Overview

In addition to CARF standards requiring that programs measure their service delivery outcomes via a performance improvement system, the organization itself must establish business goals and indicators, collect and analyze data, and then determine performance improvement needs and successes.

Accreditation Requirement(s)

To conform to these standards, the organization must show evidence of the following:

• The existence of organizational performance goals
• Measurement of performance indicators
• Data are collected and analyzed from the following sources:
  • Financial reports
  • Customer surveys
  • Accessibility status reports
  • Personnel reports
  • Technology reports
  • Board of director/governance reports
  • Health and safety reports
  • Resource allocations reports
  • Any field trends, including research reports
  • Service delivery reports
  • Risk management reports
• A report of the findings is prepared

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• Do not create any new wheels! Many of the above listed reports are already generated by the organization in response to good business practices as well as required CARF standards. It is just a matter of analyzing those reports, using them to measure performance, and make good business decisions.

• Strategic planning activities are typically conducted in organizations providing treatment services and the resulting strategic plan should have the goals for the organization already established. CARF does not specify whether those goals should be 1 year or 5 year, etc. Strategic planning activities usually involve some sort of environmental scan, which the program may already do via stakeholder surveys, client satisfaction surveys, input forums, community relations activities, and obtaining information from the field at large. This should provide a wealth of information for management personnel.

• CARF accredited organizations also do accessibility status reports on an annual basis. This activity is yet another data source for determining performance improvement.

• Many organizations already conduct exit interviews with employees, prepare reports concerning salaries, and calculate vacancy percentages. The written Cultural Competence and Diversity Plan may also yield data on training needs for employees.

• A written technology and systems report is also required by CARF. This document can provide business leaders with information for strategic planning and performance measurement.

• Typically, all programs (large or small, private or non-profit) collect and analyze much data concerning financial status.

• Most important is that the leadership of the organization needs to identify the critical business indicators it needs to develop and monitor for maintaining and flourishing in the future.

• It is suggested that the format of the plan be kept simple and manageable. While it is often tempting to identify many needs and measures, it is imperative to remember that the plan should be realistic, measurable and useful for the organization. Usually a report on the plan indicators is composed at the end of the fiscal or calendar year. This can be done by committee or by one person assigned to the task. Once again, this report should be a helpful document for management decision making. It can be in a narrative format, and have charts, tables, and attachments. This report could also be combined with the service delivery performance analysis.