Impressively long-time organizations weigh in on accreditation

We have grown and changed in breadth and reach since 1966 from one standards manual for rehabilitation to accrediting more than 150 programs, services, and specialties in the fields of Aging Services, Behavioral Health, Child and Youth Services, Employment and Community Services, Medical Rehabilitation, Opioid Treatment Programs, and Vision Rehabilitation Services. What has not changed over the years is CARF’s value belief that all people have the right to be treated equitably with dignity, respect, and inclusion; should have access to needed services that achieve optimum outcomes; and should be empowered to exercise informed choice.

Accreditation is a comprehensive review to determine if a provider’s services meet international standards of quality. Achieving accreditation means the provider is committed to delivering safe and effective services and ongoing performance improvement.

We asked a few of our impressively long-time organizations to answer some questions about accreditation and why it is meaningful to them. Below are their answers:

Q: Why is accreditation important to you?

Accreditation is important for organizations because it provides assurance of quality, credibility, continuous improvement, accountability, and transparency. The standards set clear expectations of what is expected when you work in a CARF-accredited organization. It provides broad consistency and also improved outcomes with consistent assessment, stakeholder feedback, and service delivery. CARF accreditation offers external credibility of an agency’s competence. It creates public trust for individuals served, referral sources, future employees, and all stakeholders.

–Laura Lamb, Chief Operating Officer, Vocational Guidance Services

Accreditation is a powerful tool that validates the quality, safety, and effectiveness of our programs and services. At Rancho Los Amigos, it serves as an external confirmation that we meet or exceed internationally recognized standards of care. More importantly, it reflects our ongoing commitment to continuous improvement, person-centered care, and achieving the best possible outcomes for our patients and families.

–Pattie Soltero Sanchez, DNP, RN, PHN, CPHQ, CPPS, Regulatory Compliance Officer,
 Clinical Nursing Director: Respiratory Care Services, Centralized Admissions &
 Referrals Office (CARO), Bed Control, and Patient Advocacy,
Rancho Los Amigos National Rehabilitation Center

CARF accreditation helps to validate the quality of care we provide. We share this information on our website and with those who consider utilizing our services or referring patients to our facilities.

–Marci Ruediger, Director of Regulatory Affairs, Jefferson Moss Magee Rehabilitation,
Magee Rehabilitation Hospital, Moss Rehab

Accreditation from CARF is a hallmark of quality and excellence for Henry Ford Wyandotte Hospital’s Inpatient Rehabilitation Unit. It signifies our commitment to meeting internationally recognized standards in health and human services, ensuring that our programs and services deliver safe, effective, and person-centered care since 1968. Accreditation from CARF enhances our credibility with patients, families, payers, and regulators, demonstrating that we prioritize continuous improvement, risk management, and optimal outcomes. This recognition not only validates our dedication to high-quality care but also positions us as a leader in the healthcare industry, capable of meeting the evolving needs of those we serve.

–Sarah Koppes, MSN, RN, CRRN, CNL, Administrative Director of
Rehabilitation Services, Henry Ford Wyandotte Hospital

CARF accreditation is important to us because it challenges us to monitor and raise the quality of the services we provide to individuals with intellectual and developmental disabilities. We re-evaluate whether to continue to pursue CARF accreditation periodically and always end up deciding it makes sense to continue making sure we are following the standards which come from best practices. These are things any high performing organization should be doing. We learn something with every survey and are able to apply what we learned to continually improve our services, processes, documentation, and engagement with each other, and the individuals and families we serve.

–Karen Craig, Director of Project Management and Compliance, Easterseals Arkansas

Q: What are the top business reasons for your organization to have accredited programs/services?

