Extending the Reach of Quality With CARF Accreditation

Accreditation is a common method to assess quality and plan for improvements in the delivery of health and human services. CARF accreditation was established to create standards of quality for specialty programs in rehabilitation and for community-based services. Since its inception, the person-served has uniquely been the focus of standards design, with specificity to program-based standards that address “person-centered” service needs. As a quality improvement model, CARF’s standards are referenced as typical to another respected quality assessment and improvement model, ISO standards. The importance of ensuring a person’s served focus in the health and human service industry is discussed with benefits of a peer review accreditation system and experience of accreditation based on CARF customer feedback and those served. It is posited that long-term growth for accreditation and CARF’s mission, to “enhance the lives of persons served through a consultative accreditation process,” will sustain CARF’s global acceptance and contribute to improving lives in our communities.

community-based programs began to flourish, providing medical, physical, mental, social and vocational services. A prominent U.S.-based leader in the development and support of the rehabilitation sector and the 'facilities movement' during the late 1950s and 1960s was Mary E. Switzer, the first administrator of Social and Rehabilitation Services. Her progressive support for improving the quality of rehabilitation through project grants and conferences led to early work on standards of quality. The combined work and support of two organizations established the Commission on Accreditation of Rehabilitation Facilities (CARF) in 1966-the Association of Rehabilitation Centers (ARC) and the National Association for Sheltered Workshops and Homebound Programs (NASWHP). The ARC was a national association that represented the medical rehabilitation centers in the United States; NASWHP was the national organization representing the largest vocational centers in the United States. CARF released its first standards manual in October of 1967, entitled "Standards Manual for Rehabilitation Facilities" (CARF, 1967). The rehabilitation facility, as defined in the 1960s, was an organizational and physical entity that provided integrated and coordinated services for functional and vocational restoration efforts for the handicapped, disabled children and adults. The manual had a set of core administrative standards complemented with a set of program standards that defined the types of services provided to individuals. Program standards, as an example, include items that detail admission or eligibility criteria, assessment processes, specialty qualifications of staff, individual plans to review progress on the goals established for the person, all with an emphasis that supported the ongoing engagement of the person served.
CARF, incorporated as a private independent not-for-profit entity in 1966, was a "startup enterprise" in every sense of that expression. To support its accreditation efforts, CARF looked to the Joint Commission on Accreditation of Hospitals (JCAH) to provide administrative support for the logistics of accreditation via a yearly contract under the same hospital accreditation leadership. Interestingly, many of the individuals and associations involved in the establishment of CARF recognized the need for specialty rehabilitation standards. Supporters included a major hospital association (American Hospital Association), various physicians (ex. Dr. Howard Rusk-the 'father of rehabilitation') and those who served on CARF's founding Board of Trustees. Even the traditional medical community recognized that the bricks and mortar of hospitals were only part of the resources needed to support the diverse service needs of people in the community. CARF's standards, guides and associated materials provided a foundation of quality that reflected the diversity present and unique to every person served. The people who sought rehabilitation services, with the exception of catastrophic cases such as spinal cord injury or severe brain trauma, were typically more appropriate for a community-based services rather than a hospital setting with noted exceptions. Responding to diversity in the broad-based human service, specialty health and rehabilitation market remains a key focus for CARF today.

