The focus of the November 2012 newsletter for Behavioral Health Resources, LLC is preparation for a CARF survey. On October 25, 2012, our President, Brenda Rohren, had the pleasure of interviewing Joanne Pickrel (CEO) and Amanda Herndon (Communications Specialist) of Goodwill Industries Serving Southeast Nebraska, Inc. located in Lincoln, Nebraska.
Due to continuous quality improvement and CARF-focused organizational culture, the organization received no recommendations in their June 2012 CARF Survey Report. (This represents only 3% of CARF-accredited organizations.)
Integration of CARF Philosophy in Business Practices. “It’s a part of our culture. Safety is huge with us,” said CEO, Joanne Pickrel. “We’re constantly collecting information for our CARF Show Proof. If we’re buying assistive technology, we place evidence of this in the CARF folder. Before changes are made to our policies and procedures, we first check the CARF standards. When we develop a new program, we look at the standards and develop the program around that.” Pickrel further stated, “We don’t do it because CARF says to do it. The CARF standards are there for a reason . . . to improve business and provide quality care. Being safe is more than ethical. It makes our organization better for it.” Consistent with the CARF-focused organizational culture, “the Board doesn’t question the expense if it’s CARF-related.” This culture is exemplifed by Pickrel. “I’m consistently CARF cognizant. To protect your business, your clients, and your staff.”
|Goodwill Industries demonstrates the belief of Behavioral Health Resources, LLC that continuous quality improvement is the result of teamwork between governance, leadership, staff, clients, and consultants.|
Continuous Quality Improvement. Training about CARF and the standards begins for all staff on their first day of employment during orientation. Herndon is the key contact for CARF preparation. About 15% of her time on a weekly basis is devoted to CARF-related preparation activities. She is responsible to update the CARF Matrix© and collect evidence of conformance to CARF standards. (The documentation is placed in their CARF file, otherwise known as Show Proof.) The directors are also very well-versed in the CARF standards and they provide ongoing training to staff. E-mails are sent to staff periodically regarding the standards. Input is requested regarding interpretation of the standards and asking for evidence of conformance.
CARF Survey Preparation Tools. The most valuable tool used by Goodwill Industries for ongoing CARF survey preparation is their CARF Matrix© . The Matrix is a Word document that lists all of the CARF standards relevant to their accredited programs. For each standard, there is a link to the document that demonstrates evidence of conformance. (This is a more comprehensive version of the preparation tool offered by CARF from Appendices A and B of each 2012 Standards Manual. These Appendices are Word documents that can be modified to include document links similar to what is done for the CARF Matrix©.)
Use of an Internal Consultant. Goodwill Industries International employs four full-time professionals who are experts in the CARF standards. (They are also CARF surveyors.) Their sole responsibility is to help the charter organizations practice continuous quality improvement as related to the CARF standards and to prepare for CARF surveys. They consistently attend the annual CARF conference for surveyors and publish updates regarding changes to the standards to all charter organizations.
Preparation Timeline. As suggested by CARF, the organization begins formal preparations 12 months in advance, beginning with a review of the physical plant. During the 9 months prior to the survey, the percentage of Herndon’s time that is devoted to CARF preparation increases to 75%. Staff begin to meet on a weekly basis for at least one hour to review the Show Proof and review the CARF Matrix© for accuracy. According to Pickel, “We have very engaging discussions about interpretation of the CARF standards and evidence for conformance.”
Three months notice is required to Goodwill Industries International to request the CARF consultant. “We always ask for the same person, Annette.” The internal consultant conducts a two-day mock survey with a final written report. During the mock survey, she challenges staff regarding their evidence for conformance in order to encourage critical thinking and to be prepared for the actual interviews from the CARF surveyors. During this time, she also shares best practices from other Goodwill charters and (with the Lincoln charter’s permission) shares their best practices as well. The goal within each charter and the overall international organization is to teamwork and continuous quality improvement. Shortly before the survey, binders of hardcopy documents and flash drives of the CARF Matrix© are prepared for the CARF surveyors. (These do not contain PHI.)
Strengths and Challenges. Pickrel identifies the organization’s strengths as “Willingness and commitment of our staff to learn and apply the CARF standards.” Herndon describes challenges as “Different interpretation of the standards and how to demonstrate conformance. It’s a long process. Documenting evidence of conformance.” Pickrel further reports challenges as “Lingo training to translate our organization’s terms and titles of documents to match the CARF terms.”
Final Thoughts. According to Herndon, “This is the second survey we have used our electronic Matrix for, and the CARF surveyors could not have been more pleased with it. They stated that if we had not been commended for it at our last survey, they would have commended us for it this time. One of the surveyors even requested a copy of it so they could use it for his organization.” When asked for her final thoughts, Pickrel stated, “All this equates to transparency. If we practice continuous quality improvement, we’re ready for a survey at any time . . . which is how it should be for a business.”
© 2012 Behavioral Health Resources, LLC. All rights reserved.