© 2015 CARF International. All rights reserved. A Commitment to Quality: the accreditation journey...

A Commitment to Quality:

the accreditation journey

Presenters

• Rajeev Mohindru, MSW, BSW, RSW, B.Com, B.Tec, DMS

Director of Care

•Dan Stavert, MSW, BSW, RSW

Chief Advisor

STRAW POLL

Raise your hand if….

your organization is accredited.

STRAW POLL

Raise your hand if….

you are very familiar with accreditation.

STRAW POLL

Raise your hand if…..

the thought of accrediting your organization gives you nightmares.

Overview of Session

• About CARF• The accreditation process• Standards• About PICS• Why seek accreditation?• Selecting an accreditor• Learnings and outcomes• Benefits of accreditation

CARF International Group

About CARF

•Commission on Accreditation of Rehabilitation FacilitiesCARF

•Non-profit•IndependentStatus

•Health and human services

Programs

• Aging Services

• Behavioural Health

• Business & Services Network Management

• Child & Youth Services

• Employment & Community Services

• Medical Rehabilitation

• Vision Rehabilitation

CARF Quick Facts

Founded in

First Canadi

an survey in 1969

6,800+ service

providers with more

than 50,000

accredited

programs

More than 8 million

persons served

annually by

CARF-accredite

d orgs

Incorporated in 2002

Offices in Edmonton

&Toronto

480+ service providers with

more than 3,800

accredited programs

Mission

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 centre on enhancing the lives of persons served.

CARF’s Primary Business

The CARF seal of accreditation signifies that a provider focuses on the needs of the persons served and demonstrates commitment to continuously improving service quality.

Accreditation

Recognition of CARF in CanadaBritish Columbia's Ministry of Children and Family Development (MCFD) and

Community Living British Columbia (CLBC) have approved CARF accreditation for both contracted community living agencies and child, youth, and family services.

Alberta Ministry of Health recognizes CARF as an accepted accrediting organization for Alberta’s health system, including seniors care, mental health, and addictions.

Alberta Ministry of Human Services recognizes CARF for contracted child, youth, and family services and for contracted providers of services to persons with developmental disabilities.

Ontario Ministry of Health and Long-Term Care recognizes CARF accreditation for long-term care homes and provides a funding premium to accredited homes.

Ontario’s Community Care Access Centres (CCACs) recognize CARF Canada as a choice for accreditation of both CCACs and contracted service providers.

Ontario’s Mississauga-Halton and Central West Local Health Integration Networks (LHINS) recognize CARF Canada accreditation for LHIN-funded agencies.

Ontario Association of Residences Treating Youth (OARTY) lists CARF Canada as an accreditation option for its member agencies.

Residential Care in BC“Accreditation is an external peer review process to assess and

improve the services health care organizations provide to their patients and clients, based on standards of excellence set by Accreditation Canada or the Commission on Accreditation of Rehabilitation Facilities (CARF).”1

“Many organizations that provide licensed residential community care are also accredited through agencies such as Accreditation Canada or through the Commission on Accreditation of Rehabilitation Facilities. In order to achieve and maintain their accredited status, licensees have additional standards they must meet.”2

References:

1 Fraser Health Authority website, Residential Care Facility pages (site descriptions, “Accreditation Status”)

2 A Guide to Community Care Facility Licensing in British Columbia, Ministry of Health, BC, page 3. http://www.health.gov.bc.ca/ccf/publications/a-guide-to-community-care-facility-licensing.pdf

Development of Standards

• Active support of:• Providers• Consumers• Purchasers of service

• Field-driven

• International consensus standards

• Process emphasizes performance improvement in business and service delivery

Accreditation Standards

• ASPIRE to Excellence®

• Care/Service Process & General

• Program-Specific

• Specialty

Business Practices

Section 1: Business Practice Standards

ASSESS THE ENVIRONMENT• Leadership• Governance

SET STRATEGY• Strategic Integrated Planning

PERSONS SERVED & OTHER STAKEHOLDERS – OBTAIN INPUT

• Input from Person Served and Other Stakeholders

IMPLEMENT THE PLAN• Legal Requirements• Financial Planning and Management• Risk Management• Health and Safety• Human Resources• Technology• Rights of Persons Served• Accessibility

REVIEW RESULTS• Information Measurement and Management

EFFECT CHANGE• Performance Improvement

Sample standard: Leadership 1.A.1. The organization identifies:

a. Its leadership structure.b. The responsibilities of each level of leadership.

No intent statements for this standard

The survey team verifies that whoever is identified fulfills the responsibilities of leadership. This may be done by interviews with boards, councils and management teams; by review of minutes of meetings; and by observation.

* Source: 2015 CARF Aging Services Standards Manual

Standard

Intent Statements

Examples

Required Written Documentation? No

Sample standard – Strategic Planning 1.C.2. A written strategic plan:

a. Is developed with input from:(1) Persons served.(2) Personnel.(3) Other stakeholders.

b. Reflects the organization’s financial position:(1) At the time the plan is written.(2) At projected point(s) in the future.(3) With respect to allocating resources necessary to support

accomplishment of the plan.c. Sets:

(1) Goals.(2) Priorities.

d. Is implemented.e. Is reviewed at least annually for relevance.f. Is updated as needed.

The strategic plan sets forth an organizational roadmap for the future in consideration of relevant business, environmental, and other factors. Because sound business practice demands that the plan be used as a dynamic tool, it should be reviewed at least annually and modified as appropriate.

No examples for this standard.

* Source: 2015 CARF Aging Services Standards Manual.

Standard

Required Written Documentation? Yes, Written Strategic Plan

Intent Statements

Examples

Sample standard - Input 1.D.1. The organization demonstrates that it obtains input:

a. On an ongoing basis.b. From:

(1) Persons served.(2) Personnel.(3) Other stakeholders.

c. Using a variety of mechanisms.