Market Trends and CARF's Trajectory
To ensure relevant quality standards and to remain current with market trends, an accreditor must adjust along its own quality improvement pathway. This means changes to accreditation processes and to the development, addition and revision of standards. The first breakthrough in its development in the early 1970s was CARF choosing to discontinue its relationship with JCAH and its logistical accreditation support. Factors included, but were not limited to: the expense, as revenue surplus margins were thin, the community-based rehabilitation patients served who were different than those served in a hospital, and an evolving medically oriented hospital accreditation model that dominated thinking on quality at the time for higher risk hospital settings that would practically lose "fit" with community-based services.
CARF recognized that the diversity of programs accredited was a challenge to its small employeebased surveyor workforce, a model borrowed and trialed with the JCAH. As CARF grew, it employeebased surveyors could not possess the experiential skill set for all programs accredited. CARF therefore switched to a consultative part time peer review model for surveyors, who received a small honorarium for their efforts. CARF surveyors are "peers from the field" because they work full-time for CARFaccredited program, yet work part-time for CARF, after training, as surveyors when on survey-a model sustained to this day. Most employers allow one of their staff to become a surveyor. Some employers see surveying as a beneficial experience for a valued employee, and it is a tremendous development opportunity for any professional to engage. It also is a valued contribution by the employer to support a model of accreditation as a third party independent entity, a commitment to advancing quality in the health and human service industry. This approach has contributed to CARF gaining more relevant and current program expertise in its surveyor cadre. CARF, therefore, has been able to respond to changes in the market and develop new program standards with immediate access to corresponding expertise in surveyors to review and assess programs that seek accreditation. Customers of CARF view surveyors as consultative when discussing standards conformance ratings and quality improvement actions because they are active and practicing in the field. A CARF neuropsychologist surveyor and a program-based neurologist discussing and evaluating standards in reference to program outcomes for traumatic brain injury patients provides for a richer and valued consultation with a skill set competency match. Accreditation based on the foundation of a consultative peer review, and unencumbered from perceived surveyor financial gain, provides a context of goodwill and intent to quality improvement.
With concerns on the growing costs of services in the 1980s and 1990s, CARF began to strengthen its oversight value and experienced influencing regulatory related responsibility. CARF accreditation became a pre-qualification step to be eligible as a provider or a member of a provider network. Accreditation was a step in lieu of a regulatory survey by a state or supported credentialing requirements in private healthcare networks. Regulators demanded a line of accountability post an accreditation survey in instances where providers received recommendations for not complying with standards. CARF began requiring programs to provide follow-up quality improvement plans to identify actions scheduled to address areas of nonconformance to standards provided in the accreditation outcome report. Submitted to CARF within 90 days post on-site survey, the quality improvement plan (QIP) must detail the timing of specific actions to address areas of nonconformance. The QIP demonstrates a commitment to quality and influences an organization to advance and support a culture vigilant of quality matters. The organization's next accreditation survey will also include a review of the QIP to monitor advances in quality and to assess the success of actions. Overtime, customer, public and regulatory expectations of the value of accreditation and its purposes have influenced standards development and methods of ensuring integrity of the process and value of the "CARF Accreditation Seal." As an example, advances in technology, privacy of personal health information and the virtual delivery of services have resulted in new updated standards to accommodate new models of service delivery. Accreditation integrity in its ideal state would include highly competent surveyors, reviewing conformance to relevant quality standards, with resulting accreditation outcomes scaled to overall conformance ratings of standards, paired with recommendations that provide valued direction for continuous improvement. All stakeholders benefit knowing that a neutral third party, unencumbered from a profit motivation, will provide oversight information on programs accredited to meet standards of quality. An accredited entity with a CARF accreditation seal must affirm its ongoing conformance to the standards annually, and earn the benefits of the awarded outcome repeatedly to ensure currency in quality services for persons served.
Changes in the legislative and social environment also increased the number of programs added and the development of quality standards for new programs and services. A few illustrations over a 50plus year history highlight change and the agility necessary to an evolving environment. As an example, regulatory changes in the U.S. regarding rules against mandatory mental health institutionalization contributed to the development of community-based mental health programs, leading CARF to develop standards for Psychosocial/Behavioral health programs in the 1980s. Medicaid waivers for home-and community-based services gave the states options to provide long-term care services and support in the community, resulting in the proliferation of residential and day programs with accreditation as quality oversight requirement. CARF's standards also supported and standardized service and transition pathways to "deinstitutionalization" in the U.S. Transitioning individuals with services and supports to communities from institutional care removed accessibility barriers for persons with disabilities to participate in society and further reduced stigma for persons with disabilities. CARF recognizes that both society's work and that of CARF's is incomplete regarding further integration of persons with disabilities into the community. While CARF accredits programs that are "inpatient," such as specialized medical rehabilitation services, serious substance use disorders, or serious behavioral health issues as a few examples, the vast majority of accredited programs are in community and residential settings. To reflect the difference, distinction and diversity of human service needs, growth in program-based quality standards led CARF to transition from a single standards manual to the current eight. As CARF's standards grew in response to new services offered in the expanding health and human service markets, concerns regarding quality, costs and results did as well.
The CARF accreditation model also changed in response to pressures of related to the costs of healthcare and human services by ensuring organizations focused on programmatic outcomes for persons served, demonstrating value to payers and the community. Program evaluation standards, developed in the early 1970s, directed organizations to implement systems of data collection, analysis and use, albeit in an era absent of technology support. CARF standards continue to focus on building capacity and competency in the areas of performance measurement, management and improvement. Ultimately, optimizing the desired outcomes for the persons served, and therefore program effectiveness, will help to sustain the business success of the organization.

