Identifying & Training an Internal CARF Consultant

Interviews with CARF Surveyors  –  Part 3 of a 3-part series

The March 2013 newsletter of Behavioral Health Resources, LLC features interviews with three CARF surveyors who are also CARF internal consultants in their organizations:  Pat Coleman, President & CEO of Behavioral Health Response (Admin surveyor for 5 years); Rob Snyder, Director of Quality Assurance at Gilead Community Services (Admin surveyor for 4½ years); Gloria Woodruff, Program Director at Whiteside Manor (Admin and Program surveyor for 9 years).

Most organizations do not have a CARF surveyor on staff.  Because preparing for a CARF survey can be a very time-consuming and complex process, organizations can benefit from selecting an employee to be an internal CARF consultant.

Identifying an Employee to be an Internal CARF Consultant.  Regarding the basic knowledge and skill level needed for the ideal candidate, Coleman states, “The ideal candidate usually is someone on the executive team with either a program or administrative background or both, or someone who works directly in the program areas.  They must be someone who is organized and very good with time management.  Also, they must hold the consumer in high regard.”  This is especially important as related to the CARF emphasis on person-centered care.

consultingcycleAccording to Snyder, “There are probably many viewpoints on this, but in mine, they need to be someone who has read through and thoroughly understands all the current CARF standards that apply to their organization.  And for anything they’re not sure on, they need to be able to get the training they need or call their CARF Resource Specialist for clarification.  They need to be someone who truly “GETS” why these standards are important and valuable to helping an organization improve services and that it’s NOT really about just getting accredited. They also need to be someone who is organized, objective, and good at attending to detail and examining systems and processes.”  Woodruff concurs.  “A concrete knowledge and understanding of the CARF standards and how they are connected to each other” is important.

What training and assistance should this person receive?  “This also probably depends on the person,” says Snyder, “but certainly at a minimum they should be attending the CARF 101’s or other trainings that CARF offers to increase their knowledge of the standards and how they can best be met.”

How could an external consultant be helpful to achieve this goal?   “Perhaps as part of their consulting process, they might be able to identify which staff appear to exhibit the qualities I indicated above and pursue that with them,” said Snyder.  The ideal situation would be to initially contract with an external CARF consultant to provide basic training to the internal consultant as well as provide periodic guidance.   (Hiring an external consultant on a Retainer Contract would be a useful investment for this purpose.)

Questions to Consider:  question

  1. Will the employee attend CARF trainings?
  2. Is a specific job description needed?  At minimum, the employee’s current job description would need to be revised to include these additional responsibilities.
  3. Does the organization have a “no retaliation” policy?  This could be included in the organization’s code of ethics document and/or written as a separate policy.  For external consultants, there is generally a clause in the contract indicating that the Consultant shall not be liable for any accreditation outcomes.  It is suggested that the organization have a similar policy and practice to protect the internal consultant so that accreditation outcomes are not reflected on the performance evaluation.
  4. Should the employee sign a nondisclosure statement?
  5. What percentage of the employee’s time will be designated for CARF-related activities?  (Refer to our  November 2013 Blog for reference.)
  6. What authority and responsibility will the employee have?   This includes:  requesting documents from staff; obtaining client caseload lists for each provider; overseeing and/or implementing changes to policies and procedures as well as other documents; training of staff regarding CARF standards and related issues.
  7. To whom will the internal CARF consultant report?   Will this person be someone other than the employee’s direct supervisor?
  8. Will the employee consistently attend management team meetings (if not already doing so)?
  9. Will the employee be designated as the CARF Accreditation Liaison on the Intent to Survey?  (If so, the employee will also be listed on CARF Survey Report as the Organizational Leadership.)
  10. What communication will the employee have with the CARF Admin Surveyor during pre-survey contact as well as the on-site survey?
  11. What role will the employee have during the on-site survey?

Click here to read an article that provides more information about advantages of using an internal consultant as well as challenges faced by this employee.

Commitment from Management and Other Stakeholders.  Snyder believes that commitment from the management team and other stakeholders is needed.  “I am the only CARF Surveyor in our organization, but with each of our organization’s surveys I have had the benefit of having another Senior Director at my organization assist me with the coordination and preparations to help our organization maintain and improve our CARF conformance and survey readiness.  I think one of the biggest challenges is how to get your organization’s stakeholders interested and invested in the process.  If you only have either an internal or external consultant or even just the organizational leadership involved, you’re not likely to be as successful as when you have everyone involved.”

Innovative ways to prepare for CARF accreditation.  Snyder offers a creative perspective on accreditation readiness.  “Finding innovative and creative ways to involve everyone in not only following and improving organizational policies, procedures, and Countdown_(Game_Show)_studiopractices that conform to the CARF standards, but also in preparing for the survey itself can be critical.  For example, I’ve organized things like agency “game shows” with prizes the year prior to our agency’s CARF surveys to help everyone refresh and improve their knowledge of CARF related practices, procedures, and policies in a fun and exciting way.  There are other factors as well, but I think some of the key tasks include being organized and planful in preparing for the survey (including preparing binders or electronic documentation in advance that you know surveyors will want to see), collaborating with all of your stakeholders and getting as much ‘buy-in’ into the importance of the process as possible, and then also systematically going through each and every standard and asking hard questions about not only whether the organization is conforming to it, but figuring out how they can demonstrate that conformance to an outside person (like a surveyor).”thank-you

Thank You!  We want to express our appreciation to Pat Coleman, Rob Snyder, and Gloria Woodruff for contributing to the January – March 2013 newsletters.


© 2013 Behavioral Health Resources, LLC. All rights reserved.

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