© 2015 carf international. all rights reserved. a commitment to quality: the accreditation journey...
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© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
A Commitment to Quality:
the accreditation journey
© 2013 CARF International. All rights reserved.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Presenters
• Rajeev Mohindru, MSW, BSW, RSW, B.Com, B.Tec, DMS
Director of Care
•Dan Stavert, MSW, BSW, RSW
Chief Advisor
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
STRAW POLL
Raise your hand if….
your organization is accredited.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
STRAW POLL
Raise your hand if….
you are very familiar with accreditation.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
STRAW POLL
Raise your hand if…..
the thought of accrediting your organization gives you nightmares.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Overview of Session
• About CARF• The accreditation process• Standards• About PICS• Why seek accreditation?• Selecting an accreditor• Learnings and outcomes• Benefits of accreditation
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
CARF International Group
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About CARF
•Commission on Accreditation of Rehabilitation FacilitiesCARF
•Non-profit•IndependentStatus
•Health and human services
Programs
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Programs
• Aging Services
• Behavioural Health
• Business & Services Network Management
• Child & Youth Services
• Employment & Community Services
• Medical Rehabilitation
• Vision Rehabilitation
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
CARF Quick Facts
Founded in
1966
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Accreditation Standards
• ASPIRE to Excellence®
• Care/Service Process & General
• Program-Specific
• Specialty
Business Practices
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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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
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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
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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.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Possible Accreditation Outcomes
• Three Year
• One Year
• Provisional
• Non-Accreditation
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
An Accreditation Journey
Progressive Intercultural Community Services (PICS)
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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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Selecting an Accreditation Organization
Selection criteria– Consultative Approach– Client / Person Centered– Experienced in accrediting culturally
based non profits
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Why CARF?
• Support provided• Person-centred standards• Non-prescriptive approach• Focus on outcomes• Community-based• Consultative not inspective• Experience of non-profit
community organizations
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
PICS Accreditation Journey
2012
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The Journey Begins
Selected CARF
Resource Specialist Support
Select programs
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Program Selection
Aging Services
Assisted Living
Adult Day Services
Independent Senior Living& GOVERNANCE
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Self-Evaluation
• PICS decided to utilize the services of a CARF consultant who supported PICS through out the process.
Non-prescriptive approach
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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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
PICS Awarded….
MAXIMUM AWARD: Three Year
accreditation
First Canadian organization
accredited under the Independent
Senior Living standards
Only CARF-accredited
ADS program in BC!
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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)
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
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 [email protected]
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
STRAW POLL
Raise your hand if…..
the thought of accrediting your organization is a little less scary
than it was 45 minutes ago.
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Dan StavertChief Advisor
[email protected] ext. 3008
Contact
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Questions?
© 2015 CARF International. All rights reserved.© 2015 CARF International. All rights reserved.
Thank you!