1. A Commitment to Quality: the accreditation journey
Dan
© 2013 CARF International. All rights reserved.

2. Presenters Rajeev Mohindru, MSW, BSW, RSW, B.Com, B.Tec, DMS
Director of Care
Dan Stavert, MSW, BSW, RSW
Chief Advisor

3. Raise your hand if…. your organization is accredited.
STRAW POLL
Raise your hand if…. your organization is accredited.

4. Raise your hand if…. you are very familiar with accreditation.
STRAW POLL
Raise your hand if…. you are very familiar with accreditation.

5. STRAW POLL
Raise your hand if….. the thought of accrediting your organization gives you nightmares.

6. Overview of Session About CARF The accreditation process Standards
About PICS
Why seek accreditation?
Selecting an accreditor
Learnings and outcomes
Benefits of accreditation
Rajeev

7. CARF International Group
Dan’s section

8. About CARF
CARF
Commission on Accreditation of Rehabilitation Facilities
Status
Non-profit
Independent
Programs
Health and human services

9. Programs Aging Services Behavioural Health
Business & Services Network Management
Child & Youth Services
Employment & Community Services
Medical Rehabilitation
Vision Rehabilitation
AS and ECS program standards applied to PICS

10. CARF Quick Facts Founded in 1966 First Canadian survey in 1969
6,800+ service providers with more than 50,000 accredited programs
More than 8 million persons served annually by CARF-accredited orgs
Incorporated in 2002
Offices in Edmonton
Toronto
&
480+ service providers with more than 3,800 accredited programs

11. 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.

12. CARF’s Primary Business
Accreditation
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.

13. Recognition of CARF in Canada
British 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.
Note: , “A Guide to Community Care Facility Licensing in British Columbia” mentions CARF and states, “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. “(page 3)

14. 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:
Fraser Health Authority website, Residential Care Facility pages (site descriptions, “Accreditation Status”)
A Guide to Community Care Facility Licensing in British Columbia, Ministry of Health, BC, page 3.

15. 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

16. Accreditation Standards
Business Practices
ASPIRE to Excellence®
Care/Service Process & General
Program-Specific
Specialty

17. 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

18. 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: CARF Aging Services Standards Manual
Standard
Intent Statements
Examples
Possible question for delegates: How does your organization outline leadership structure in their organizations? How are staff/board/others made aware of structure/responsibilities?
Required Written Documentation? No

19. 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.
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: CARF Aging Services Standards Manual.
Standard
Intent Statements
Examples
Required Written Documentation?
Yes, Written Strategic Plan

20. 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: CARF Aging Services Standards Manual
Standard
Intent Statements
Question for delegates: How does your organization get ongoing input from stakeholders? See next slide for examples.
Required Written Documentation? No

21. 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: CARF Aging Services Standards Manual, 1.D.1. Examples.

22. Accreditation Process
STEP
PROCESS
TIMEFRAME 1
Contact CARF Canada staff — CARF International Resource Specialist assigned
Recommended 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
Consultative

23. Possible Accreditation Outcomes
Three Year
One Year
Provisional
Non-Accreditation

24. Benefits of CARF Accreditation
“98%
of CARFs customers report accreditation helps improve their business*”
Business improvement
Service excellence
Competitive differentiation
Risk management
Funding access
Positive visibility
Accountability
Peer networking
* CARF Brochure – The Value of Accreditation 2009.

25. An Accreditation Journey
Progressive Intercultural Community Services (PICS)

26. About PICS
Mission 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

27. 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.

28. Selecting an Accreditation Organization
Selection criteria
Consultative Approach
Client / Person Centered
Experienced in accrediting culturally based non profits

29. Why CARF? Support provided Person-centred standards
Non-prescriptive approach
Focus on outcomes
Community-based
Consultative not inspective
Experience of non-profit community organizations

30. PICS Accreditation Journey
2012
Rajeev

31. The Journey Begins Selected CARF Resource Specialist Support
Select programs

32. Program Selection & Governance Aging Services Assisted Living
Adult Day Services
Independent Senior Living
Employment & Community Services
Community Housing
Community Employment Services: Job Development
Employee Development Services
Self-Employment Services
& Governance

33. Non-prescriptive approach
Self-Evaluation
PICS decided to utilize the services of a CARF consultant who supported PICS through out the process.
Non-prescriptive approach

34. Peer Review Survey PICS survey experience: Consultative approach
Observation
Tours
Services
Interviews
Persons served
Staff
Other stakeholders
Documentation
Records
Policies
Procedures
Plans
PICS survey experience:
Consultative approach
Helpful recommendations
Knowledgeable peer surveyors
Celebrating strengths

35. PICS Awarded…. MAXIMUM AWARD: Three Year accreditation
First Canadian organization accredited under the Independent Senior Living standards
MAXIMUM AWARD: Three Year accreditation
Only CARF-accredited ADS program in BC!

36. 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)

37. 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

38. Aging Services Webinar
Join us for a complimentary webinar!
Introduction to CARF Aging Services Accreditation June 10, :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 ext. 3009 or

39. STRAW POLL
Raise your hand if….. the thought of accrediting your organization is a little less scary than it was 45 minutes ago.
Dan

40. Contact Dan Stavert Chief Advisor dstavert@carf.org
ext. 3008

41. Questions?

42. Thank you!