Why accreditation failed agencies serving the blind and visually impaired.

Currently there are at least four organizations providing nationwide accreditation services, the Accreditation Council on Services for People with Disabilities (ACD), the Commission on Accreditation of Rehabilitation Facilities (CARF), the Joint Commission on the Accreditation of Health Care Organizations, and the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC). These accreditation programs frequently focus on a particular aspect of rehabilitation, such as blindness, developmental disabilities or medical aspects of rehabilitation not necessarily related to vocational rehabilitation.

Rehabilitation usually involves a continuum of services and comprehensive agencies try to provide a continuum of care or services. Accreditation becomes a general concern when the accrediting organizations, themselves, become specialized and may only be able to accredit certain aspects of an agency's complete program (Grove, 1995).

Some states require any agencies receiving state appropriations to be certified. Such certification is sometimes done "in house" using state employees for the certification process. Other states, such as Missouri, require that agencies receiving state funding have some form of national accreditation. This brings a national perspective to the state funded programs and does not require the direct use of state funds, which can then be used for client services (Solum, 1995).

The cost of national accreditation is becoming an issue with some agencies. The cost usually varies with the size and complexity of a rehabilitation program. For example, the Accreditation Council for Services for People with Disabilities may charge as low as $3,000 and as much as $18,000. The larger figure would be for a complex agency with several locations. A typical figure would be $8,O00 for a two year accreditation (Nudler, 1995).

Accrediting agencies are created to assure the public that economic resources are properly utilized, that facilities are both safe and adequate and that they have a properly educated staff. Duplication of programs can be minimized and, as the process of professionalization continues, task differentiation can be certified (Rothman, 1987). As a profession develops, it tends to seek increasing control over the organizational settings where services are provided (Abbott, 1988; Larson, 1977). This frequently produces internal conflicts as agencies resist external domination. Conflicts within a profession and consumer criticism and opposition may become insurmountable barriers for an accrediting organization. This paper analyzes the sources of the decline of the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC) and suggests alternatives for a more effective accreditation program.

Following World War II there was a rapid growth in the number of agencies serving the blind and visually impaired. With this growth came concerns about the quality of programs and the qualifications of professional workers. This concern led to the development of the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped (NAC) in 1967. NAC began with great expectations among professionals who work with the blind and visually impaired. However, it never met the expectation that it would become financially self-supporting and at its height accredited only a small portion of the agencies and organizations in the field of blindness. It has been in decline for the past decade and has been consistently opposed by the largest consumer organization of blind people, the National Federation of the Blind (NFB). It recently lost the financial support of the American Foundation for the Blind (AFB). The AFB had been crucial in providing the financial and staff resources for the process that led to the creation of NAC and had been its largest single source of financial support for over fifteen years. In 1994, the United States Secretary of Education informed the National Accreditation Council that it had been dropped from the Secretary of Education's list of recognized national accreditating agencies (Pierce, 1995). As this paper will show, the number of agencies accredited by NAC has been dropping steadily for the past nine years, moving from a high of one hundred and four to its present sixty-four. NAC's decline comes at a time of increasing national concern about accountability and an increasing emphasis upon the outcome of education and rehabilitation programs (Szymanski & Linkowski, 1995).

Origins of NAC

Two years of a carefully planned organizational effort leading to the formal establishment of NAC attracted both consumer and professional criticism. Disregarded criticism led to a lukewarm support from agency professionals and intense consumer opposition; more articles have appeared in The Braille Monitor about the failures of accreditation than on any other single topic. For more than fifteen years large numbers of blind people, usually between two hundred to three hundred fifty, have come from all over the United States to publicly demonstrate against the failures of NAC (Rabby, 1984). To understand the roots of this conflict, it is necessary to examine some of the developments in the field of working with the blind over the three decades preceding the establishment of the National Accreditation Council. It is then possible to analyze the process by which the new agency was established, along with its goals and early successes. It is also important to consider the reasons it was continually opposed by consumers and why it has been ignored or boycotted by many agencies and professionals working with people who are blind.

