60 years of CARF: Leadership, legacy, and global impact

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Q: How does the longevity involved with people at CARF influence the organization?

A: We are a mission-based organization focusing on enhancing the lives of persons served. As the President and CEO of CARF for 25 years, I am an active custodian of something that started way before me and is going to continue after me. The collective of surveyors, Board of Directors, and staff—past, present, and future—has and will continue to guide the organization forward toward all good things because of who we are and what we do. It is our mission: Enhancing the lives of persons served.

Our strength lies in our surveyors—some that I recently saw at our annual Surveyor Continuing Education conference, who have been conducting CARF accreditation surveys, some of them for 35 and 40 plus years. They have seen and experienced how our standards and the health and human service industry have changed. They have helped CARF to remain relevant and current. The only way we can do this is through our extended enterprise of stakeholders that we intersect with globally–the persons served, surveyors, regulators, payers, insurers, government entities, organizations, and associations.

The core of CARF is the values imparted through our standards and the recognition we have optimizing the human experience via a focus on accreditation and its impact on delivering quality services to people served. Accreditation focuses on outcomes for the persons served, which ultimately benefits the communities in which services are delivered.

Q: How does implementing standards with the help of persons served make a difference?

A: CARF continues to engage persons served as an active participant when we develop standards because there is a constant need to remain vigilant to the needs of the persons served. Research has shown that their engagement and effort in services provided directly impacts the results of service–their outcomes. Further, including their input as an “expert panel participant” ensures current relevance and highlights key value points for consideration to organizations and other stakeholders when designing, delivering, and paying for services. The engagement of persons served ensures we stay true to our mission. Their input is embedded in our standards because it reinforces the value, dignity, and worth of human beings as a CARF accreditation expectation that organizations remain person-centered and committed to that enduring orientation.

Q: How do we gather input from others in regard to the organizations we accredit?

A: When surveyors go on site to conduct an accreditation survey, they interview and speak with persons served at the organization. By CARF’s definition, persons served could also be legal representatives, family members, or anyone authorized to represent the person if they are not able to truly represent themselves. Surveyors find ways to communicate with people even where level of education, understanding of a language, and those whose verbal capacity may be compromised. Soliciting feedback and input requires that CARF surveyors must be mindful of the culture, customs, and even language proficiency of those from whom they receive feedback.

In addition to interviews, notice posters of upcoming surveys are displayed at locations in advance of the survey. The Survey Notice Posters request input from individuals served by the organization and explain how they can contact CARF with comments and concerns. Organizations are required to gather input, which many do through feedback surveys. We look at the results of those satisfaction surveys and the outcomes of the programs for the persons served. Surveyors also interview program leadership such as Board members, management, supervisors of staff, the staff themselves, and even external stakeholders such as referral sources and funders/payers. The onsite survey is an extensive exercise to confirm standards conformance.

All those ways of gathering input help us corroborate with what the surveyors observed on-site. Conformance to standards is also supported by review of data, reports, and other forms of empirical evidence. Nothing speaks louder than the opinion of the service a persons served received and their feedback about whether they felt they were treated with dignity and respect, able to participate in planning, if their input was solicited, where to go to voice their concerns, if their presenting issues were addressed, and if they are better off than they were prior to coming into service.

Q: Tell me about the surveyors and how they represent CARF to providers?

A: I always say this about surveyors—without them, CARF fails to exist. A part of the design brilliance of CARF is the peer-review approach and consultative process to surveying. Because surveyors have experience in the field of expertise that they are surveying, it is a “form of self-regulation” or professional honor because surveyors come with a value set that matches CARF–their own organizations are accredited and by default are protecting the value of the CARF accreditation seal, and they are ensuring persons served have the opportunity to feel confident in the services they receive from an accredited program.

Delivering services to enhance the lives of persons served is core to our mission. The blueprint or structure of our standards and the evolution of those standards over time creates a business framework that organizations, whether small or large, use to stay current to mitigate typical business risks and provide outcome-oriented service.

We choose surveyor candidates that have great experience and competencies and we train them extensively on becoming surveyors, including a mentorship program. Surveyors follow a field-designed protocol of applying a review of program documents against our standards that optimizes the best potential outcomes for persons served. This includes reviewing measures of program service that demonstrate the program is working towards and maintaining its effectiveness, efficiency, advancing access to services in the community, and delivering services to the satisfaction of the person served. This activity allows surveyors to offer consultations for improvement, often highly regarded by our customers, as part of our mission for continuous improvement and desired aspirational operating excellence. In the world of CARF, a recommendation is an opportunity for improvement, not a simple “failure point.” Continuous organizational learning is continuous improvement.

