Achieving Quality Through CARF Accreditation

Michael W. Johnson, M.A., C.A.P.Managing Director of Behavioral Health

INTRODUCTIONS

Agenda

• CARF Overview

• The Value of Accreditation– The Value of CARF

• The Survey Process – Preparation

– The Standards

Overview

OUR NAME

Commission on Accreditation of Rehabilitation Facilities

CARF’s Mission 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 the 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 and service delivery

• Diversity and cultural competence in all CARF activities and associations

Overview of CARF

International: North America South America Europe Africa

Asia / Southeast Asia

Accreditation Areas– Behavioral Health - OTP– Child & Youth Services– Employment & Community Services– Medical Rehabilitation– Aging Services

(Adult Day Services/Assisted Living)

Overview (continued)

• Private non-profit established in 1966.

• Recognized in approximately 48 states under mandated or “deemed” status.

• Standards apply to small organizations in rural areas as well as large or urban.

• 1400 volunteer surveyors in U.S. and Canada.

• Approximately 100 CARF staff members

Where is CARF?

As of 2/5/13

792

23007

975

19198

3836 1001

AS BH CYS ECS MED OTP

CARF Accredited Programs Over 8.4 Million Persons are

Served

• Starting in 2014, all health plans that want to participate in health insurance Exchanges or marketplaces must be accredited; if they offer behavioral healthcare services through an MBHO, contracting with accredited organizations will help them in the accreditation process.

• News release July 30, 2013

Value of Accreditation

• Accreditation is an internationally recognized evaluation process used to assess and improve the quality, efficiency, and effectiveness of healthcare organizations.

• It is also a way to publically recognize that a health care organization has met external quality standards.

Value of Accreditation

Accredited organizations enjoy:• Assurance to the public that a neutral third-party has

reviewed the quality of programs and services provided

• The ability to contract with a variety of payers that require accreditation of their providers

• Better reputation among persons served and enhances their awareness and perception of quality of care (Greenfield, Pawsey & Braithwait, 2008)

• Increased overall satisfaction level with services (Al Tehewy, 2009)

Value of the Process

• Although there is significant value to the status of accreditation, the real added value of accreditation is in the process.

• The process provides a framework to improve quality and organizational effectiveness in preparing for the survey, and afterwards between surveys.

Value of the Process

• Before and after the survey, the process stimulates sustainable quality improvement efforts and assists programs to modify their practices to reflect changes in knowledge of generally accepted practices in the field.

• As knowledge and practices in the field change, the standards change, allowing executives to rely on the accrediting body to assist them to design and manage a modern and effective organization.

Evidence for Accreditation

• Provides organization with a well-defined vision for sustainable quality improvement initiatives (Baskind 2010)

• Strengthens interdisciplinary team effectiveness (Pomey, Lemieux-Charles, 2010)

• Promotes sharing of policies, procedures, and best practices among health care organizations (Davis 2007)

• Improved outcomes for the persons served (Thornlow & Merwin, 2009)

Why CARF?

• Field driven standards continually reflect best practices

• Choice of programs to be included in survey

• Multiple pathways to conformance – “non-prescriptive”, “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 accreditation is “do-able”

Standards Manual: Roadmap/Blueprint

CARF Standards provides organizations with:

• A means of ongoing self-evaluations and continuous systems improvement for service delivery.

• An authoritative resource to use to prepare for a survey and accreditation.

• Guidelines for business development and practices and the development and delivery of new programs and services.

• An educational resource on good business and service practices.

The Survey Process

Preparing for a Survey

• Acquire the correct standards manual!

• Staff and leadership buy-in is critical to success

• Make accreditation preparation an organization- wide team effort

• Use the standards manual to help write and refine policies and procedures

Tip: Organize P&P to reflect how you do business (cross-walk to the standards)

Preparing for a Survey

• Attend a training (face-to-face, web)

• May want to speak with or visit other CARF accredited organizations

• Self evaluation will establish your to-do list

• Develop time lines to have things done

• Simplify, simplify, and then simplify again

• Alert all persons served, staff, outside stakeholders to the dates and review the process with them - POSTER

• Consultation ?

Steps to Accreditation

STEP PROCESS TIME

1Consult with CARF resource specialist

1½ - 1 year prior to survey

2 Conduct a self-evaluation 6 months (suggest 9-12)

3 Submit Intent to Survey 4 months (suggest 6)

4 CARF invoices feeAfter application is received

5 Survey team selected 30 days before survey

6 Survey

7 Outcome rendered (email report) 6-8 weeks after

8 QIP Submitted 90 days after award

9 ACQR (3 year only) Anniversary date

10 Maintaining contact Ongoing

Resource Specialist

• Resource Specialists are your:– Guides – Experts in interpretation of the standards

and CARF process

• Resource Specialists help with: – Selection of appropriate field categories

(BH) and programs.– Time lines for submission of pre-survey

documentation and fees.

• Resource Specialists will set you up in Customer Connect.

CARF Contact for New Hampshire

• 6951 E. Southpoint Rd Tucson, AZ 85756

• 888-281-6531• Kathy Lauerman,

ext.7168• klauerman@carf.org• www.carf.org

Time Frame at a Glance Preferred Time

FrameIntent Due to CARF 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

Accreditation Outcomes Three-year accreditation – substantial conformance to the standards. Demonstrated improvement from previous periods of CARF accreditation.

One-year accreditation – areas of deficiency, but evidence of capability and commitment

Provisional accreditation – one year, awarded only once, after one year accreditation.

Non-accreditation – numerous and/or major deficiencies in many areas. Serious questions about program benefits, health welfare or safety. (Inability to achieve a Three Year Accreditation following a Provisional Accreditation)

The Standards

The Standards

• benchmarks that can be achieved by competent providersAchievable

• reflect field consensusConsensual

• positive relationship between development and implementationCost Effective

• leaves the organization free to meet the standards in its own mannerNon-prescriptive

• grounded in day-to-day world of service deliveryPractical

• makes sense to those who implement the standardsRelevant

• reflect current knowledge in the field and emphasize best practicesState-of-the-Art

Principles of the Standards

A “Typical” Standard

Standard (bold)

1.I.2. The organization implements an accessibility plan that includes, for all identified barriers:

a. Actions to be taken.

b. Time Lines.

Check the Glossary

Intent Statement

There may be barriers identified that the organization does not have the authority or resources to remove: effective accommodations may be the appropriate action to be taken in those circumstances.

Examples

Written documentation of potential barriers to services exists. When identifying potential barriers to services, the org. considers various barriers which may include attitudes of staff members toward persons with disabilities and how this will impact initial and ongoing access to services.

Key Definitions

Policy: Written course of action; guidelines adopted by the leadership

Procedure: A “how to” description of actions-to-be-taken. Not written unless specified

Written procedure: Requirement that the procedure is described in writing

Plan: Written future direction that is action oriented and related to a specific project or defined goal.

Section 1 ASPIRE to Excellence®

ASSESS THE ENVIRONMENT Leadership Governance

SET STRATEGY Strategic 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 Performance Measurement and Management

EFFECT CHANGE Performance Improvement

Section 2 – BH / CYSGeneral Program

StandardsA Program Service Structure

B Screening and Access to Services

C Individual Plan

D Transition / Discharge

E Medication Use

F Non-Violent Practices

G Records

H Quality Reviews

Program Standards Sections 3, 4, 5

BH: 3. Core Program Standards

4. Specific Population Designation Standards

5. Community & Employment Services

Addictions Pharmacotherapy

Child and Adolescent

Consumer RunEating Disorder

Criminal Justice Juvenile Justice Medically Complex

Questions