Input is requested and collected to help determine the expectations and preferences of the organization’s stakeholders and to better understand how the organization is performing from the perspective of its stakeholders. The input obtained relates to the organization’s services, persons served and business practices. The organization identifies the relevant stakeholders, besides the persons served, from whom it solicits input.

* Source: 2015 CARF Aging Services Standards Manual

Standard

Required Written Documentation? No

Intent Statements

Input Mechanisms – Examples

Formal & Informal

Written surveys

Suggestion boxes

Complaint or incident summaries

Strategic planning

Advisory groups

Input forums

Councils or committees

composed of persons served

Telephone Surveys

* Source: 2015 CARF Aging Services Standards Manual, 1.D.1. Examples.

STEP PROCESS TIMEFRAME1 Contact CARF Canada staff — CARF

International Resource Specialist assignedRecommended 6-18 months prior to submitting Application

2 Conduct a self-evaluation Work with your Resource Specialist on an ongoing basis

3 Submit Application and fee At least 3 months before survey timeframe

4 CARF invoices for the survey fees; survey scheduling begins

After CARF has reviewed the Application

5 CARF notifies organization of survey date(s) and team

At least 30 days before survey

6 SURVEY

7 CARF renders accreditation decision & provides report

6–8 weeks after survey

8 Quality Improvement Plan (QIP) submitted to CARF

Within 90 days of accreditation award

9 Annual Conformance to Quality Report (ACQR) submitted to CARF

Accreditation anniversary date

10 Communication Ongoing

Accreditation Process

CONSULTATIVE

Possible Accreditation Outcomes

• Three Year

• One Year

• Provisional

• Non-Accreditation

Benefits of CARF Accreditation

• Business improvement

• Service excellence • Competitive

differentiation • Risk management• Funding access • Positive visibility• Accountability • Peer networking

“98% of CARFs

customers report accreditation helps

improve their business*”

* CARF Brochure – The Value of Accreditation 2009.

An Accreditation Journey

Progressive Intercultural Community Services (PICS)

About PICSMission statement: To promote harmony and intercultural understanding

for the purpose of building a more inclusive and mutually respectful society; to ensure equal access to jobs and services and to work with to work with other agencies and institutions.

History: PICS was established in 1987 as a one-man organization by Dr Charan Gill (CEO). It has now developed into a major community organization with over 100 staff members. Charan Gill is the founding President of Progressive Intercultural Community Services (PICS)

Programs: We offer many programs and services including:– language and settlement services– employment programs– housing for seniors– training– programs for women and youth.

Locations: Surrey, (Two Locations), Delta, White Rock and Vancouver

Persons served: About 30,000 per year

www.pics.bc.ca

Contemplating Accreditation

Why pursue accreditation?

• To enhance professional credibility of the organization

• To increase opportunities for grants and funding.

• To maintain standard guidelines, policies and procedures amongst various departments of the organization.

Selecting an Accreditation Organization

Selection criteria– Consultative Approach– Client / Person Centered– Experienced in accrediting culturally

based non profits

Why CARF?

• Support provided• Person-centred standards• Non-prescriptive approach• Focus on outcomes• Community-based• Consultative not inspective• Experience of non-profit

community organizations

PICS Accreditation Journey

The Journey Begins

Selected CARF

Resource Specialist Support

Select programs

Program Selection

Aging Services

Assisted Living

Adult Day Services

Independent Senior Living& GOVERNANCE

Self-Evaluation

• PICS decided to utilize the services of a CARF consultant who supported PICS through out the process.

Non-prescriptive approach

Peer Review Survey

PICS survey experience:• Consultative approach• Helpful recommendations• Knowledgeable peer surveyors• Celebrating strengths

Observation• Tours• Services

Interviews• Persons served• Staff• Other

stakeholders

Documentation• Records• Policies• Procedures• Plans

PICS Awarded….

MAXIMUM AWARD: Three Year

accreditation

First Canadian organization

accredited under the Independent

Senior Living standards

Only CARF-accredited

ADS program in BC!

Learnings• CEO has seen the potential of standards to hold his staff to a

higher accountability

• Staff realize that although the work may be important it is difficult to prioritize and complete the depth and breadth of the work

• Staff have reported that the process has increased training and collection of feedback for quality improvement

• Staff have reported that Health and Safety focus makes them feel more prepared for an emergency

• Regular education and training have created enhanced awareness amongst the staff

• Accreditation has created streamlined services both internally, (e.g. policy development and implementation) and externally (e.g. service delivery)

Outcomes & Benefits• More accountability by staff at all levels

• Structurally setting up dedicated QA and agency-wide Health and Safety committee has increased internal accountability

• There is consistency with the training protocols, procedures and processes

• The annual performance report collates a wealth of statistics in one place

• Provides CEO with a new lens of management requiring a higher level of accountability for policy compliance

Aging Services Webinar

Join us for a complimentary webinar!

Introduction to CARF Aging Services AccreditationJune 10, 2015

10-11:30 am (Pacific Daylight Time)

This webinar will provide a basic overview of CARF accreditation for Aging Services programs, including Independent Senior Living (supportive housing), Assisted Living, Person-Centred Long Term Care Communities (residential care), Adult Day Services, and Home & Community Services.

To register, contact CARF Canada at 1-888-281-6531 ext. 3009

or email canadainfo@carf.org

STRAW POLL

Raise your hand if…..

the thought of accrediting your organization is a little less scary

than it was 45 minutes ago.

Dan StavertChief Advisor

dstavert@carf.org1-888-281-6531 ext. 3008

Contact

Questions?

Thank you!

© 2015 CARF International. All rights reserved. A Commitment to Quality: the accreditation journey...

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