The experience and competencies that people bring to their role as a surveyor are critical, inclusive of their person-centered value set, but assessing organizational/program conformance to standards and offering consultation on conformance to standards is what we teach them and what customers experience every survey. That is why I say the program design is brilliant. We have a double helix of quality built into it–the competency of a peer review with that application of best practice standards.

Q: How does CARF keep the standards relevant?

A: CARF keeps standards relevant as we are an extended enterprise that interfaces with many people who offer so much input. Over the years, we figured out how to harness the best of the best. Every year we review each manual as part of our redesign, reconsideration, and change to standards based on input from organizations, persons served, our surveyors, and adjustments to market needs. We actually live continuous improvement. If we didn’t, we would not be considered relevant, or our standards of value.

The recent feedback we received from our customer survey responses shows that 97% of our providers state that they have had some form of improvement in business performance because of CARF accreditation. Whether that business performance improvement is documentation, policies and procedures, performance improvement practices, delivery of quality services, or health and safety, I am quite sure not many of the big consulting companies can say that they get that feedback from their customers!

Q: Tell us about your early experiences at CARF.

A: I will do that from two perspectives.

As a customer of CARF:

The first time I went through a CARF survey at my organization in Canada, it involved all the heavy lifting of preparation that all our organizations go through. Understanding and appreciating the complexity of the standards and recognizing that the preparation for a survey has a lot of value because it highlights both your strengths and weaknesses for self-correction. Living up to the standards, not just because a CARF survey is coming, but because the standards represent good business practices and good service or intervention practices. With the standards, you already have a blueprint to judge yourself against.

Preparing for a survey is like doing your own operational audit and assessing what you have done as a leader, what you have done as a supervisor of a program, what you are doing as an individual practitioner, or as part of a multidisciplinary or interdisciplinary team while working with persons served to generate an outcome for that person served.

The survey, of course, gives you third-party feedback from your peers and is a great quality consultation experience. The surveyors have a comparable professional background and typically work in an organization similar to yours. It has its own explicit and implicit value. It was also great for my staff because we collectively learned so much about ourselves preparing for the survey, internally debating about whether we could even meet some standards or if we should, and then the collective experience of the exit conference and post survey relief and joy that it was over. The CARF accreditation experience helps to create or solidify company culture in a good way!

As a surveyor:

The opportunity to travel and to represent CARF comes with a burden of responsibility due to those self-regulatory items mentioned earlier such as sustaining the value of the accreditation seal, bringing yourself out of your organization, and assessing conformance to standards in a consultative manner with recommendations for improvement. This experience is quite fulfilling when you are the surveyor, and you can evolve your skills and experience through this process and be of more value to your own organization with these experiences. You learn a lot, and it is something that adds to your experience as a practitioner or as a business leader.

Having gone through a survey, working with the standards as a surveyor, seeing the results, and the difference in your own outcomes and organization is what ultimately sold me on CARF. I was able to see a higher satisfaction with staff and the people we served, as well as better results in getting people to their desired outcomes in the programs I operated.

Q: Your early experiences of CARF were when you lived and worked in Canada even as a Board of Trustee member. What made you decide to apply for the position?

A: As a Board of Trustee member, I became involved in and initiated a board project that transitioned the Board after I was hired as the President/CEO and that resulted in downsizing the board from its 52 members to its current 11. At the same time, the President/CEO Don Galvin announced he would be retiring. With that committee work, I interviewed all 52 board members, and one of the Trustee members asked if I would consider applying for the President/CEO position.

My professional background experience is in Children and Youth Services programs, Medical Rehabilitation, and Behavioral Health. Aging Services was relatively new to CARF at the time. I was a licensed and practicing psychologist, so I had all relevant core experience for the position. The Board thought that my background and work history made my candidacy competitive, so I applied. My experience in senior leadership of a workers compensation insurance company advanced my managerial and leadership skills.

I was a good fit, and I also came with no historical encumbrances. I was like the candidate from Switzerland. I had no political leanings. I was neutral and met a lot of other requirements. I had interfaced with CARF on many levels and engaged in many white paper leadership events and Standards Advisory committees, so I came with some knowledge of the CARF basics. That was just over 25 years ago, so along with our Board, staff, and surveyors, we collectively have created a vibrant organization.