Before World War II most teaching of the blind occurred either in special institutions, in schools for the blind, or in a home setting by itinerant home teachers. Beginning shortly after World War II rehabilitation centers were established in several parts of the United States. The number of blinded war veterans and the financial support from the Veterans Administration were one source of this growth. These centers, sometimes developed in tandem with sheltered workshops, aimed at helping blind people adjust to their blindness, learn skills and be evaluated for vocational training or educational purposes.

As early as 1932 there was concern about the degree or adequacy of the training of home teachers of the blind. These teachers were mainly women and the majority were blind. They found themselves interacting with the rapidly expanding profession of social work which was developing its own standards for educational requirements. In 1932 a regional organization of home teachers appointed its own committee to develop minimum standards of practice (Koestler, 1976). Further impetus toward standards came from the federal government in the 1939 amendments to the Social Security Act. All persons employed in the federally funded welfare programs would have to participate in a merit system. "In many states the commission for the blind would have to meet the same civil service standards as those of the sighted civil service workers employed in other facets of welfare assistance" (Koestler, 1976, p. 291). As Koestler noted, the question arose concerning whether or not blind people employed as home teachers would lose their jobs or be replaced by more educationally qualified sighted teachers. The possible displacement of blind workers was the earliest source of resistance.

In 1938, the American Foundation for the Blind convened a special conference to work out the philosophy and principles of home teaching. Following this, the American Association of Workers for the Blind (AAWB) appointed a board for certification of home teachers. The new standards were adopted by the 1941 convention of the AAWB and included two levels. Class 1 required two years of college training including courses in social work and education. In addition, braille, typing and proficiency in six handicraft skills were required. Four years of experience could be substituted for the college training. Class 2 required completion of the college course work of Class 1 and at least one year of post-graduate training in social work. In 1947, the annual convention of AAWB was informed that sixty Class 1 and three Class 2 certificates had been granted (Koestler, 1976).

Reporting as chairman of a 1952 committee to explore standards, Roberta Townsend stated to the 1953 AAWB convention that a lack of unanimity of thought and standards had resulted in "many sporadic programs" and frequent duplication of services. Following her report, the AAWB adopted a resolution "asking that `a manual be devised of useful criteria and standards for the guidance of agencies' and that it be developed by the American Foundation for the Blind" (Koestler, 1976, p. 340). In the same year the organization issued another blunt report criticizing empty or shallow agencies which provided almost no services but sought funds from the public, ostensibly to provide help to the blind. It noted that more than six hundred agencies for the blind were making conflicting approaches to the public for support with sometimes counterproductive results. Both reports led to a growing concern for standards which would result in a seal of approval for agencies in compliance with the agreed upon criteria.

In 1956, the Federal Office of Vocational Rehabilitation, along with the American Foundation for the Blind, sponsored a conference intended to develop principles and standards to guide the proliferation of work for the blind. Development had been rapid because of the increasing support from the federal government in areas such as the Veterans Administration, the Office of Vocational Rehabilitation, and the Hill-Burton Act, which made funds available for constructing rehabilitation facilities independent of hospitals themselves. Private agencies serving the blind were growing in both number and size in almost every large American city. The 1956 conference invited carefully selected workers in the field of blindness. As Koestler notes, many of these were the same individuals who had met at previous AFB sponsored conferences to deal with standards and accreditation. "Out of the work of the seventeen people who spent five days in sub-committees and general sessions came a set of precepts that largely foreshadowed the standards later adopted by COMSTAC" (1976, p. 297). The Commission on Standards and Accreditation of Services for the Blind (COMSTAC), would lead to the establishment of the National Accreditation Council.

Robert Barnett, then President of the American Foundation for the Blind, recognized that a structured process, which would involve standards and a method of implementing them, would be necessary to achieve the maximum benefits for blind people, given the proliferation of agencies and funds available for rehabilitative services. Following this lead, the President of the AFB Board in 1961 said, "It is not our intention that the American Foundation for the Blind will itself conduct a policing program, but rather that it will arrange to expedite a service program of evaluation and accreditation which would find its authority in a democratic representation of all legitimate interests in this field" (Koestler, 1976, p. 342). As this article will subsequently show, the conflict that swirled around this accreditation effort resulted, in part, from confusion about the meaning of "democratic representation of all legitimate interests in this field." It later became a central contention of the leadership of the only national organization of blind people existing at that time that not only were blind people not adequately represented, but the entire process leading to the National Accreditation Council was tightly managed by a small group of professionals and orchestrated by the American Foundation for the Blind (Vaughan, 1993).

