How are CARF International standards created?

Foundational basics

Dr. Connolly’s comments and answers below provide insight into the CARF process regarding its standards. He wanted to lay some groundwork and provide more information before describing the standards process.

Dr. Connolly explains that accreditation is a unique process. I want people to understand that there is a lot of effort and thought that goes into standards creation, so they can have confidence in the standards.

We are an international nonprofit. Our ISACs and field reviews are all done internationally and include literature reviews. We engage the world’s best people in a multidisciplinary approach to the specific program that we are trying to develop. We get them together, we talk with them and listen, then we develop standards from that discussion.

Consultative accreditation process

CARF Surveyors who are involved in organizations’ surveys are people who actually work in that specific field, and they are conducting surveys for CARF on an intermittent basis. For example, they have a primary job of a speech language pathologist in a medical rehabilitation facility, and they have been trained as a CARF Surveyor and know how to rate an organization’s conformance to the CARF standards. The vast majority of surveyors work in CARF-accredited organizations and use the standards themselves, and when they are on a survey, they are there as a peer to help you improve. They are not there to find things wrong, but to verify how you conform to the standards that are written by international experts.

CARF Board of Directors’ mandate

The moral ownership of CARF International is the person served. They are people who are served by the organizations that have the programs and services that we accredit. That is why we use the term “person served.”

CARF is neutral

CARF is nonpartisan and is not affiliated with any one organization or any government, regulator, or payer. We develop standards that are international and that are appropriate based on the experts in the field and the literature that is available worldwide.

An overview–the standards process is lengthy

We appreciate individuals in the field and their dedication to the time involved.

Take us through an actual standards creation process.

Q: How do you determine there is a need, a market for a set of standards?

A: I will use our new concussion rehabilitation standards as an example. We interviewed people in the field and surveyors. It can take up to a year or longer to see if there is truly enough need and interest (market) for it. By that, I mean there needs to be people and organizations who really want to be accredited for that particular set of standards.

Then we move forward and we create an ISAC. In that committee, we get the best people for a specific topic. So, in our concussion example, we did not just have physicians and CARF staff involved. There were also speech language pathologists, physical therapists, social workers, and, like any ISAC we establish, we always include at least one person served—somebody who has experienced the issue or a family member or both. The person served is an equal part of the committee.

We also include CARF staff, and we bring everybody together. It is typically a two-and-a-half-day process held in Tucson, Arizona. After two 10-hour days, we have a draft of the standards. The remaining half day is used to review the draft standards thoroughly before committee members leave.  

It all starts with a process to focus the discussion, known as brainwriting, and culminates in formal standards. So, to visualize, it goes from a piece of paper on the wall with all kinds of comments on it to formal standards published in a standards manual.

However, after the ISAC committee work, these are not the final standards, but they are a good rough draft. After the ISAC, the standards are internally evaluated to ensure they make sense, are ratable, and aligned with the existing literature.

Q: What is the advantage of having in-house physician expertise?

A: It impacts the standards and the conversations. During introductions, I tell the committee I am the chief medical officer, and I am an internist and geriatrician. That I am here as an additional resource of medical expertise and to mainly listen and offer input to keep things on track as we fine-tune the standards, because we only have them (the committee) for two and one-half days.

Q: What happens after the ISAC drafts the standards?

A: Once the ISAC committee is comfortable with the standards, we send the standards to a whole group of other experts, our International Advisory Council (IAC), which is a forum of stakeholder, provider, and professional associations and organizations that provide guidance on standards development and insight on issues affecting the fields that we accredit. Their valuable feedback is incorporated into the draft standards that are then available for public field review, which is posted on the CARF website and open for public comment.

We get a significant amount of feedback and pay close attention to the responses, as it helps evolve the standards. So, what was written originally by the ISAC may not be what the final standards look like when complete.

Q: Why is it important to gather comments from outside CARF?

A: It is important to highlight how much work, thought, and input from people outside of CARF go into the standards to give people confidence that standards are not created randomly or in a vacuum.

There would be no standards if not for all the global expertise in the fields that we accredit. It would be impossible to have in-house expertise to adequately produce standards related to the more than 150 programs/services that we accredit. We stand behind the standards and our process of partnering with experts to collectively develop standards that are always evidence- and literature-based.

Q: What does conformance to standards mean to you?

A: Assessment of conformance to the standards is made independently by a CARF surveyor who looks for how the organization is meeting the requirements of the standards. It is not a gotcha moment. It is an opportunity to show how you are meeting the standards, and if you are not, we will discuss it with you and provide ideas on how you can do things differently.

CARF standards are person-centered, field-driven, and can be universally applied. For example, using the concussion program standards again, they can be applied anywhere… in the United States, Sweden, the UK, or in South America. When we write standards, we create latitude so that there are multiple ways that you can satisfy conformance to a standard.

So, you could be a three-person organization in a rural area or a giant organization in a highly complex metro area in any country in the world and still conform to the standards because of that latitudinal understanding that there are multiple ways to meet the same goal.

Also, CARF ensures its standards are current by reviewing and adjusting them, if needed, annually.

Q: What makes CARF unique?

A: CARF is unique because it is consultative and not inspective. It really is about quality improvement and focus on the person served. We actually live this in our own offices. CARF is a nice place to work. That is why people work here for 25 to 30 years. There are not a lot of places like that. The organization lives what is stated in its mission and vision.

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