| Overview
Organizations should be client-driven and
show evidence of active client involvement
in programming, decision-making, treatment
planning, and outcomes. The purpose of obtaining
input is to continually improve the services
being delivered to clients. Obtaining meaningful
input from clients, family members, and
advocates is a core value of CARF. These
standards, which imply that action will
be taken once the input is received, are
one of the most frequently cited standards
in CARF survey reports.
Accreditation Requirement(s)
Requiring input from the persons served
and relevant stakeholders is the first standard
in the CARF accreditation manual and makes
evident the importance and value CARF places
on client and stakeholder expectations.
The organization should be prepared to describe
the mechanisms it currently uses to obtain
client, family, and stakeholder input; how
input is used in program and policy development;
monitoring and evaluation of programs; and
changing program practices. Leadership staff
and governing body should review this information.
The information is then used for planning,
advocacy, and performance improvement purposes.
Implementation Tips
Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.
- The organization should define who
its stakeholders are, such as family members,
referral sources, funding sources, regulators,
caregivers, and advocates. Usually either
focus groups or an annual survey are utilized
to capture stakeholder input. Stakeholder
input can be helpful for identifying new
opportunities for the organization, revising
current program services, and changing
program practices and policies.
- It is recommended than an organized
system for the ongoing attainment of input
is put into place. This is not a one-time
activity. CARF does not dictate the frequency
of input, the tools utilized, the methodology,
or the reporting of the data. Tailor the
venues to mesh with your organization's
culture and environment.
- Designating the clinic/program manager
or the organization quality improvement
personnel to oversee this endeavor would
be helpful. Capturing the results from
the data collection methodology, analyzing
those results, reporting on them in at
least a summary fashion, and then utilizing
the information to make changes and decisions
is what is needed to meet the intent of
the standards. Ultimately the findings
should be integrated into the planning
process and the performance analysis.
- Do not try to do too much! If utilizing
a questionnaire, then asking more than
10 questions on a survey is usually enough
to obtain the critical information. Conducting
surveys for long-term clientele more than
every 6 months is unnecessary and burdensome
to the clients. Most opioid treatment
programs (OTPs) have found it useful to
develop their own unique instrument and
style. However, it is best to perform
a literature search and use valid and
reliable tools rather than creating a
new survey tool.
- Once the information is collected, it
should be analyzed and integrated into
the regular business practices of the
organization. Decisions should be based
on the data received and used for program
planning, strategic planning, financial
planning, resource planning, performance
improvement, and advocacy efforts.
- The process of seeking and utilizing
input from persons served contains the
following basic components:
- Obtaining input from persons served
and their families on a regular basis
- Reviewing the input through all
levels of administration and management
- Ensuring that our programs are "input
driven" and reflect the needs
and preferences of the persons we
serve
- Using the input to change the practices
and policies of the organization
- Examples of activities that an organization
could use to gather client, family, and
stakeholder input, include, but may not
be limited to, the following:
- Focus Groups
The Focus Group Protocol is used with
all stakeholder groups to ensure a
consistency in methods and reliability
and validity of results. The program
managers conduct focus groups on an
ongoing basis, and the results are
summarized by the program managers
and reported in the management team
meeting. The management team utilizes
the results to develop and integrate
specific changes in practices, policies,
and procedures. These activities and
the feedback concerning changes are
reflected in the management team minutes,
distributed to all employees of the
organization, and summarized in a
monthly report to the Board of Directors.
- Client Surveys
The organization may conduct an
annual survey process within all programs
and/or demographic regions to obtain
ongoing input from clients and other
stakeholders. The survey process is
used with all stakeholder groups to
ensure a consistency in methods and
reliability and the validity of results.
The program managers designate a week
in time during the year to distribute
specifically designed surveys, and
the results are summarized by the
program managers and submitted to
the management team. The management
team utilizes the results to develop
and integrate specific changes in
practices, policies, and procedures.
These activities and the feedback
concerning changes are reflected in
the management team minutes, distributed
to all employees of the organization,
and summarized in a monthly report
to the Chief Executive Officer.
- Suggestion Boxes
The organization may employ client
suggestion boxes in visible locations
throughout the enterprise. Suggestion
forms and pencils are available at
each suggestion box along with a sign
that encourages feedback and suggestions.
Each month, suggestions are gathered
by the Facility Manager and shared
with employees at that location in
a regularly scheduled staff meeting
for consideration of programmatic
changes that might better meet the
needs of persons served. Changes are
made at the facility level if they
involve daily activities and issues
that are specific to that location
and do not require organizational
policy and procedural changes. All
suggestions are submitted to the management
team, and any suggestions that would
require overall policy, procedure,
or programming changes are considered
by the management team, which determines
final disposition and actions. These
activities and the feedback concerning
changes are reflected in the management
team minutes, distributed to all employees
of the organization, and summarized
in a monthly report to the Board of
Directors.
- Client Advisory Board/Committee
The Client Advisory Board/Committee
(CAB) may conduct regularly scheduled
monthly or quarterly meetings, and
is chartered through bylaws that provide
a purpose and structure for the CAB
to conduct its business. Within those
bylaws are specific components that
empower the CAB to serve as an advocate
for all persons served. As a result
of its activities, the chair of the
CAB provides a monthly report to the
management team that may include recommendations
for the organization to consider in
changing policy, procedures, and practices.
These activities and the feedback
concerning changes are reflected in
the management team minutes, which
are distributed to all employees of
the organization and summarized in
a monthly report to the Board of Directors.
- Staffing Conferences
The organization could conduct
weekly clinical staff meetings with
all providers, facilitated by their
respective program managers. These
meetings include a consistent flow
of information regarding communication
between persons served and the treatment
staff. Any specific information that
would warrant further inquiries or
investigation are forwarded to the
management team, which utilizes the
information to modify, revise, or
change practices, policies, and procedures
as a result of receiving and analyzing
the information. These activities
and the feedback concerning changes
are reflected in the management team
minutes, distributed to all employees
of the organization, and summarized
in a monthly report to the Board of
Directors.
- Family Feedback Project
The organization may employ a
process to seek relevant and specific
feedback from family members and/or
guardians of persons served by the
organization. Family members may be
provided with satisfaction surveys
unique to family issues, asked to
participate in family focus groups,
and/or be invited to family "Town
Hall" meetings to solicit input
to evaluate whether or not the organization
is meeting the needs of persons served.
Information is expected to be analyzed,
trended (using graphic formats for
ease of understanding), and provided
to the management team for consideration
in changing policy, procedures, and
practices.
- Public Forums
The organization may invite input
from the community-at-large by holding
public hearings in its catchment area.
These hearings are advertised by direct
mailings, newspaper, newsletter, and
cable television. Any citizen can
attend the hearings and provide feedback
concerning administrative operations,
programs, and services. This information
is collated and considered as part
of the strategic planning process.
|