In 1962 an ad hoc committee appointed by the American Foundation for the Blind recommended that an autonomous commission be appointed to develop standards and regulations and to create a permanent accrediting body. The American Foundation for the Blind agreed to partially finance the commission's work while allowing it autonomy. Over the four years of the commission's work, the AFB provided $300,000 plus the labor of many of its staff members, while an additional $138,000 was obtained from three private foundations and the Vocational Rehabilitation Administration.

The resulting committee reports were reviewed at a conference attended by more than four hundred people in 1965, and the revised standards appeared in "The COMSTAC Report: Standards for Strength in Services." This report recommended that an organization be established to carry out the accreditation process. Thus, the National Accreditation Council for Agencies Serving the Blind and Visually Handicapped was established in 1967 with Arthur Brandon, the former chair of the COMSTAC, as its first president. A. F. Handel, the new executive director, had also been executive director of COMSTAC. The founders of NAC projected a ten year plan which would conclude with levels of economic support sufficient to eliminate external subsidy. The organization would be supported by fees paid by the agencies seeking accreditation. To underwrite the program during the developmental phase the American Foundation for the Blind and the Vocational Rehabilitation Administration assumed the greatest burdens. By 1972 NAC had accredited forty-seven agencies with approximately fifty more involved in some stage of the accreditation process (Koestler, 1976). By 1972 it was apparent that self sufficiency was not possible, and it would require an additional period of subsidizing.

The enthusiasm for NAC was not unanimous. Support was concentrated in larger private agencies. Koestler's interpretation of reasons for resistance or lack of enthusiasm on the part of some groups included the following: 1) Professional standards might threaten the positions held by some blind people who might not measure up to new requirements in public and private agencies; and 2) the interests of blind people working in sheltered workshops were threatened by an accreditation process that might ignore their concerns about minimum wage, collective bargaining and other labor practice issues (Koestler, 1976). Consumer literature reflected a concern that a small group of self designated professional staff people had their own agenda for managing and controlling the field of blindness. Consumer groups particularly argued that they had been under-represented and even ignored in the COMSTAC process. However, before turning to the consumer's point of view, we will review some of the early reported enthusiasm by the officers of NAC as well as some agencies who experienced accreditation.

The first accreditations were granted in 1968 and were lauded in the first annual report of NAC. Its president commented, "The ferment continues. Out of it will come rising numbers of accredited agencies giving even better service to the blind and visually handicapped. And even as the numbers grow, the ferment spreads" (NAC Annual Report, 1968). The first three accredited agencies were proud of their accomplishments and began immediately using the seal of approval on their stationery and in their publicity. In NAC's first years a three hundred forty-two page study guide was published. The check list and rating scales, intended to guide self-study, covered eleven aspects of agency activity: function and structure, financial accounting and service reporting, personnel administration and volunteer service, physical facilities, public relations and fund raising, library services, orientation and mobility services, rehabilitation centers, sheltered workshops ( in multi-service agencies), social services, and vocational services.

The professional literature, as reflected in the two major journals of that time, presented no critique of COMSTAC or the resulting accreditation agency, NAC. Articles extolled the virtues of being accredited. The strongest agencies would be further challenged and the weakest improved. Through the self study process staff members would be exposed to national perspectives, and agencies would no longer be isolated. Facility improvements could become the basis of fund raising appeals based on the need to be nationally accredited. NAC had been created as the only source of the seal of approval.

