Glossary

This Glossary has been prepared to describe terms and concepts used on our website and as related to CARF accreditation consulting.

Refer also to the Glossary section in each 2013 CARF Standards Manual for another diverse glossary  of terms.


 

Accredit.  To recognize as conforming to and maintaining a specified set of standards; to give official authorization to.

Accreditation.  Through the process of accreditation, conformance to a set of recognized standards is reviewed to ensure that the agency is operating at the highest level of organizational effectiveness and efficiency.  Accreditation is an indication that high quality services are provided.

Accreditation Decision.  The result  of an accreditation survey.  The outcome is determined by CARF based on the findings of the CARF surveyors who conduct on-site reviews.  There are five possible accreditation decisions:  Three-Year accreditation; One-Year accreditation; Provisional Accreditation; Nonaccreditation; and Preliminary Accreditation.  Refer to the CARF website for more information about the guidelines used to determine each accreditation decision.

Accreditation OutcomeSee Accreditation Decision.

Audit.  A formal, methodical  examination of an organization and it’s business practices.  This is not a term used by CARF.  (See the definitions for the terms Survey, Re-Survey, and Original Survey.)

Business Associate Agreement.  A contract between an individual or company and its associates who will use Protected Health Information (PHI) for administrative, clinical, quality assurance, financial, and/or research purposes.

CARF.  CARF is the Commission on Accreditation of Rehabilitation Facilities located in Tucson, Arizona. Established in 1966, CARF International is an independent, nonprofit accreditor of health and human services providers.

Client.  Behavioral Health Resources uses this term to refer to the individual who receives behavioral health services.

Conformance.  Confirmation that requirements of accepted practices or prescribed standards are adequately met.  Conformance to standards is assessed during on-site reviews by CARF surveyors who are peer reviewers (i.e., currently employed in a CARF-accredited organization).

Continuous Quality Improvement (CQI).  An objective, methodical management system of identifying areas for improvement and continually increase quality of work processes.  CQI involves the use of statistical tools to identify problems.  Specific expectations for improvement and the means to measure them are established.  Implementation of identified changes are directed towards preventing future problems in these areas and involves the setting of goals, education of staff, and measurement of results which are shared with stakeholders.  Empowerment of employees is a critical part of this process.

Consultant.  A recognized expert in the field who provides independent, objective evaluation of programs and services.  Because of their exposure to and relationship with numerous organizations, consultants are aware of industry “best practices.”

Contingency Fees.  Payment of a pre-determined fee only when the desired goal or outcome has been achieved.  For example, the independent accreditation consultant may receive payment only if the organization achieves a Three-Year CARF accreditation (if this was the outcome desired by the organization).  If the goal is not achieved, the consultant is not paid.

Consumer.  The individual who receives behavioral health services.  (See also Client.)

Contract.  A document that is a binding agreement between two or more parties and is legally enforceable.

Co-Occurring.  Mental health and substance use conditions often co-occur. In other words, individuals with substance use conditions often have a mental health condition at the same time and vice versa. The term co-occurring is becoming the more commonly used term in behavioral health and is synonymous with dual diagnosis.

Cost-Effective.  Economical in terms of tangible benefits produced by money spent; effective and productive in relation to cost.

Cost-Plus Pricing.  A fee structure also known as markup pricing.  The consultant first determines the baseline cost of the service, then adds a proportion as a markup (e.g., 20%) which results in the total cost to the customer.  This fee schedule provides the consultant with his or her desired profit margin.  The purpose of cost-plus pricing is for the consultant to maximize his or her profits.  The proportion of markup over cost may reflect current market demand for services.

Customer.  Behavioral Health Resources uses this term to refer to the organization that contracts for consulting services.

Daily Rates.  A type of fee structure in which the consultant has a fixed daily rate.  Fees for independent accreditation consultants can range from $700 to $2,000 per day. There may be a minimum number of days required  (e.g., a two-day  minimum).

Dual Diagnosis.  See Co-Occurring.

External Consultant.  An expert who is employed externally by the organization and whose expertise is provided on a temporary basis, usually for a fee.  This type of consultant usually contracts with multiple clients concurrently.  In contrast to internal consultants, external consultants may be preferred when there is a need for deeper levels of expertise and/or an increased level of objectivity.

Fixed-Fee.  A uniform pricing menu for the service provided.  All customers receive the same price for the same service.

HIPAA.   The Health Insurance Portability and Accountability Act of 1996 (HIPAA; Pub. L.104-191, 110 Stat. 1936) was enacted by the United States Congress on August 21, 1996.  Various components of these confidentiality guidelines  require national standards for electronic health care transactions as well as provisions for the security and privacy of health data (i.e., Protected Health Information; PHI).

Hourly Rates.   A fee structure in which the consultant has a fixed hourly rate for on-site and off-site services.  Fees for independent  accreditation consultants can range from $50 to $200 per hour.

