...
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CARF ACCREDITATION IN ASSISTIVE TECHNOLOGY SUPPORTS AND SERVICES
Transcript of CARF - University of Pittsburgh · HFAP DNV COA URAC ACHC CARF. Why Get Accredited? ... meets or...
CARFACCREDITATION IN ASSISTIVE TECHNOLOGY
SUPPORTS AND SERVICES
Disclosure/Bias
▶ I do not work for CARF▶ I am an employee at the University of Vermont
Medical Center▶ I am a consultant for the University of Pittsburgh▶ I believe that the effective implementation of
Assistive Technology can be life changing for a user
Accreditation - What is is?
▶ Voluntary Process of review to demonstrate the ability to meet predetermined standards established by a professional accrediting agency
Who Does it?
TJC
NCQU
HFAP
DNV
COA
URAC
ACHC
CARF
Why Get Accredited?
Sign of quality
Access to Funding
Continuous Improvement
Accountability
Cost?
Manuals
Application fee
Survey fee (~ 2 surveyors over 2 days)
Who are the surveyors?
Peers
>5 years experience in program area
employed CARF acc. org.
consultative vs. inspective approach
What will Surveyors look at?
EVERYTHING!!Clinical Practice
Policies and Procedures
Quality Assurance
Safety Standards
Staff Credentialing/training
Outcomes
Information management
Available services
Availability of equipment and
expected wait times
Potential conflicts of interest
Observe treatment sessions
Sit in on team conferences
Talk to persons served
Talk to Team members
Speak with physicians
Survey Outcome
▶ Three-Year Accreditation - meets or exceed CARF standards - next review in 3 years
▶ ONE- Year Accreditation - some deficiencies, with commitment toward correcting these - next review 1 year
▶ Non-accreditation
Where to Begin?
1.COMMUNICATE
CARF SURVEYS CAN BE:
STAND ALONE BLENDED
2. CALL CARF & ORDER MANUALS
3. REVIEW THE STANDARDS
4. SELF EVALUATION
5. PICK A DATE&
PREPARE
An organization MUST be providing direct services AND working in compliance to the standards for AT LEAST 6 MONTHS prior to survey!
Preferred Time Frame Survey application due to CARF no later than:
Preferred Time Frame Survey application due to CARF no later than:
Jul/Aug Feb. 28 Dec/Jan Aug 31
Aug/Sept Apr 30 Jan/Feb Sep 30
Sept/Oct May 31 Feb/Mar Oct 31
Oct/Nov Jun 30 Mar/Apr Nov 30
Nov/Dec Jul 31 Apr/May or May/Jun Dec 31
Plan a MOCK SURVEY
Submit the INTENT to survey
at least 3 months prior to targeted time frame
Time ManagementBe prepared – keep track of dates
Deadline
URGENT
Important
Standards for AccreditationIn Assistive Technology Supports and
Services
Section 1 – ASPIRE Section 2 a – Program Service Structure Standards Section 4 – Assistive Technology Supports and Services Program StandardsNote: Manuals are updated annually - the above information may change
Understand the STD’s Manal
Each standard has 3 parts:
STANDARD - written to be outcome focused
INTENT - Identifies why CARF thinks the STD is important
LEARNING/TEACHING - provides examples and resources
3.Q.12. When a person exits services, a summary report contains:
a. A description of assistive technology services provided and approximate training time.b. Identification of potential future assistive technology needs and recommended implementation plan.c. Maintenance, troubleshooting, and repair source(s).
Intent StatementsBefore leaving services, a person served is given a summary of services.
ExamplesAn organization might give a copy of the summary report to
the person who received services to ensure that subsequent providers are informed of potential identified needs.
2015 Employment and Community Services Standards Manual CARF p.289
ASPIRE to ExcellenceTHE NEW FRAMEWORK ORGANIZES CARF'S STANDARDS INTO LOGICAL,
ACTION-ORIENTED BUSINESS PRACTICES.
Section 1A – Access the Environment The focus is the person served with leadership’s guidanceS – Set Strategy Strategic planning.P – Persons Served Obtain Input from persons served and other stakeholderI – Implement the Plan Financial and Regulatory SustainabilityR – Review Results Performance MeasurementE – Effect Change Performance Improvement
You will be expected to know and provide access to ASPIRE standards – You need to own this if doing a stand alone survey!
