chap 16: navigating the accreditation, certification, or licensure process

accreditation: Voluntary process by which the performance of an organization is

• measured against nationally accepted standards of performance 

  

accreditation: many accrediting bodies require healthcare organizations to have a plan that

• explains their method of fulfilling quality management activities

accreditation: Frequently change based on government regulations and

•  input from individual groups in the healthcare industry

  

accreditation: the past decade has seen as

• explosion of quality metrics

standards and requirements of QM plan: some standards and regulations have explicit requirements

• regarding plan and structure of improvement activities

  

standards and requirements of QM plan: examples: TJC does not require written plan, but does require

• organizations take systematic approach to performance improvement

  

standards and requirements of QM plan: examples: DNV states

• “the org shall clearly outline its methodology, practice, and related policies for addressing how quality and performance are measured, monitored, analyzed, and continually improved (DNV 2020, 12)

  

standards and requirements of QM plan: examples: PA hospitals require a patient safety committee that includes

• two residents of community who are served – but not agents, employees, or contractors of – the facility (Commonwealth of PA 2006)

  

payment models: continue to evolve from traditional fee-for-service to

• value-based payment models in which payments are modified based on the achievement of measure-based quality goals

  

payment models: hospitals that participate in the

• Value-Based Purchasing Program have a percentage of Medicare payment at risk, depending on comparative quality performance

  

payment models: physician office services are increasingly being tied to the

• achievement of quality goals and the submission of quality metrics

  

payment models: want to go from fee-for-service to

• value-based purchasing program

ACA: all federal plans offered through ACA

• must be accredited

ACA: overall accreditation status is calculated based on:

• . Clinical performance

  • 1. Healthcare Effectiveness and Data Information Set (HEDIS scores)

    

ACA: overall accreditation status is calculated based on:

• Member satisfaction

  • 1. Consumer Assessment of Healthcare Providers and Systems (CAHPS Survey)

    

If a healthcare organization chooses to meet multiple standards and/or regulations, which requirements should they follow?

• Go with the one that is most stringent, one with the highest bar (meet this, the rest will be met)

  

certification: facility = must meet conditions of participation (CoP) to

• receive Medicare or Medicaid funding

  

certification: facility: grants approval for healthcare organization to

• provide services to specific group of beneficiaries

certification: practitioners = american board of medical specialities (AMBS) is

•  recognized as leader in setting gold standard for physician specialty certifications

  

certification: practitioners: show significant achievement of

• being skilled and knowledgeable in specific area

  

certification: being certified is

• voluntary

licensure: act of granting a healthcare organization of an individual healthcare provider permission to

• provide services of a defined scope in a limited geographical area 

  

licensure: state government issue licenses based on

• regulations specific to healthcare practices

licensure: facilities evaluated on an annual basis by the

• state health department

  • Many publish “report cards”

    

licensure: is illegal for organizations and professionals to

• provide healthcare services without

licensure: is

• not voluntary

accreditation and licensure surveys: preparation for accreditation and licensure processes

• cannot be accomplished a few weeks before the organization is due for review 

  

accreditation and licensure surveys: solid accreditation and licensure infrastructure must be

•  built and maintained so that the organization is ready for an inspection at any time

  

accreditation and licensure surveys: some are scheduled;

• others are unannounced

survey process: surveyors want to be assured the facility’s leadership and staff can successfully

•  execute organizational policies and procedures

  

survey process: surveyors want to be assured the facility’s leadership and staff are continuously

• monitoring and improving performance in the organization and that those improvements are tied to the organization’s strategic plan

  

survey process: no standard review process, voluntary processes are more

• flexible and tailored to the organization

  

survey process: no standard review process governmental processes tend to be

• more bureaucratic

JC accreditation standards: assesses the alignment of an institutions practices,

• policies, procedures, and documentation with its standards of performance 

  • Is quality of care being monitored for continual improvement

    

JC accreditation standards: 270 standards and

• ~2,000 elements of performance

  

JC accreditation process: site visit every 3 years with midpoint

• self-assessments that include correction action plans

  

JC accreditation process: unannounced surveys

• began in 2006

JC accreditation process: shifts organization focus from

• survey preparation to continuous survey readiness

  

JC accreditation process: surveyors will come with knowledge of the organization =

• Midpoint assessment action plan

• Any consumer complaints

  

JC accreditation process: surveyors will come with knowledge of the organization =