A Quality Improvement Framework From Industry and a Human Service Accreditation Model
To illustrate the commonalities of an accreditation model to another respected quality improvement framework, the CARF model compared at a high level to the International Organization for Standardization-ISO 9000:2015 Quality Management Systems (confirmed in 2021) demonstrates congruence in concepts and general approach. As illustrated below in table 1, both of the frameworks guide organizations to engage in quality improvement activities directed to advancing the success of the organization, and the review processes conducted offer many similarities.
Both quality review models include an on-site visit by the reviewers (registered auditors/ surveyors) to assess compliance/conformance to standards, with a positive outcome pending for the organization or program, either certification or accreditation. ISO has follow-up surveillance audits  1966 (many) 1947, 1987, 1994, 2000, 2008, 2015 Orientation Recognition that an organization demonstrates quality, value, and optimal outcomes of services through continuous improvement focused on enhancing the lives of persons served Recognition for quality management systems and guidance for performance improvement -a written assessment report. on corrective actions of noncompliance, with optional follow up visits. CARF requires a submitted quality improvement plan within 90 days post-accreditation outcome to address quality improvement recommendations. There is an additional requirement for CARF-accredited programs to submit an Annual Conformance to Quality Report (ACQR) to sustain its accreditation status. In keeping with the concept of gradients in quality, a CARF-accreditation outcome can be a full status of three years with substantial conformance to standards, one year if partial conformance, or a non-accreditation outcome. Within the granted three-year accreditation period, the organization must submit the ACQR, a leadership attestation that the organization remains in conformance to CARF standards for the programs that were accredited. This submission provides information on key organization/program wellness factors (ex. financial position, significant leadership change, location and service changes, etc.). Further, there are reporting requirements for "significant events," for critical incidents such as crimes, violence, unintended harm, etc. These events can place an organization "on notice" with accreditation requirements to address areas of immediate concern and nonconformance. For accreditors in the health and human service domain, safety and organizational stability has a preeminent place in the award of and sustained accreditation status.
In summation, setting aside the similarities and unique differences of each model, a continuous quality improvement culture with supporting infrastructure and processes are supported with each of the respective cycles of PDCA or ASPIRE, as referenced in the above chart. However, like most high-level comparisons, the specificity of standards, demonstration of adherence to standards, purpose of the on-site review and its engagement approach to a quality review all offer additional detail that demonstrates the value of any model, and identifies the special fit of an accreditation model from other options.