Q: Tell me what are the top challenges you have faced at CARF?

A: There have been four top challenges in my years at CARF. The first was the September 11, 2001, attacks (9-11). I was six months into my new position at that time. We had to figure out how to get the surveyors who were at survey sites back home safely. When will travel return? What is our protocol for this unusual crisis? We learned a lot about our organization’s vulnerabilities and risks in those early days of my leadership. It was a trying time both here in the U.S. but also for many of our global customers/surveyors.

The second challenge was the financial crisis in 2008 and 2009 which rippled through many industries and impacted us as well. It was just as CARF was beginning to be more financially stable and could handle the environmental challenge. The prospect of financial collapse loomed large, and the government introduced monetary strategies to handle the risk. CARF, like all businesses, operated in that risky environment, but also took advantage of purchasing its current office building at dramatically low cost for the value presented. Our financial well-being gave us confidence in doing so during a stressed real estate market.

The third challenge was COVID-19 in 2020 and how we pivoted on embracing options that technology provided, something not available to us during the 9-11 attack. The technology platform for virtual surveys did not exist at that time, but by 2020 our technology had advanced. While we had many questions on how to get things done differently during COVID, we had technology in place that we could employ. So, with staff ingenuity, our MS Teams platform allowed for another pivot and the introduction of the digitally enhanced site survey (DESS).

The fourth challenge is a current event or disruption because of a combination of events. There are changes globally in the federal governments in many countries, often resulting in the realignment or prioritization of funding for health and human service programs that affect our customers. We are also amid global conflicts. CARF has two other international companies for which we are responsible, Canada and Europe. The impact of geopolitical matters and complexities on our growth along with travel challenges for our surveyors have changed the risk parameters for CARF’s future business strategy.

Q: When you joined CARF all those years ago, could you have imagined how this organization would grow?

A: I certainly could not! We have become more accepted as a global quality benchmark; the CARF accreditation seal has impact. International growth and supporting the business has become more complex. There is a lot of work in the United States and in the North American footprint, but we are growing globally in South America, Asia, the Middle East, and Europe. There are multi-language and cultural issues that add to business complexity. Plus, the advances in technology means our technology investments must be core to our long-term plans.

The continued global program growth has brought us to where we are today, accrediting more than 68,000 programs and services at close to 32,000 locations. That has created a very complex logistical business environment for us. The engine to all of this is our surveyors, the ones who represent CARF on site. When a customer thinks of CARF, they think of that experience.

This is why our organizational chart is inverted. At the very top are the persons served, CARF’s moral owners. The organizations that serve them are next on the organizational chart–they are our customers. Beneath the organizations are our surveyors, around 1700 plus strong. Next are all the CARF staff that support the surveyors. And at the very bottom of the organizational chart is me with our Board of Directors, who have been masterful in embracing a Policy Governance model of oversight to support, with monitoring verification, the global growth of our mission. That tells you how important the extended enterprise is to our mission success. It is our official organizational chart. I think it is why we are truly unique. It is why I feel like an active trusted custodian. Do not ruin a good thing. It is that simple.

Q: Is there anything you would like to add to what we have talked about?

A: I think the future is strong for CARF as it learns to embrace all the complexities of the marketplace in different countries, cultures, and languages. Adding to that is the overlay of technology that will support who we are and what we do. We may have some interim bumps along the road, especially when you consider the impact of artificial intelligence and what is being trialed right now, but the mission will endure.

Having been a customer, a surveyor, a Board of Trustee member, and now the President/CEO of CARF, I, as much as anyone else who has been involved with CARF, understand how entangling it is being engaged with CARF. I mean that in a positive way because there are many professional and personal experiences that you gain in your association with CARF that adds meaning to your life, and it is multifactorial in that sense.

You get to learn, live, and grow as an individual in your relationship with CARF and that is what keeps people engaged. As we celebrated service awards during the Surveyor Continuing Education conference this year, 87 people received awards for having been surveyors for 20, 25, 30, 35, and 40 years. Last year we had two surveyors who celebrated 45 and 50 years of service! We are a collective of people that share values around the importance of delivering services to people in need to improve their lives.

It sounds simple, but it is very complex in the delivery. That is what keeps us engaged because of the people we care about. Whether it is a grandparent, child, friend, spouse, or ourselves, at some point in our lives, we are persons served. And to me, that is the ultimate measure, and we have come full circle!

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