Accreditation isn’t just about checking boxes—it’s about formalizing how your clinic operates, serves clients, and continuously improves outcomes.

For outpatient mental health clinics pursuing CARF accreditation, policies and procedures serve as the backbone of organizational structure. These documents are not merely administrative; they reflect how care is delivered, how risk is managed, and how your team is led. CARF expects policies and procedures to be more than compliant—they should be practical, easy to access, and actively integrated into day-to-day operations. Curry Coaching and Consulting^TM can help to guide you through this process and get your facility CARF standard ready.

What CARF Looks for in Policies and Procedures

When reviewing policies, CARF surveyors are looking for documents that are clear, current, and actually used by your team. Policies must be easy to understand and updated regularly to reflect the clinic’s current operations. CARF places special emphasis on areas such as client rights and informed consent, risk management, personnel qualifications, emergency preparedness, clinical care coordination, and systems for data collection and performance improvement.

Start with a Policy Audit

The first step in aligning your clinic with CARF standards is to conduct a thorough policy audit. Begin by gathering all existing policies, including those related to clinical care, administration, human resources, and safety. Next, compare your existing policies to the CARF standards using either your standards manual or a simplified checklist. As you do this, identify any gaps—such as missing policies, outdated references, language that lacks clarity, or documents that no longer reflect your clinic’s actual practices. These gaps will serve as your starting point for updates or new development.

Revise or Create Policies with Purpose

When rewriting or developing new policies, consistency and clarity should guide your approach. Each policy should follow a standard format that includes a clear purpose, the responsible party, a review cycle, and detailed procedures. Whenever possible, align each policy with the corresponding CARF requirement, including cross-references to relevant standards. Importantly, your procedures should be practical and actionable—staff should be able to follow the steps as written, not just read them. For example, an emergency preparedness policy should go beyond stating that a plan exists. It should include detailed procedures, assigned roles, and guidance on where the plan is posted or stored.

Keep Your Policies Active and Updated

Strong documentation is only part of the equation. Your policies need to be living documents—regularly reviewed and actively used. Establish an annual policy review calendar to ensure all documents stay current. As you update policies, track staff sign-offs to confirm that everyone is informed of changes. It’s also essential to revise policies when service delivery models shift, new technology is introduced, or staffing structures change. This ongoing maintenance keeps your clinic responsive and compliant.

Preparing for a CARF Survey

As your CARF survey approaches, it’s critical to have a well-organized policy manual—either in digital or printed format—that is easy to navigate. Surveyors will not only want to see the policies, but also how they are used in practice. Be prepared to demonstrate usage through staff training logs, incident response documentation, and examples of performance improvement initiatives that tie back to policy. One helpful strategy is to create a policy index that cross-references each document with the applicable CARF standard. This makes it easier for surveyors to find the information they need and shows your clinic’s commitment to transparency and alignment.

Engage Your Team in the Process

Your policies will be most effective when your team is actively involved in their review and implementation. Include both clinical and administrative staff in the policy development process to ensure procedures make sense from every perspective. Use staff trainings, checklists, and walkthroughs to help team members internalize and apply policies in their daily work. It’s also essential that every employee knows where to access policies and understands their responsibilities in following them. This promotes accountability and supports a culture of compliance and quality care.

Need help reviewing or writing CARF-ready policies?

Schedule a strategy call with the Curry Coaching and Consulting^TM team today. We’ll help you identify gaps, refine your documentation, and ensure your policies are not only compliant—but effective. Reach out to us here and we will be happy to help your facility!