The CARF differentiator-Critical design of Quality Focused on the Person Served
In the review of the quality frameworks listed, each system differentiates standards to specific industries with a unique focus -a sector based adaptation. As an example, the ISO criteria apply to multiple industries as a quality management system, including healthcare. CARF criteria currently exist for eight broad health and human service sectors, with additional quality standards in specific program areas, as illustrated by the examples listed below in Table 2.
As noted above, each CARF sector has additional and specific quality criteria referred to as "program standards" designed around the specific service needs of the person served. Program standards articulate processes and skills required to meet the rehabilitation needs of the person served, including the assessment and planning of services around individual characteristics of the person served. Standards development efforts, conducted by an International Standards Advisory Committee (ISAC), include input from key stakeholders, as each participant has a critical role in the 'system of service' and the individual delivery of service. This development approach acknowledges and engages individuals who are representative of the multiple system levels (regulators, payers, expert providers and various associations known as CARF's International Advisory Council) in the complex health and human service delivery environment. Each party has a participation role to create standards to realize valued results. However, to reinforce a person served orientation, when CARF develops standards, it currently targets a minimum 10% representation rate for persons served as an active contributing participant in its "expert panel." The importance and inclusion of the person served is in the mission of CARF: "to promote the quality, value, and optimal outcomes of services through a consultative accreditation process and continuous improvement services that center on enhancing the lives of the persons served." Further, persons served also sit on the CARF board of directors. The CARF board has determined that the persons served shall be CARF's moral owner, guiding the application organizational accreditation resources to three benefitted outcomes: People shall have the opportunity to live fulfilling lives; Providers of service shall meet CARF quality standards that lead to optimal outcomes for the persons served; and, Providers shall achieve organizational success. The CARF mission and its focus on persons served drives the line of sight for CARF accredited organizations -their leadership, people and related business and service processes -for persons served results.
Key differentiators to CARF's successful history is ensuring that the person served and results for persons served are at the core of any health and human service accreditation outcome. Program standards, building quality around the relevant health and human characteristics of the populations served, provides the declarative guidance necessary to realize and discover person-by-person, and in aggregate form, program outcomes. CARF's growth can be attributed to its program based design of standards around the persons served, paired with the consultative peer surveyor experience. Without specific programs standards and specialty skilled surveyors, CARF fails to exist as a unique accreditor.

Standards with Person Served at the Core
The structure of CARF's quality standards delineate the business and program standards necessary to optimize resulting value to persons served ( fig. 1). Value to the persons served derived from services is core to any quality outcome. Even for a payer of service, if their client or member does not get the service, within the time, effort and results expected, there is a diminished perception of value. Delivering on value for persons served is a complex interplay of people, program processes and supporting business infrastructure. Leadership establishes the purpose and planned direction for the organization supported with resources: people-processes-technology. Setting the cadence of organizational activity with expectations of performance, while managing risk and retaining skilled staff sustains the organization as a going concern, consistent with the adage…"no margin, no mission." Organizational resources and processes that create a line of site to aspire to human service excellence, will necessarily demonstrate a commitment to a person served orientation.
Program standards ensures that those entering a program of services receive assessment of their circumstances, and are engaged in their service planning and delivery. Program information presented to the person served is in a format that is understandable, reflecting the importance of health literacy in treatment engagement and potential success (Slatyer, et al, 2022). An individual service plan acknowledges the influences that language, cultural or social determinants of health may support or present as a barrier to treatment success. Persons' engagement in their program plan supports adherence to a treatment regimen and thereby affects the success of service and interventions. The individual service or care plan utilizes evidence-based practices or guidelines with progress reviewed and shared with key members of the team, including, where appropriate, the support network of the persons served. This enhances communication, collaboration and coordination across services and as part of program discharge when not a continuity of care in the community. Program results gathered measure the success of the program and include persons' results achieved, and a follow-up to determine sustainability of results. Program performance information provides an opportunity to demonstrate value-based performance to multiple interested parties -prospective persons served, payers, government funding agencies, shareholders, etc. Performance measurement, management and improvement are the most important steps in any continuous improvement system focused on persons served.

Cluster Analysis of Key Competencies Based on Standards Conformance Performance
Standards conformance information from an accreditation survey can lead to opportunities for action and quality improvement. Conformance to standards, stratified across a continuum of the accreditation level awarded to organizations, shows an expected level of standards conformance for a 3-year, 1-year or a non-accreditation outcome. As illustrated below, with each specific standard assessed as being fully met, partially met or not met, a stepwise progression for the percentage of conformance to all standards clustered to a theme and its related accreditation outcome can be provided to any one organization and programs as needed. Themes provided to an organization during a survey can give an organization an area of improvement that may help advance performance and outcomes in many key areas. A sample of themes analysis provided below highlights the following competency areas: person served orientation, business structure and performance measurement, management and improvement: The thematic clusters in figure 2 offer opportunities for organizations to benchmark their conformance performance and to identify thematic-based areas for development and improvement. Expectedly, organizations granted full 3-year accreditation had notably higher conformance rating percentages on most themes. Predictably, the lower standards conformance rating percentages, the lessor accreditation outcome. The theme that focuses on rights of persons served, in today's vigilant social media charged environment, shows high conformance ratings for all accreditation outcomes. This area includes items such as policies and procedures that ensures confidentiality of information, privacy requirements, access to service records, informed consent, complaint procedures, etc. However, conformance differences seen in standards that relate to input from key stakeholders may also be related to low scores in performance measurement, management and improvement results because the voice of the persons served, or a referral source, are not being heard, thereby impacting better results. Themes analysis supports the exploration of improvement opportunities -only an accreditation model that ties these themes to specific human service programs serving defined populations offers the detail necessary for specific improvement actions.