• Previous accreditation data

• Core measure data

  

JC survey process: survey team then develops

•  preliminary report of onsite survey, noting any deficiencies

  

JC survey process: exit conference: report probable

• accreditation decision

JC survey process: exit conference: summarize findings and

• explain any deficiencies

JC survey process: opening conference: outline the

• schedule of activities

JC survey process: opening conference: identify individuals to be

• interviewed

JC survey process: opening conference: leaders are expected to provide an overview of the organization’s mission and vision,

• strategic goals and objectives, current experiences and outcomes, performance monitoring, and improvement activities

  

JC accreditation process: composition of survey team varies depending on the size of the organization =

• Physician

• Administrator

• Registered nurse

• Other masters-level clinicians

  

JC accreditation process: composition of survey team varies depending on the size of the organization =

• State Licensing agency representative

• Expert in environment of care and life safety issues

• Length of the survey process also depends on the size of the organization (3-5 days)

  

tracer methodology: assess standards compliance and follows a number of patients through an

• organization’s entire health care delivery process to identify performance issues in one or more steps of care process

  

tracer methodology: focuses on patient care at

• the point of care

tracer methodology: patients selected based on current census of

• patients that have a typical case mix

tracer methodology: high-risk process or systems areas:

• Medical management

• Infection control

  

tracer methodology: high-risk process or systems areas:

• Data management

• Restraints

  

JC accreditation categories =

• accredited

• accreditation with follow-up survey

• contingent accreditation

• preliminary denial of accreditation

• denial of accreditation

CMS CoP certified: requires hospitals submit >60 measures in

• addition to Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPHS) survey results 

  

CMS CoP certified: also require measures for long-term care,

• physician services, dialysis centers, some ambulatory care settings

  

deemed status: demonstrates that an organization not only meets but

• exceeds expectations for a particular area of expertise

deemed status: health care organizations that want to participate in and recieve payment from

• CMS must be certified as complying with CoP, or have received accreditation through a national accrediting organization that CMS has provided with deemed authority standards, set forth in federal regulations 

  

deemed status: CMS lists organizations with

• deeming authority

deemed status: health care organization would be exempt from

•  federal inspections to ensure compliance with CMS requirements of participation

CMS conditions of participation: _________ surveys

• unannounced

CMS conditions of participation: survey team drops in on an annual basis or in

• response to complaints from patients or employees

  

CMS conditions of participation: surveyors usually from state department of health,

• however one to two Medicare officials from the regional office may be present

  

CMS conditions of participation: process like

• state licensure surveys

certification and licensure of long-term care: usually,

• scheduled reviews

certification and licensure of long-term care: two surveyors who came from

• nursing, pharmacy, dietetic, or clinical laboratory background

  

certification and licensure of long-term care: look for evidence of three trigger issues: excessive percentage of

• patients suffering from dehydration

certification and licensure of long-term care: look for evidence of three trigger issues: decubitus ulcers in

• low-risk residents

certification and licensure of long-term care: look for evidence of three trigger issues: fecal

• impaction

Psychiatric and rehabilitative care: CARF accreditation: commission on

• Accreditation of Rehabilitation Facilities (CARF)

  

Psychiatric and rehabilitative care: CARF accreditation: three

• surveyors

Psychiatric and rehabilitative care: CARF accreditation: flexible

• survey process

Psychiatric and rehabilitative care: CARF accreditation: tailored to patient care services and

• community of interest of the organization

CARF survey process: opening conference =

• Must be accessible to all communities of interest

  • Payers

  • Staff members

  • Referring agencies

  • Members of the community

  • Patients

    

CARF survey process: document review =

• Examines policies and procedures, administrative rules and regulations, administrative records, human resources records, and case records of patients

  

CARF survey process: interviews with program staff and patients =

• Validate information gathered from the document review

• Determine where staff or patients have any important issues regarding patient care services

  

CARF survey process: exit interview with organization leaders =

• Identify any deficiencies

• Present an overall summary of findings

  

DNV-GL healthcare accreditation: offers the national integrated accreditation for healthcare organizations (NIAHO),

• which incorporates International Organization for Standardization (ISO 9001) quality management standards

  

DNV-GL healthcare accreditation: alternative option for

• healthcare organizations because of its facility-friendly yet stringent accreditation philosophy

  

DNV-GL healthcare accreditation: granted deeming status from

• CMS in 2008