Consumer Perspective

During the period discussed in this article, the National Federation of the Blind, founded in 1940, was the only broad based organization of blind people. Its regular publication, The Braille Monitor, focused on the harm caused by "custodialism" - any practice which diminished the independent living capabilities of blind people. While a fairly small group of carefully selected leaders in the profession were developing the process and agenda for COMSTAC, The Braille Monitor was publishing articles about agencies and practices which, it alleged, provided either exploitive or unequal treatment to clients receiving rehabilitation services. For example, in May 1963, the journal described the firing of forty blind people from the Berkeley workshop of California Industries for the Blind. They were "laid off" because of their demands for better pay and their efforts to organize a labor union. In September 1964, an article entitled "Struggle Against Odds" in The Braille Monitor, described the efforts of its members in New Mexico to obtain an orientation center for their state (Matson, 1963).

During the years immediately preceding the creation of COMSTAC, members of the National Federation of the Blind and of other organizations such as the Blinded Veterans Association were working to improve the economic and social conditions faced by blind people. There were requests for new rehabilitation centers, union recognition of employees of sheltered workshops, demands for better pay for blind workers in these workshops, and the initiation of many types of legislation to benefit blind people. Prominent national political leaders such as Senators Robert Kennedy, Vance Hartke and Frank Moss spoke at the NFB National Convention in 1965 praising the Federation's efforts on behalf of blind people. More than one hundred congressmen attended the conference's final banquet. Clearly, the National Federation of the Blind was a strong and growing force in the struggle for equal opportunities for blind people. As its journal suggested, the federation frequently worked with private and state agencies in mutual efforts to secure improved legislation and new programs. However, there appears to have been almost no relationship between the rapidly growing organized movement of blind people and the relatively small leadership group which had been shepherding the effort to professionalize the field of "work for the blind" (Vaughan, 1993).

Opposition to NAC had been voiced even before NAC was created. In 1965, tenBroek stated, "Organizations of the blind themselves, such as the National Federation of the Blind, have been conspicuously absent from the roster of groups and individuals asked to formulate supposedly objective 'standards' to be applied to all organizations in the field" (1965, p. 25).

Many articles would soon appear claiming that the American Foundation for the Blind and a related social network of professionals were attempting to dominate and control all agencies. The National Federation of the Blind was founded in 1940. Its purpose was to empower blind people -- so that they would not be taken care of but would instead take care of themselves. However, because the COMSTAC Commission and the establishment of the National Accreditation Council occurred in the 1960's, the decade of the equality revolution in the United States, the reaction of the National Federation of the Blind was probably more intense than it would have been at an earlier time (Gans, 1974). Almost every minority and gender group in the United States was demanding equal treatment. The convergence of the interests of these different movements brought political responses, leading to the civil rights legislation of that decade. Self-determination and full participation were "in the air." Professionals in the blindness field who were providing leadership during the COMSTAC period could not have picked a less propitious time to launch a new program and organization which did not include the full participation of the consumers in a rapidly growing social movement of blind people dedicated to self-determination. Dr. Jacobus tenBroek, president of the National Federation of the Blind during this period, was a nationally recognized scholar in the field of welfare rights, showing interest in and participating in other social movements of that day (Vaughan, 1993). He also served as chairman of the California Board of Social Welfare. Through 1966 articles appeared in The Braille Monitor condemning a lack of consumer participation in the planning process and the regressive nature of many recommendations being proposed for the future NAC. The Commission was criticized for institutionalizing practices resulting in dependency. Too many blind people, as well as several agency directors, a small group of professionals with similar and overlapping institutional affiliations were trying to dominate the field of rehabilitation through a new inclusive organization which was saddled with negative and regressive assumptions about blindness (Vaughan, 1993).

The gulf between the organized blind movement and the professionals in charge of COMSTAC is perhaps illustrated most clearly in a February 14, 1966, letter from the President of the National Federation of the Blind to Arthur L. Brandon.

Our right to participate in the

preparation of plans for our own lives and

our own future -- or if you will, in the

formulation of standards for our institutions

and services -- cannot any longer be casually

spurned as if it were an argument about the

formulation of a standard or the punctuation

of a sentence. That right is not in any

sense complied with by a form request to any

of us to submit our views, which the

professionals then may not pay attention to

in their work on our lives (tenBroek, 1966,

p. 26).