Perception of the Value of the CARF Accreditation Experience
As a consultative improvement model, CARF offers the valued resource of the peer surveyor to discuss opportunities for improvement when non-or partial conformance to standards results in a recommendation for improvement. Rather than a punitive noncompliance stamp of failure, recommendations are additional learning and improvement opportunities discussed with the organizations to accelerate improvement efforts along a performance pathway. A consultation example might be offering a work experience program seeking employment opportunities for persons with cognitive disabilities ideas on how to engage prospective employers to support such a program. Clearly some recommendations are serious, as previously mentioned, and those that put recipients of service at potential harm or risk-usually health and safety standards related-will result in non-accreditation. The surveyor may also recognize and acknowledge an exemplary practice for affirmation and support. The greatest value of a CARF accreditation model, that its customers embrace, is the consultative interchange of improvement solutions, highlighted in assessing conformance to standards, between the surveyor and the organization.
To illustrate post-accreditation survey satisfaction results from CARF's 3269 surveys conducted in 2021, satisfaction feedback with the 'surveyors being consultative' was at 96%; 'standards applied being relevant to their service' at 95%; 'survey report gives guidance for improvement'' at 92%, and 'business improvement being realized as part of the accreditation process' at 95%. Standards areas valued most by accredited organizations via ranking include risk management processes (policiesprocedures and processes), performance improvement focus (directs focus on improve performance and practices), infrastructure vigilance (information management-technology) and focus on persons served (service and engagement oriented improvements).
The CARF accreditation process has provided empirical returns of value for its many stakeholders. CARF accredits 'nursing homes' referenced as person-centered long-term care community (PCLTC) standards. In a comparison study of 246 CARF-accredited PCLTC's compared with 15,393 nursing homes, CARF accredited organizations demonstrated better quality with regard to short-stay quality measures -influenza, pain, delirium, pressure sores, etc. (Wagner, et al, 2013). Senior Resources Group (SRG), a privately held assisted-living company in the U.S. utilized CARF accreditation to support and advance its service and business growth objectives. Their private study tracked results of accreditation and found more market leads and tours requested by prospective residents, a positive impact from an enhanced focus on safety resulting in a 2% decrease in reported residential falls, a reduction in use of psychotropic drug administration by half, and medication errors reduced by 34% (Matthiesen & Johnson, 2005). CARF's own study "Impact of Accreditation Study" (Shen & Andre, 2019) looked at accredited organization's growth over a 10-year period (2008-2017). The study found on average each accredited organization served 19% more people, expanded their programs by 10% with a corresponding increase in staff by 17%, and realized a 50% increase in annual revenue. Lastly, in the 2022 rankings by U.S. News and World Report of the top rehabilitation hospitals (U.S. News and World Report, 2022) 26 out of the top 30 hospitals have CARF accredited rehabilitation programs. Investment in preparation for and experiencing accreditation and its use as a quality improvement framework can pay dividends.

