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Accreditation for SCI Rehabilitation: Quality, Accountability, and Transparency. ESCIF Congress 18-20 May 2011 De Rijp, The Netherlands. CARF International. First question what does CARF stand for? Commission on Accreditation of Rehabilitation Facilities (CARF). Second question….

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Accreditation for sci rehabilitation quality accountability and transparency

Accreditation for SCI Rehabilitation:Quality, Accountability, and Transparency

ESCIF Congress

18-20 May 2011

De Rijp, The Netherlands

Carf international
CARF International

  • First question what does CARF stand for?

    • Commission on Accreditation of Rehabilitation Facilities (CARF)

Second question
Second question….

  • What is accreditation?

    • Systematic approach to review and address performance of organizations

    • Uses standards that are developed in a variety of ways

    • Should be third party and independent

    • Should be not-for-profit

    • Surveyors are from outside the organization but should have expertise in the area being surveyed

Carf international1
CARF International

  • An international accreditation and standard-setting organization

    • Develop and revise standards

    • Consultative accreditation process

  • 1966

  • Private, not-for-profit, independent

  • Health and human services accreditation across the lifespan and continuum of care

  • Field driven – consumers, providers, payers, regulators

  • Moral owners – persons served

    • Person centered

Carf values
CARF Values

  • 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

Carf international areas of accreditation
CARF International Areas of Accreditation

  • Aging Services

  • Behavioral Health Service

  • Children and Youth Services

  • Employment/Community Services

  • Medical Rehabilitation Services


    • Durable Medical Equipment and Prosthetic/Orthotic Supplies

  • Opioid Treatment Programs

  • Quality Insurance Practices (Non-US)

Medical rehabilitation focus
Medical Rehabilitation Focus

  • Only accreditor focused on medical rehabilitation

  • Specialty programs to differentiate yourself in the market…for example

    • Stroke

    • Brain Injury

    • Amputee

    • Spinal Cord System of Care

    • Interdisciplinary Pain

    • Occupational Rehabilitation

    • Pediatrics

    • Health Enhancement

    • Case Management

    • Inpatient, Outpatient, Home and Community Services, Residential, Vocational

Carf international2
CARF International

  • International: US, Canada, Europe, Asia, Africa, South America, Middle East

    • 19 Countries

    • 8.7 million people served in 2010

    • 6,700+ organizations

    • 48,700+ programs

    • 20,000+ locations

  • More than 2,600 surveys annually

  • More than 1,500 peer surveyors

  • 106 accredited Spinal Cord Systems of Care

Mission and accountability
Mission and Accountability

  • The mission of CARF:

    • Promote quality

    • Value

    • Optimal outcomes of services through a consultative accreditation process that centers on enhancing the lives of persons served.

  • Accountable to the CARF Board of Directors

Accreditation within a care system
Accreditation within a Care System

  • Supports:

    • Innovation

    • Empowerment

    • Productivity

    • Accountability

    • Better ways to deal with competition through planning

    • Provide a continuum of high quality care in an accessible, responsive and caring manner and at a reasonable cost

Accreditation as an innovation
Accreditation as an Innovation

  • Learning new ways to get work done through:

    • Creative problem solving that utilizes continuous quality improvement tools

    • Critical to streamlining work processes and finding better ways to achieve success with fewer resources

    • Use of accurate, complete, reliable and valid data to make decisions

Accreditation as a quality strategy
Accreditation as a Quality Strategy

  • Important principle:

    • Understanding that the organization will never again be “still”

    • Won’t have a finish line – continuous improvement

    • Will require organizations and people to look for ways to better serve their customers in a more cost effective manner

    • Quality framework – ISO, Six Sigma, LEAN, etc.

Why accreditation
Why Accreditation?