Koestler observed that opposition to COMSTAC and NAC also came from blind workers whose positions were threatened by professional standards. She noted that some groups objected to work conditions, labor practices and low wages being paid in sheltered workshops, many of which were or would be accredited and given the seal of approval by NAC.

In a 1971 convention address Dr. Kenneth Jernigan made clear that the NFB's quarrel with the National Accreditation Council was neither over the concept of accreditation nor because of efforts to improve services to blind people. In this same speech Jernigan explained his perception of NAC and the way it operated. Consumer participation was minimal -- tokenism. To Jernigan, key issues not included in NAC's purview ". . . does the shop pay at least minimum wage? Do its workers have the rights associated with collective bargaining? What sort of image of blindness does it present to the public?" (p. 21-22). Jernigan felt that board members were not aware of these issues and not aware of the significance of consumer's almost complete exclusion from the board (Jernigan, p. 21-22).

Over the next twenty years an average of seven articles per year appeared critiquing and exposing alleged and documented shortcomings of NAC accredited agencies. Up until 1990, the annual NAC board meetings were picketed by two to three hundred blind people who traveled from all over the United States to meeting sites (Rabby, 1984). In almost every state, federation members continually tried, often with success, to persuade agencies to disassociate from NAC. The conflict has become a struggle with no middle ground. However, the criticism of NAC has been ignored within the professional literature of blindness rehabilitation. The issue was too divisive for a nascent organization of professionals. Some small agencies did not want to incur the cost of accreditation. The various professions comprising the field-- "work for the blind"--had long histories of being independent. Although they were now merged in one professional organization, principals and teachers in schools for the blind had different traditions and social networks than the private agencies, which often represent social work activities. Each state also now had its own rehabilitation programs funded with public money and become yet another state holder in this field. Many professionals from these three areas saw no reason to incur costs and give up autonomy to a new national accrediting organization.

The Present Situation

However, in the past two years, there has been a declining base of economic support and failure to accredit even a small portion of agencies and programs serving the blind and visually impaired. The National Accreditation Council is in crisis and by only a slight margin failed to vote for its own dissolution.

The high point for NAC accreditation, according to its annual reports, was 1986 when one hundred four agencies were listed as accredited. "On February 21, 1991, the National Industries for the Blind officially announced that its funding of NAC would cease in June, 1991, and the American Foundation for the Blind made the same decision shortly thereafter" (Vaughan, 1992, p. 159). On April 7, 1991, the NAC board met to consider its financial crisis. The board then voted by a 12 - 2 vote to disband NAC. Subsequently, the board learned that a vote by the entire membership was required for dissolution. On May 5, 1991 with ten members present and ninety-one proxy votes, the National Accreditation Council voted 53 to 48 to continue its accreditation efforts (Megivern, 1991). The president and vice president of the board resigned after this vote.

The Association for the Education and Rehabilitation for the blind and visually impaired (AER) is the most influential and comprehensive professional organization in the field of blindness rehabilitation. In her coverage of NAC's problems, Megivern (1991) in her AER Reports mentions NAC's financial problems and its failure to accredit new agencies. She provides no background information concerning these "failures" but does report that business goes on as usual.

The following table (Pierce, 1995) illustrates the decline in the number of agencies accredited and displays the ratio of accredited agencies to potentially accreditable agencies.

Decline in NAC Accreditated Agencies

                            1990       1992     1994

Schools for the Blind:      26/71(*)   20/71    18/71
State Vocational
  Rehabilitation Agencies   10/52       5/52     4/52
Sheltered Workshops:        33/82      21/82    18/82
Regional or City Based
Private Agencies: (**)      28         32       29
Total                       97         78       69

(*) X/Y: X equals number of NAC accredited agencies Y equals total number possible

(**) The number of private agencies fluctuates from year to year

The consumer criticism, particularly from within the National Federation of the Blind, continues an unrelenting effort of investigative journalism concerning agencies that have come to the attention of the general public for either financial mismanagement practices, endangering the safety of children and students, or sexual harassment and abuse. For example, beginning in November, 1994, The Braille Monitor staff reported newspaper articles from the Arkansas Democrat-Gazette reporting on a series of financial irregularities and culminating in charges of sexual harassment of present employees with former blind female students. The superintendent, Mr. Leonard Ogburn, was suspended June 24, 1994 and resigned on September 23 of the same year. Formal charges were filed and when his case came to trial, "Ogburn, former superintendent at the school, pleaded no contest Wednesday to harassing a female employee by saying he wanted to spank her. Little Rock Municipal Judge, Lee Munson, placed Ogburn on probation for one year and fined him $250 court cost" (Pierce, 1994a, p. 128).