Assistive Technology Supports and Service
Currently 13 Standards
Informed Choice
● Program information
● Process
● Expectations
● Options
● Cost
● Disclosure
Individual
● goals
● experience
● dynamic nature of disability
● environment
● barriers/risks
Communication
● all parties
● timelines
● expectations
● outcomes/performance indicators
Community/ Integration
● training
● collaboration
● referrals
● resource
Performance Improvement
● Access
● Effectiveness
● Efficiency
● Satisfaction
RICHMOND VA MEDICAL CENTER(Program Name)
(FY Year) PERFORMANCE MEASURE REPORTREPORT PERIOD:DOMAIN: ACCESS
OBJECTIVE MEASURE APPLIED TO POPULATION
TARGET LEVEL DATA SOURCE
Quarter % N
1st Quarter
2nd Quarter
3rd Quarter
4th Quarter
Fiscal Year
FINDINGS ACTIONS/RECOMMENDATIONS
RICHMOND VA MEDICAL CENTER(Name of Program)
PERFORMANCE IMPROVEMENT SUMMARY (YEAR)
Access
Process Name:Specific Measure:Process Owner:
Description of Measure:Link to Strategic Initiative/Key Business Driver:Process Changes (Interventions):Method of Measurement:Data Source:
PREPARE
OBSERVATION
INTERVIEW
DOCUMENTATION
OBSERVATION
Clinical practice
Physical environment
Treatment sessions
Team conferences
INTERVIEW
Direct Staff
Persons Served/family
Leadership/Admin
Funders
Sample Questions:
How satisfied are you with services?
How have you provided or used input?
How has the program improved?
Tell me about your training - professional growth opportunities.
What is your role...on the team...in the community?
What have you done to improve accessibility?
Tell me about your strategic planning process.
Have you participated in/received outcome measures?
How often do you review job descriptions?
DOCUMENTATION
Policies/ProceduresMedical Records
Personnel RecordsClinical Practice Guidelines
Safety StandardsBudgets
Strategic PlanProgram Structure
What’s in your head NEEDS to be on Paper!
“Paper” does NOT mean it has to literally be on a printed page:
• Can be accessed on the computer• Can be a web-based document• Can be a printed flyer, posted
notification or postcard
IT DOES NEED TO BE READILY ACCESSIBLE TO A SURVEYOR
Sample Documentation:
Required Written Documentation -
Appendix A provides a table that identifies the standards that explicitly require some form of written documentation.
Standard Requirements Location of Documents
3.Q.12. Exit summary report for persons served
Sample Documentation cont.:
Operational Timelines - Appendix B provides a table listing standards that
require tasks be conducted at designated timed intervals.
Activities to be conducted Annually
Standard Activity Date of last Occurrence
Document Source
2.A.1.c. Review of scope of services
Develop relationships with those who can help you:
Quality Management OfficeHuman ResourcesEngineering and SafetyOther sister hospitals who have AT clinics…..
DON’T REINVENT THE WHEEL!
Survey Exit
Most all leave with recommendations
Red flags: high rates of turnover, multiple changes in management, not making payroll
Frequently Cited Standards
Health and Safety
Cultural Compliance and Diversity
Measuring Efficiency
HELP IS AVAILABLE!
Collaborative/peer review process
Resource Specialist at CARF
Ask “How am I supposed to show this?”
· Organizational Charts· Facility MCMs (relevant to program. ASPIRE has its own binder)· Accessibility Report· Incident Report· Complaints· Cultural Competency· Ethics
· Functional Statements· Competencies· Trainings· Staff Orientation· Strategic Plan· Denials· Technology Plan· Performance Improvement/outcomes
Suggestions/Summary
1. Prepare CARF program binders for:
2. Learn and understand ASPIRE
3. Understand efficiency and effectiveness
4. Allow time following Mock Survey to make changes
5. Develop relationships with other departments
6. Reach out to other AT programs
7. Use your CARF Resource person
8. Attend any offered trainings
9. Complete Survey Preparation Workbook
10. Refer to the CARF Standards Manual
CARF International, 6951 E Southpoint Road, Tucson, AZ 85756-9407, USA Toll Free: (888) 281-6531, Fax: (520) 318-1129 TTY: (520)495-7077
CARF Canada, 501-10154 104 Street NW, Edmonton AB T5J-1A7, CANADA Toll Free: (888) 281-6531, Fax: (780) 426-7274
CARF Europe, 4th Floor, Rex House, 4-12 Regent Street, London SW1Y 4RG, UK Phone: +001 (520) 325-1044, Fax: +001 (520) 318-1129
WWW.CARF.ORG
Remember:Don’t reinvent the wheel
&Stick to your timelines
You can do this!
Dawn Hameline, OTR/L, ATP [email protected]