The Ultimate Voice of Value-the "Person Served"
The long-debated criticism of any accreditation model is that it is very process focused, defining but not capturing all the necessary outcome data to affirm quality. In the case of CARF, given the breadth of programs accredited, such an undertaking would be impractical. However, with CARF's focus on the person served, gathering persons' served experience has inspired CARF to offer separate services, not a requirement of accreditation, to solicit persons' experience of services via a survey process. uSPEQ® (Universal Stakeholder Participation and Experience Questionnaire -pronounced, "you speak"), supports continuous improvement in health and human services. uSPEQ's Consumer Experience and Employee Climate Surveys evolved from the field's desire to aspire to excellence.
Results from almost 20,000 consumer (person served) surveys collected from June of 2020 to June 2021 found the following evidence shown in table 3 of standards influence and persons served satisfactory experiences realized based on survey feedback .
Feedback to an organization from the consumer or person served in their programs may provide additional insights into processes that impact results for the person served and, in particular, identify areas for additional review and improvement and support evidence for value-based care reimbursement. CARF also has the ability to provide benchmark results from the Consumer Experience survey for customer use against approximately 70,000 to 100,000 persons served cases for organizations to assist in setting comparative attainment goals for measurement and improvement.

Growth of Quality with an Agile Accreditation Model and Extending the Quality Reach.
The CARF accreditation model, designed with core business standards and selected program standards has allowed CARF, government entities and providers great flexibility in establishing a quality framework globally, for a myriad of program delivery systems. The nature of standards development, an inclusive effort with persons served balancing other critical stakeholder input, provides for immediate market acceptance and many value points to CARF's customers. The result is national and global growth. As of the date of this article, across all sub-sectors, CARF serves over 9,000 organizations with 65,000 health and human service programs accredited at more than 28,000 locations. CARF's account growth over its 50 plus years demonstrates its ability to adjust to meet changing demands in the market ( fig. 3).
In the 1970-1990s time period, Employment and Community Service and Medical Rehabilitation programs were the dominant markets of CARF's business. Now there is a recognized need for increased behavioral health services to address various mental health and substance use disorders, with this market a predominant customer base representing over 50% of CARFs business. CARF has also witnessed its use by many government entities to supplement and advance quality oversight. Currently over 200 forms of recognition in the U.S. require providers to be accredited. In British Columbia, Canada, the Provincial Ministry of Children and Family Development and Community Living British Columbia have established accreditation as a strategy to assure quality and continuous improvement with its community of contracted providers. In some instances, accreditation is a blueprint for developing and standardizing quality systems in evolving markets, specific to a country's desire for achieving universal quality health coverage (Mate, et al, 2014). Private assisted living facilities in China are seeking CARF accreditation. In Latin America, the Middle East, and various European locations such as Sweden and Norway, to name a few, many health systems accredit their specialty medical rehabilitation programs. CARF continues to respond to these growth opportunities to extend its mission reach. CARF will support international growth opportunities with subsidiary entities in Canada and the United Kingdom, and international surveyors serving countries beyond those borders.

Focus on Person Served Sustains the "Willed Future" of CARF
CARF leadership has experienced many challenges in its history and has continuously adjusted to an evolving operating environment. CARF's ability to adapt has sustained its mission resilience as an accreditor, as fueled by its purpose, "…to enhance the lives of persons served". As an extended enterprise, CARF will grow its relationship with global stakeholders as part of its mission aspirations. Continued growth outside of the North American footprint, while recognizing CARF's traditional customers, will challenge and improve CARF's accreditation model. The engagement of diverse thought leadership from the global health and human service community will facilitate CARF's acceptance as an accreditor in new markets, along with the cultural fit of attracting and utilizing peer surveyors from those markets. CARF also recognizes that advancements in technology make accreditation accessible to new, remote and developing markets. Discontinuous change imposed by the recent pandemic created a new virtual platform for CARF accreditation with uses that are varied, and many, in application. CARF will ensure the person served remains the central focus in creating program standards. The constant revision and development of program standards keeps CARF current to changes in the delivery of services, retaining the future relevance of CARF by development design, therefore its "willed future." Patient experience surveys will support the critical central theme of the persons served. Offering this service to a greater audience will support the intent of accreditation to help organizations transform from the "conformance to performance impact" of standards on their operation. In a leadership role at CARF, it is a professional privilege to participate in an entity that binds key participants with a common set of values, all directed to ensuring quality services to people. As a participant and coordinator of the CARF quality collaborative, what better role can there be than to advance quality for the persons served to the benefit of the communities in which we live, love, work and play.

ACKNoWLEdGMENT
The author would like to thank Lori A. Rogers, MPA, for conducting background research for this paper.