The National Accreditation Council's publication, The Standard-Bearer, in its annual report, 1994, lists the Arkansas School for the Blind as one of four schools continuously accredited for twenty-five years. Mr. Ogburn became superintendent of the Arkansas School in 1985 and was a member of the NAC Commission on Accreditation. Following his resignation from the Arkansas School, he was no longer eligible to be a member of the NAC National Commission on Accreditation (Westman, 1995). The Braille Monitor has reviewed a long history of similar publicly documented abuse or mismanagement cases, all associated with NAC accredited agencies. To its consumer critics, NAC has frequently placed its stamp of approval on some of the more regressive and badly managed agencies in this area of education and rehabilitation. "Three quarters of the residential schools for the blind in this country have chosen to have nothing to do with NAC. Of the eighteen that do find it handy to wave the NAC flag, five (Alabama, Arkansas, Florida, Illinois and Maryland), which is almost a third, have found their way into the front pages of the newspapers because of some sort of scandal during the last five years" (Pierce, 1995b, p. 294).

Why NAC Failed

Why has the National Accreditation Council of Agencies Serving the Blind and Visually Handicapped not been successful in accrediting agencies? It began with more than two years of preparation. At that time it envisioned accrediting more than five hundred agencies. The initial effort was supported by the prestigious American Foundation for the Blind, originally created to advance the interests of professionals working in the field of blindness. The project also had financial support from the U.S. government and the leadership of many prominent individuals in this field.

First and possibly most important, the originating process, COMSTAC, and the later NAC organization did not significantly involve the organized blind. By 1965, the National Federation of the Blind was a strong and influential organization. Its membership and leaders were committed to full participation in decisions that affect them. They also opposed NAC because, from their analysis and investigations, it accredits some of the most regressive agencies.

Second, the profession is comprised of diverse occupations providing educational and rehabilitation services. It represents groups with different historical origins and consequently different social networks and interests, including principals of schools for the blind, staff workers in private agencies, directors in state agencies and directors of sheltered workshops. Differences between these groups are sometimes greater than concerns that unite them. It may not have been in their interest to have "the field" controlled or regulated by a relatively small group who created and have continued to support NAC. Many agencies wish to avoid the negative publicity, for fund raising if nothing else, of the continuing consumer opposition to NAC.

Third, the large state funded rehabilitation programs never became significantly involved with NAC accreditation. Such agencies are more vulnerable to consumer opposition. Consumer groups have lobbied their state and national political representatives to "stop wasting money on NAC." Also, some requirements associated with licensing are sometimes seen as discriminatory in publicly supported agencies. For example, one state director of rehabilitation services for the blind told me, "we consider applicants for positions on the basis of ability, training and education - not on their visual acuity" (Vogel, 1992). This is contrary to the requirements of AER, the primary supporter of NAC that orientation and mobility instructors be sighted. More recently, vision tests have been replaced by functional requirements which still exclude blind workers. The applicant would need to demonstrate his or her ability to perceive what a sighted instructor would consider a potentially dangerous situation. However, this "functional" approach is now being debated within the profession. The policy is currently under review by the Certification and Review Committee of AER (Weessies, 1995). The Americans with Disabilities Act requires reasonable accommodations, for example, a blind mobility instructor might well argue that he or she could use an assistant when providing mobility training in a potentially dangerous area.

Consumers have less ability to influence smaller private agencies such as The Lighthouses. Consumers have less leverage in these agencies because the boards of directors are primarily comprised of wealthy or prominent citizens who frequently know little about the issues involved. Management can usually rely on board support to disregard consumer complaints.

