Understanding CARF and JCAHO Outcomes Requirements

If you own a treatment center or work at one, it is essential that you understand the treatment center accreditation requirements, as these can be very specific and go through regular updates. The differences between CARF and JCAHO requirements are especially important as these are two of the most significant organizations that provide accreditation for treatment centers. 

In this article, we will be discussing the CARF and JCAHO differences regarding their requirements for accreditation, specifically in terms of outcomes reporting guidelines. So, keep reading to find out what these requirements are and how you can ensure your rehab center is in compliance.

What is CARF?

Before you understand the CARF outcomes reporting requirements, we first need to discuss what CARF actually is. This stands for the Commission on Accreditation of Rehabilitation Facilities, and it is a nonprofit organization that accredits certain types of facilities. It uses a consultative and peer-reviewed approach when evaluating facilities to decide if they meet the behavioral health accreditation requirements.

CARF primarily focuses on rehabilitation and recovery facilities and has a person centered approach that focuses on identifying areas that could be improved upon and providing quality improvement solutions.

Treatment centers will have to go through the application process to ensure it meets the CARF standards to become accredited. Facilities will also have to meet the standards for a minimum of six months before the on-site survey is scheduled. Overall, the entire process can take over a year as a facility has to establish that the accreditation standards are being upheld on a continual basis.

There are also different types of CARF accreditation that have specific requirements and will last for a certain amount of time. For instance, you can obtain a three-year accreditation, one-year accreditation, or other facility specific accreditations.

The key requirements for treatment center compliance include the following:

• Assess the environment and facility operations.

• Find room for improvement and set a strategy.

• Obtain input from persons served and key stakeholders

• Use outcomes reports and data to implement the plan.

• Review results and share outcomes information.

What is JCAHO?

The Joint Commission, previously known as JCAHO, is a top accreditation organization that evaluates healthcare facilities. It has a strong clinical focus and looks closely at the safety and risk management for healthcare facilities. It evaluates healthcare organizations to ensure they meet the accreditation standards of safety, compliance, and high-quality care.

The standard timeline for JCAHO accreditation can range anywhere from 3 to 4 months to a year in order to collect the information required. You will have to provide proof that your facility has complied with the accreditation standards on an ongoing basis in order to qualify. Once you receive accreditation, this will usually last for three years, but ongoing monitoring and review will still be necessary.

The Joint Commission uses a medical model approach when it comes to examining and accrediting healthcare organizations. Depending on the specific organization, the standards may look a bit different since they cover a broad spectrum of services and practices, such as:

• Facility safety and security

• Staff qualifications and training

• Patient care and treatment center processes

• Infection control and prevention

• Performance improvement

• Patient safety initiatives

• Medication management

• Patient rights and responsibilities

• Leadership and governance

To receive accreditation and to showcase that you meet these requirements, you will need to provide documentation and performance data analysis as well as agree to interviews and on-site visits.

CARF and JCAHO Differences

CARF and JCAHO are two of the biggest accreditation organizations and have many similarities but they are also a bit different in their approach. For instance, The Joint Commission is primarily medically-based while CARF, on the other hand, is more focused on the individual industry. Because of this, CARF accreditation is more commonly pursued by recovery and treatment centers.

The CARF and JCAHO differences also include different approaches to requirements and standards in order to become accredited, include things such as:

• Requirements for staff

• Method of collecting data

• Reporting frequency

• Required Documentation

• Necessary services

Outcomes Measurement Requirements and Data Collection Standards

A very important aspect of treatment center accreditation requirements is the accreditation reporting guidelines when it comes to outcomes. Outcomes reporting is a critical component of tracking how treatment centers are running and making the necessary improvements to improve efficiency and care. Because of this, both CARF and The Joint Commission have their own set of standards and requirements you will need to meet to become accredited.

These standards often include things like follow up periods, response rates, quality of life measures, post discharge tracking, treatment completion, and relapse prevention.

CARF

CARF requires treatment centers to have an outcomes system in place that can track the effectiveness of the services provided. This needs to include things like cost to benefit ratios, the ratio of resource use to outcomes, responsiveness, and timeliness.

The specific outcomes measurement requirements and data collection standards for CARF include collecting and reporting:

• Effectiveness measures

• Efficiency measures

• Consumer satisfaction measures

• Stakeholder satisfaction measures

• Consumer characteristics

• Persons receiving services

• Staff members

• Key stakeholders

• Governance authority

• The public

• Information pertinent to the services provided

The purpose of all data and information collected and reported is to develop a strategic plan, improve the service quality for each individual, review, modify, and improve the services and the individual’s experience.

The Joint Commission

The good news for treatment centers is that The Joint Commission does not have overly complex outcomes measurement requirements, making these relatively simple to comply with. These standards include:

• EP1: Organizations must use a standardized tool or instrument to monitor each individual's progress.

• EP2: Organizations must analyze the data generated by the standardized tool or instrument and use the results to inform the individual's objectives and goals.

• EP3: Organizations must use this data to evaluate treatment, services, and outcomes of care.

The Joint Commission also requires regular data reporting that includes numerator and denominator figures for these measures, not just the rates, for better quality assurance. The types of data that treatment centers are required to collect and report include things like:

• Medical errors

• Client satisfaction measures

• Adverse drug reactions

• High risk and volume, problem-prone process, and restraint/seclusion

The goal of collecting data is to better understand the outcomes of care and use this information to inform the goals and objectives of the care, treatment, and services provided for each individual. Data should also be collected on patient race and ethnicity information as well as any other types of sociodemographic characteristics and health-related social needs.