Quality, credibility, continuous improvement, accountability, and transparency for all levels of our organization including administratively, and especially programmatically. –Laura

• Trust and credibility: Accreditation reassures patients, families, referral sources, and payers that Rancho meets rigorous quality standards.
• Competitive advantage: It differentiates Rancho as a leader in rehabilitation care.
• Operational excellence: Accreditation drives the use of best practices, resulting in improved efficiency, reduced risk, and better resource utilization.
• Regulatory alignment: CARF standards help ensure compliance with local, state, and federal requirements. –Pattie

The increased focus on quality and safety helps to prevent costly adverse events and errors. Additionally, accreditation may help to drive referrals to our sites of service. U.S. News and World Report also recognizes that endorsements from organizations such as CARF are a strong indicator of high standards. –Marci

The business reasons for pursuing and maintaining CARF accreditation at Henry Ford Wyandotte Hospital include:

1. Enhanced market position: CARF accreditation distinguishes our hospital as a provider of high-quality, standardized care, making us a preferred choice for patients, healthcare providers, and insurance companies. This strengthens our ability to negotiate favorable reimbursement rates with payers.
2. Regulatory compliance and funding opportunities: Accreditation ensures compliance with state and federal regulations, often a prerequisite for maintaining licenses or securing funding. It demonstrates fiscal and operational accountability to our stakeholders.
3. Risk management and operational efficiency: The accreditation process helps identify and mitigate risks through comprehensive safety protocols and streamlined processes, reducing liabilities and enhancing organizational resilience.
4. Stakeholder confidence: Accreditation instills confidence in patients, donors, and community partners by showcasing our commitment to excellence, which can lead to increased referrals, partnerships, and community support.
5. Continuous improvement: The consultative peer-review process provides actionable feedback, enabling us to refine our programs and maintain a competitive edge in delivering innovative, high-quality services. –Sarah

Other than continuing to perform at a high level with regard to quality and overall provision of services, the primary business reason for being CARF-accredited is that the governing regulations of most of our programs require accreditation either through CARF or The Council on Quality and Leadership (CQL). Despite this being a recommendation only for some of our programs, we choose to maintain CARF accreditation for multiple programs where there is no accreditation requirement due to the value we get from the triennial review of our programs and services. –Karen

Q: How have the CARF standards or the accreditation process been integrated into your daily operations? Please provide an illustrative example.

One example of how VGS has integrated CARF standards into our operations is the financial review of bills (1.F.7.). There is a systematic, quarterly review of bills for open receivables, accuracy, trends, and ways to improve if additional training is needed. –Laura

CARF standards are embedded into Rancho’s operational framework. For example, our patient admission and discharge planning processes were redesigned to align with CARF’s person-centered focus. This includes involving patients and families in goal setting from the very first day, documenting progress toward those goals in the care plan, and coordinating seamless transitions of care. This daily practice not only meets CARF’s criteria but also improves patient satisfaction and clinical outcomes. –Pattie

Many of the CARF standards have been integrated into our daily operations. One easy example is the incorporation of a thorough review of all durable medical equipment that is delivered to the hospital before it is released to the patient, to ensure that the equipment is exactly what was ordered and that it works properly. Other examples include the regular review of key program-specific metrics and the provision of written disclosures to patients related to the services that will be provided to them during their rehabilitation, their estimated length of stay and any responsibility for payment. –Marci

CARF standards are deeply integrated into Henry Ford Wyandotte Hospital’s daily operations, serving as a framework for our policies, procedures, and quality improvement initiatives. The standards guide our approach to patient care, staff training, and operational management, ensuring alignment with best practices. When we are making changes to processes within our department, we refer to the CARF standards manual to ensure it meets those standards before moving forward. –Sarah

As an organization we try to maintain a continued state of readiness instead of “getting ready” for the survey as it approaches. The work we do as an organization to maintain compliance with the CARF standards therefore has to be embedded in our daily operations. For example, to ensure regular review of policies and procedures we have a policy management software where we have loaded all organization-wide and department-specific policies and procedures. In this system we can set dates for documents to be reviewed with reminders sent to document owners. This way our document review processes are ongoing monthly instead of all right before the survey. Another example is development and management of our accessibility plan. We have a survey that is completed annually to help identify accessibility barriers. Once completed, the survey responses are shared with a specific organization-wide committee where we discuss what we think we can and cannot tackle in the upcoming year and assign owners to each task. We review progress monthly and update the plan throughout the year. –Karen

Q: How has accreditation had an impact on the quality of your organization’s programs/services?