Future Prospects

If the development of a broadly supported and effective accreditation program for agencies serving the blind and visually impaired depends on NAC, the prospects appear bleak. Richard L. Welsh, President of NAC in the 1994 Annual Report of NAC makes the following comments, "this heart is still beating strong even though there is less blood flowing through the arteries and veins." He goes on to comment that this National Accrediting Organization belongs to its volunteers. "As long as enough volunteers and agencies see a value in the process, it will continue to exist and to be of service to schools, agencies and programs that serve the people with visual impairments." Based on the evidence of decline we have presented, it is unlikely that this relatively small, beleaguered group will be the vanguard of a new accreditation program that could attract broad support in this specialized area of rehabilitation and education.

Agencies which require accreditation or find it otherwise useful may seek accreditation outside the "blindness field." For example, the Cleveland Society for the Blind, after dropping its relationship with NAC, sought and obtained accreditation from the Commission on Accreditation of Rehabilitation Facilities (CARF). Many agencies which serve multiple client groups including blind people are already accredited by CARF. Most professionals working in the field of blindness strongly support the need for specialized services for their clients and would probably prefer an accreditation process focusing on their specialized agencies.

Throughout education, for diverse reasons, politicians and educators are demanding accountability. This concern is increasingly focused on the outcome or results of education programs (Loganecker, 1994). Applying these concerns to the rehabilitation of blind individuals, the primary focus will not be on credentials, physical facilities or rehabilitation procedures. It will focus on the outcome of rehabilitation processes. Are graduates able to live more independently and find competitive employment? Can agencies be compared using these criteria? Measurement and comparison of outcomes in this area is not easy, but it is the direction that CARF and other accrediting organizations are moving. Client participation and client satisfaction will be necessary ingredients.

It is possible that the long term supporters of NAC may conclude that their organization is not adequately serving their agencies and their profession. New leadership may emerge and begin the process with full consumer participation from the beginning. That might result in a broadly supported accreditation organization that would focus on the results of rehabilitation efforts.

Although this has been an historical analysis of the decline of NAC, the issues raised appear in most areas of rehabilitation services. With one exception, almost all of the national accrediting organizations, have not been successful in attracting voluntary cooperation from large numbers of agencies. "Rehabilitation agencies face many challenges as they seek to improve their services in the coming decades. Increased demand for accountability and effectiveness, combined with dedication to empower clients, present major program goals" (Mason, 1990; Emener, 1991). In this context, rehabilitation counselors are asking for more autonomy in decision-making to better serve clients (Jackson, 1995). Most states continue to prefer national accreditation, ensuring broader perspective and a basis for making comparisons with programs from similar cultural regions and economic conditions. The most comprehensive and the most successful in accrediting programs is CARF. In 1995, the number of CARF accredited programs surpassed 11,000 for the first time (Galvin, 1995).

The Commission on Accreditation of Rehabilitation Facilities recently expanded it's acronym to reflect philosophic changes in the organization's approach to accreditation. It is now CARF . . . Rehabilitation Accreditation Commission. It has avoided many of the problems NAC encountered by incorporating organizational and programmatic changes as the organization evolved. It's large governing board, forty-two members, has significant representation from consumer and advocacy groups. Evaluation includes effectiveness, efficiency and client satisfaction. An agency is not told what its goals should be, but the agency is expected to attempt to measure or access the outcomes of its program efforts. The agencies are asked to document the extent to which they have incorporated suggestions from previous evaluations or have developed on going arrangements for self-evaluation.

Accreditation does not disregard structure and organization, but the focus is on the outcome or results of the rehabilitation process. Programs, not agencies are accredited. The organization provides a comprehensive approach, with an ability to accreditate all aspects of the rehabilitation process. Its success in accrediting agencies permits a budget sufficient to provide educational materials, conferences and backup support for agencies. Comprehensiveness, consumer involvement, a focus of programs and a national perspective are important elements in the success of this particular model.

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C. Edwin Vaughan, Department of Sociology, 220 Sociology Building, University of Missouri, Columbia, Missouri 65211.