Treatment centers are also encouraged to collect data that is not standardized or necessarily required by The Joint Commission if it could benefit the patients or provide strategies for better care.

Treatment Center Best Practices for Meeting Requirements

Due to the nature of rehab center accreditation standards and regulations, it can be a challenge to maintain compliance in the long term. Treatment centers need to establish certain best practices to ensure that they stay compliant and provide the utmost quality. This will help your treatment center to not only stay compliant, but to also stay competitive with other treatment centers.

Here are some best practices you can take advantage of to ensure compliance so that you maintain accreditation.

Use Digital Systems

In the age of the digital world, there is an endless amount of digital resources available for treatment centers who need to track outcomes and data. Not only will this help significantly when it comes to better time management and resource optimization, it is one of the necessary standards set by both the CARF and JCAHO.

You need to have standardized systems set up that track things like response rates, treatment completion rate, documentation, etc. Some systems are able to manage many different things at once allowing for better integration and less room for information being collected partially or lost entirely.

Digital tools and systems also allow for better tracking solutions so that important information is cataloged so that it can be reported on. You should take advantage of automation options that allow you to streamline certain tasks to save time so that your staff can focus on other duties.

Train Staff Appropriately 

To maintain compliance with JCAHO and CARF requirements, you need to ensure your staff are appropriately trained. All staff members must go through the appropriate training courses and ongoing education so they are up-to-date on their credentials and the necessary skills needed to do their work.

Staff members should be up-to-date with treatment center policies and procedures especially when it comes to outcomes reporting and data collecting. You also need to ensure your staff have all of the credentials and training required by both the CARF and The Joint Commission.

Ensure Patient Privacy

When you use digital systems to track things like outcomes, data, and other forms of patient information, you need to ensure patient privacy. This is a significant part of remaining compliant and ensuring sensitive information is secure, especially when it comes to health information. You also have to keep in mind that behavioral health organizations have to maintain compliance with the government privacy requirements for these systems.

HIPAA establishes federal safety standards for sensitive health information, so you will need to follow the HIPAA rules and regulations for patient privacy.

Hire a Compliance Officer

Although it is not necessary to maintain compliance, it can be incredibly beneficial for treatment centers to appoint a compliance officer. A compliance officer is an individual who is up-to-date with all of the compliance requirements and oversees these areas of the treatment center.

A compliance officer will have a thorough understanding of CARF and JCAHO standards and requirements as well as statewide and government requirements. They can oversee all compliance measures, looking for areas that could be improved upon or areas that are not meeting the compliance standards. 

Common Treatment Center Compliance Challenges

Meeting the CARF and JCAHO outcomes requirements can come with some challenges since these requirements are often extensive and require that you have several systems in place. These are a few of the areas where many treatment centers may struggle when they are trying to become accredited.

A common issue you may run into is staff coordination as all of your staff members need to understand what compliance measures are necessary. This challenge can be overcome by utilizing appropriate staff training, continued education, and delegating specific tasks. Regularly reviewing performance can also prevent ongoing mistakes and issues that might otherwise be overlooked.

Treatment centers may also have a difficult time with resource allocation and time management, especially if they are doing certain tasks manually. Updating systems, using integration, and automating certain tasks could help with time management, meeting response rates, and taking some of the burden off of staff members.

If you are struggling to remain compliant with either CARF or JCAHO outcomes requirements, you may want to consider using an outcomes management tool to simplify this process. An outcomes management tool can help with tasks such as automating follow-ups, creating instant accreditation reports, utilizing a standardized data collection, etc. This can help you move several tasks to one system so that there is less room for error and information can be processed more efficiently.

How Treatment Centers Can Maintain CARF and JCAHO Compliance

Aside from utilizing treatment center best practices, there are other things that you can do to maintain accreditation reporting guidelines and standards. Something to keep in mind is that you need to maintain the standards for CARF and The Joint Commission if you have accreditation from either of these organizations, as well as the standards in your state and through the government.

Keep in mind that receiving accreditation from CARF or The Joint Commission is an ongoing process that requires continuous improvement. Ongoing surveys, on-site visits, and reports will all be necessary to maintain accreditation.

Here are some ways you can maintain compliance:

• Regular audits: Understand when evaluations, audits, and on-site visits are necessary for accreditation and stay up-to-date with regulatory changes. You should also conduct internal reviews or practice audits to address any potential compliance issues ahead of time.

• Continuous improvement: Create room for continual improvement by having open communication with staff, managers, and patients. You can also use digital tools to do this through things like surveys and questionnaires.

• Staff training: Provide continuous educational resources for staff and set training protocols that they must adhere to.

• Documentation updates: Maintain all vital client records as well as facility operation records, regularly checking to make sure nothing is lost or incomplete. 

• Quality assurance: Use quality assurance programs to check for any areas of care that could be improved upon, as well as evaluate performance metrics and individual client feedback.

Conclusion

There are many rehab center accreditation requirements that managers and staff need to be aware of and this is especially important when it comes to things like CARF and JCAHO outcomes requirements since ongoing compliance will be needed to maintain accreditation. Treatment centers can maintain these requirements with digital tools, automated systems, appropriate staff training, and quality control measures.

Because there are so many tasks treatment centers need to stay on top of, it is often best to outsource this by using an outcomes reporting system. For help managing and monitoring your outcomes reports, contact us today at I Am Sober to join our waitlist.