VGS has been accredited with CARF since the 1960’s. We have embraced the standards and have built our programs, services, and administrative polices based on CARF. This accreditation covers all administrative and programmatic guidance that an organization needs to thrive. –Laura

Accreditation has elevated Rancho’s culture of accountability and continuous improvement. Through CARF’s requirements for outcome measurement and program evaluation, we have developed robust performance reporting structures to monitor patient outcomes, satisfaction, and access to care. As a result, we have been able to identify trends more quickly, address barriers proactively, and implement evidence-based changes that enhance quality and safety.
–Pattie

To maintain our accreditation, we track metrics such as whether patients who have had strokes have been taught how to prevent another stroke, and whether patients who have had spinal cord injuries have been able to return to productive activity, such as work, school, volunteering, parenting, household management, recreation, etc. These data help us to identify program-specific areas for improvement that we might not otherwise identify. The CARF focus on continuous improvement definitely helps to drive improvements in programs and services. –Marci

CARF accreditation has elevated the quality of Henry Ford Wyandotte Hospital’s Inpatient Rehabilitation program and services. The rigorous self-evaluation and peer-review process required for accreditation has driven us to critically assess and refine our practices, resulting in measurable improvements. By maintaining conformance to CARF’s evolving standards, we ensure that our programs remain at the forefront of quality and innovation, directly benefiting the patients and communities we serve. –Sarah

Being CARF accredited has helped improve the quality of our organization’s programs and services. Applying the standards across each program helps us take an in depth look at each program in terms of service delivery, outcomes for individuals served, communication with stakeholders, documentation, policies and procedures, and performance improvement. Our most recent survey was very thorough. Each of the recommendations and consultations identified opportunities to strengthen our programs operations and service delivery, which will ultimately result in improved outcomes for the individuals we support. –Karen

Q: What advice would you give to an organization considering accreditation for the first time?

While accreditation is an investment of time and financial resources it is worth it for quality services. There are many resources available to assist a new organization to be successfully accredited, you just need to lean into the process utilizing all expertise and resources. The CARF manual is a detailed guide of how to prepare, what should be considered, and what needs to be implemented in writing for documentation. –Laura

Approach accreditation as more than a compliance exercise—view it as an opportunity to strengthen your organization’s foundation for quality. Engage staff at all levels early in the process, and integrate CARF standards into your policies, procedures, and daily workflows rather than treating them as a separate checklist. Most importantly, foster a culture where feedback and continuous improvement are valued, so that the benefits of accreditation extend well beyond the survey. –Pattie

For an organization considering accreditation for the first time, we suggest communicating with CARF as well as other accredited entities to understand the benefits of CARF accreditation as well as the initial and ongoing work involved in preparing for a survey. Organizations often begin their accreditation journey by accrediting only one program. It is critical to identify people who can lead the preparation process and develop a gap analysis as well as a plan to close the gaps between current processes and what might be needed to come into conformance with the standards. CARF has many resources to help with preparation. It’s very important to understand the intent of the standards and to clarify what is required when questions arise in the preparation process. There are often many ways to meet the intent of the standards. –Marci

For organizations considering CARF accreditation for the first time, Henry Ford Wyandotte Hospital offers the following advice:

• Start with a thorough self-assessment: Begin by conducting an internal evaluation to compare your current practices against CARF standards. This self-study, which may take 6–12 months, is critical for identifying gaps and preparing for the survey. Engage all levels of staff to foster buy-in and collaboration.
• Leverage CARF resources: Work closely with your designated CARF resource specialist who provides guidance and access to tools like the Customer Connect portal. Consider attending CARF’s educational webinars and networking events to stay informed about standards and best practices.
• Build a culture of continuous improvement: View accreditation as an ongoing commitment rather than a one-time event. Integrate CARF standards into daily operations to make survey preparation seamless and sustainable.
• Engage stakeholders early: Involve patients, staff, and community partners in the accreditation process to ensure their perspectives shape your quality improvement efforts. This aligns with CARF’s emphasis on person-centered care and stakeholder input.
• Plan for the long term: Accreditation is a multi-year journey. Develop a quality improvement plan (QIP) to address survey findings and maintain conformance through annual reporting. This proactive approach ensures sustained excellence and simplifies re-accreditation. –Sarah

Remember it is a consultative process, not a punitive process. It is an opportunity to showcase all the great things you are doing today while also creating a culture of continuous improvement. –Karen