  • Quality strategy

  • Business strategy

  • Communication system

  • Management tool

  • Establishes baseline of quality for an industry

  • Refocuses business on person served/resident

  • Establishes and re-establishes relationships with stakeholders

Design framework

Section One ASPIRE to Excellence



Integrated Strategic Planning

Input from Persons Served

Legal and regulatory Requirements

Financial Planning and Management

Risk Management

Section One ASPIRE to Excellence

Human Resources

Health and Safety


Rights of Persons Served

Accessibility – Removal of Barriers

Information and Outcomes Management – both business and clinical

Performance Improvement


Design framework1

  • Section 2:

    • 2.A Program/Service Structure

    • 2.B Rehabilitation and Service Process for the Person Served

    • 2.C Service Process for Persons Served in Home and Community Services

    • 2.D Health Enhancement

    • 2.E Case Management

    • 2.F Rehabilitation and Service process for Children and Adolescents

Design framework2

  • Section 3 – Specific Programs

    • Spinal Cord System of Care meets

      • Comprehensive Integrated Inpatient Rehabilitation Program standards

      • Outpatient Medical Rehabilitation program standards

      • Spinal Cord System of Care standards

    • If the SCSC has Home and Community Services, Residential Rehabilitation Services, and/or Vocational Services in its continuum and they meet the program description they must seek accreditation in those areas

Persons served perspective
Persons Served Perspective

  • Moral Owners of CARF –

    • Who we can not fail to protect

  • Starts in leadership with the standard that says:

    • A person centred philosophy:

      • Is demonstrated by:

        • Leadership

        • Personnel

      • Guides the service delivery

      • Is communicated to stakeholders in an understandable manner

Person served perspective
Person Served Perspective

  • Active listening in ongoing way

    • What you do with the information

  • Rights

  • Removal of barriers

  • Staff that are competent to assist with person served meeting their goals

  • Answering the question :

    • What happens for a person like me in your program? (RESULTS)

Person served perspective1
Person Served Perspective

  • Access to services

  • Value or Satisfaction from person served perspective

    • uSPEQ: The Voice of the Consumer

  • Member of the decision-making team

  • Active participant in their rehabilitation

  • Preferences

Carf process
CARF Process

  • A consultative, peer review survey process versus “inspection”

  • Performance improvement/quality framework

  • A journey … no finish line

  • Assistance throughout the process - not just about your survey

  • Network and build connections

  • Person-centered

  • Surveyors are your peers from the field. Their consultation adds value and quality to the survey

  • Standards revised every 3-4 years – raises the bar for rehabilitation

Survey process
Survey Process

  • 2-3 days with surveyors from all over

  • Orientation Conference

  • Physical Plant Tour

  • 3 components of a survey:

    • Interview

    • Observation

    • Review of documents

  • Exit conference

Survey process1
Survey Process

  • Organization preparation

    • Assigned a resource specialist to work with you

    • No charge for consultation via emails, phone, use as often as you want

    • Trainings could be through CARF 101s, webcasts, audiotapes

    • Quick to respond and people who answer questions are clinicians

Survey process2
Survey Process

  • How long does it take to prepare?

    • Depends upon how organized you are as a business

    • Have to have a minimum of 6 months track record of use of the standards

    • Start by thorough review of standards and identify which ones you are not doing at all (if there are any like that) and begin there

    • Use CARF resource specialist to assist – do not hesitate to ask questions instead of wasting time trying to figure it out!

Survey process3
Survey Process

  • Accreditation Outcomes:

    • Three Year

    • One Year

    • Provisional (a second one year in a row; third time we visit if not a three year the organization is non-accredited)

    • Non accreditation

Carf international3
CARF International

  • Peer review process

  • Process emphasizes the person served, performance improvement, business and service delivery aspects of human service, and good management process

  • Strong case managed approaches throughout process sets of standards as well as program standards

  • Framework that includes business and clinical guidance

Always a question about costs
Always a question about costs

  • $995 (USD) non-refundable Intent to Survey fee (like an application)

  • $1950 (USD) per day per survey includes

    • Travel

    • Hotel/meals

    • Survey

    • Survey report

    • Certificate

  • Typical survey 2-3 surveyors (depends upon how many programs you are getting accredited) for 2-3 days ($7800-11,600)

Which organizations choose carf
Which organizations choose CARF?