Independent Contractor.  As defined by the U.S. Internal Revenue Service (IRS), “an individual is an independent contractor if the payer has the right to control or direct only the result of the work and not what will be done and how it will be done.”  (See also External Consultant.)

Internal Consultant.  An expert within an organization who is available to be consulted on specific topics by other departments or individuals within the organization.

Management Consultant.  An external, independent contractor who objectively helps organizations improvement their performance.  See also External Consultant, Independent Contractor, and Private Consultant.

Mock Survey.  A simulation of an actual survey which may include:  review of policies, procedures, and practices; review of documents and forms; records review; tour of the main office and program sites; and interviews with governance, leadership, funders, staff, and clients.  The purpose of a mock survey is to identify areas of improvement for implementation of correction prior to the actual survey by the accreditation organization (e.g., CARF).

Original Survey.   The first survey (i.e., on-site review) of an organization that is conducted by CARF surveyors and results in an Accreditation Decision.   Click here for information about how to prepare for an original survey.

On-Site Survey.  A review of business operations and interviews with stakeholders that occurs on location at the organization and it’s satellite offices.   Surveyors review all components identified previously in the definition of a mock survey.

Person-Centered.  CARF emphasizes a person-centered approach.  This means that the organization fosters a culture that supports autonomy, diversity, and individual choice.  Leaders are committed to integrating this value in their organization structure and strategy.

Person Served.  This is the term used by CARF to refer to the individual receiving behavioral health services.

Private Consultant.  See Management Consultant, External Consultant and Independent Contractor.

Proprietary.  Something that is used, produced, or marketed under exclusive right of the inventor or owner.  Proprietary information is protected by copyright or patent and cannot be used without permission.  When providing consulting services, it is the practice of  Behavioral Health Resources to use, publish, and distribute CARF-related documents and materials that are in the  public domain (e.g., available on the CARF website).

Protected Health Information (PHI).  Information that directly relates to an individual’s health and contains personal identifiers of the individual as well as for relatives, employers, or household members of the individual.  PHI includes: (1) the past, present, or future physical or mental health or condition of the individual; or (2) the provision of or payment for healthcare to the individual.  For a list of PHI examples, click here.

Quality Improvement Plan (QIP).  Within 90 days after receiving notification of an accreditation decision, a CARF-accredited organization is required to submit a written report (i.e., the QIP) describing the actions that have been or will be taken to correct areas where recommendations were given in the Survey Report.  (For organizations receiving a One-Year or Provisional Accreditation decision, the QIP is submitted to CARF within 45 days.)

Quarterly Records Review.  A systematic review of records of the persons served.  CARF requires that a representative sample of open and closed records be reviewed.  Although CARF does not indicate what percentage is a representative sample, CARF surveyors often determine this to be at about 10%.

Re-Survey.  CARF surveys that occur subsequent to the Original Survey.

Retainer Contract.  Compensation is paid for access to the consultant and his or her expertise for a pre-determined period of time.  The fee is paid when the Consulting Agreement is signed and before services are provided.  Discounts can be applied for long-term contracts.  (For example, a six-month retainer contract may be less expensive than a three-month contract.)  Authorized staff of the organization have unlimited access to the consultant for advice.  No specific project is identified. Click here for more information.

Return on Investment (ROI).   A performance measure used to evaluate the efficiency of an investment, i.e., the ratio of money gained or lost on an investment relative to the amount of money spent.  ROI is usually expressed in a percentage.

Standards.  Something that is considered by an authority to be a required or agreed upon level of quality.  The CARF standards for each service unit (e.g., Behavioral Health) are published every year and are effective at the beginning of every Standards Manual Year which begins on July 1.

Survey.  The on-site review conducted by CARF surveyors to assess conformance to the standards relevant to the specific service areas being reviewed (e.g., Behavioral Health, Children and Youth Services, Opioid Treatment Programs).

Trauma-Informed.  As defined by SAMHSA:  “When a human service program takes the step to become trauma-informed, every part of its organization, management, and service delivery system is assessed and potentially modified to include a basic understanding of how trauma affects the life of an individual seeking services.”   There is an emphasis on modifying service practices to avoid re-traumatization.

Transparency.  Implementation of business practices that focus on openness, communication, and accountability.

Value-Based Fees.  The fee is established collaboratively with the customer based on the project, type of services requested, identified objectives, and the project timeline.  Options are individualized to meet the unique needs and budget of the organization. Click here for more information.

42 CFR Part 2.   These are the federal regulations that protect confidentiality of substance abuse records and are more restrictive than HIPAA guidelines.  The following  statement is placed on documents such as substance abuse evaluations:  “Federal regulations prohibit re-disclosure of this information without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations.  A general authorization for the release of medical or other information is not sufficient for this purpose.”

 Consultants of Behavioral Health Resources, LLC do not represent CARF


Staff at Behavioral Health Resources are committed to continuous quality improvement.  If you believe that a definition is not clear and/or another term should be added to the Glossary, please contact our President, Brenda Rohren, at brenda@bhr-llc.com or (402) 486-1101.