1. Achieving Quality Through CARF Accreditation Michael 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 STEPPROCESSTIME 1 Consult with CARF resource specialist 1½ - 1 year prior to survey 2Conduct a self-evaluation6 months (suggest 9-12) 3Submit Intent to Survey4 months (suggest 6) 4CARF invoices fee After application is received 5Survey team selected30 days before survey 6 Survey 7Outcome rendered (email report)6-8 weeks after 8QIP Submitted90 days after award 9ACQR (3 year only)Anniversary date 10Maintaining contactOngoing

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 Preferred Time Frame Intent Due to CARFExpiration Month *Jul/AugFeb 28Aug *Jul/AugMarch 31Sept Aug/SeptApr 30Oct Sept/OctMay 31Nov Oct/NovJune 30Dec Nov/DecJuly 31Jan Dec/JanAug 31Feb Jan/FebSept 30Mar Feb/MarOct 31Apr Mar/AprNov 30May Apr/May or May/JuneDec 31June

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

30. benchmarks that can be achieved by competent providers Achievable reflect field consensus Consensual positive relationship between development and implementation Cost Effective leaves the organization free to meet the standards in its own manner Non-prescriptive grounded in day-to-day world of service delivery Practical makes sense to those who implement the standards Relevant reflect current knowledge in the field and emphasize best practices State-of-the-Art Principles of the Standards

31. 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.

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 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

34. Section 2 – BH / CYS General Program Standards A 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

35. 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 Run Eating Disorder Criminal JusticeJuvenile JusticeMedically Complex

36. Questions