  • Some don’t choose some are “mandated”

    • Government

    • Payer

    • Associations

  • Those wanting to differentiate themselves

  • Those wanting a performance improvement system that reflects their daily work

    • ISO

    • Six Sigma

    • Lean

  • The competitor is doing it so “I have to do it”

  • New organizations

  • The “bad apples” usually don’t

  • Those that already have a reputation don’t see the need unless there are competitors in their geographic area that have it

European organizations that have chosen carf
European organizations that have chosen CARF

  • National Spinal Injuries Centre Stoke Mandeville Hospital – Aylesbury England

  • NRH - Dun Laoghaire, Ireland

  • Sunnaas – Oslo, Norway

  • University of Lund - Hoor, Sweden

  • Uppsala University Hospital, Uppsala, Sweden

Accreditation not a guarantee but
Accreditation Not a Guaranteebut …

  • A foundation

  • Identifies necessary components for excellence

  • Addresses stakeholder needs around accountability in efficiency, results or outcomes of services, satisfaction with services and the organization

  • Uses a quality framework that is embedded in all quality awards

Specific topics in carf


Medical/ physiological



Research capability

Aging with a disability

Case management

Resource management

Transition planning

Life-long follow-up


Life-ling health promotion

Resources for independent living and community integration

Prevention related to potential risks and complications

Safety for persons served and environments in which they participate

Specific topics in CARF

Specific topics
Specific topics

  • Provide directly or link:

    • Behavioral health

    • Independent living centres

    • Clinical research centres

    • Consumer advocacy groups

    • Driver rehabilitation

  • Arranges for or provides diagnostics

  • Specialty physicians and staff

  • Ventilator persons served

Specific topics1

Education program for person served and families/support systems based on needs:

Access to benefits and systems

Autonomic dysreflexia

Bladder and bowel management

Cardiovascular risk factors

Chemical use/abuse/dependency

Consumer advocacy organizations



Diabetes prevention

Edema management

Emergency preparedness

Follow-up medical care –

need for and access to

Independent living

Life care planning

Medical nutrition therapy

Musculoskeletal issues

Pain management

Specific Topics

Specific topics2

Education: systems based on needs:

Psychosocial issues

Pulmonary care

Self-advocacy and consumer competency

Self-management of health

Sexual counseling and education including information about reproductive issues


Skin care and prevention of pressure ulcers

Spasticity management

Spinal cord injury research, including access to current research

Use of leisure time

Weight management

Specific Topics

Specific topics3

Services systems based on needs:

Opportunities to try new equipment and technology

Demonstrate expertise in:

Assistive technology

Electronic aids to daily living

Environmental controls

Environmental modifications

Personal care attendants

Peer counseling

Work with community on emergency preparedness

Leadership role in adaptive sports and recreation

Lifetime information on health and wellness resources

Life long follow-up

Comprehensive annual reviews

Educate community

Specific topics

What does carf mean for improvement
What does CARF mean for improvement? systems based on needs:

  • Standards revised so “raises the bar”

  • Internal structure for performance improvement on both business and clinical practice

  • Opportunity to network and work with others in the field

    • Presentations

    • Articles

    • Webcasts

How are people engaged
How are people engaged? systems based on needs:

  • International Standards Advisory Committee

  • Field Review

  • Use their resources in standards

    • National Spinal Cord Injury Association

  • Could develop a system like we have in pediatrics of “Liaisons”

Contact us
Contact us systems based on needs:

  • Chris MacDonell – Managing Director


    • 202-664-3314 mobile



  • Cathy Rebella – Resource Specialist for Europe