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Achieving Quality Through CARF Accreditation Michael W. Johnson, M.A., C.A.P. Managing Director of Behavioral Health

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.

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Achieving Quality Through CARF Accreditation Michael W. Johnson, M.A., C.A.P. Managing Director of Behavioral Health

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  1. Achieving Quality Through CARF AccreditationMichael W. Johnson, M.A., C.A.P.Managing Director of Behavioral Health

  2. INTRODUCTIONS

  3. Agenda • CARF Overview • The Value of Accreditation • The Value of CARF • The Survey Process • Preparation • The Standards

  4. Overview

  5. OUR NAME Commission on Accreditation of Rehabilitation Facilities

  6. 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.

  7. 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

  8. 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)

  9. 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

  10. Where is CARF?

  11. CARF Accredited Programs Over 8.4 Million Persons are Served

  12. 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

  13. 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.

  14. 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)

  15. 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.

  16. 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.

  17. 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)

  18. 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”

  19. 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.

  20. The Survey Process

  21. 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)

  22. 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 ?

  23. Steps to Accreditation

  24. 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.

  25. 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

  26. Time Frame at a Glance

  27. 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)

  28. The Standards

  29. The Standards

  30. Principles of the Standards

  31. A “Typical” Standard 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. 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

  32. 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.

  33. Section 1ASPIRE 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

  34. Section 2 – BH / CYSGeneral Program Standards

  35. Program Standards Sections 3, 4, 5 BH: 3. Core Program Standards 4. Specific Population Designation Standards 5. Community & Employment Services

  36. Questions

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