HSCI 4700 Accreditation, Certification, and Licensure

voluntary process by which the performance of an organization is measured against nationally accepted standards of performance

accreditation

t/ff: some standards and regulations have explicit requirements regarding plan and structure of improvement activities

true

hospitals that participate in the ___ have a percentage of medicare payment at risk, depending on comparative quality performance

value-based purchasing program

who are increasingly being tied to the achievement of quality goals and the submission of quality metrics?

physician office services

• all federal plans offered through this must be accredited

• overall accreditation status is calculated based on clinical performance and member satisfaction

affordable care act

what is the overall accreditation status calculated by?

• clinical performance (healthcare effectiveness and data information set (HEDIS scores)

• member satisfaction (consumer assessment of healthcare providers and systems (CAHPS survey)

• grants approval for healthcare organization to provide services to specific group of beneficiaries

• must meet conditions of participation (CoP) to receive medicare or medicaid funding

facility

• show significant achievement of being skilled and knowledgeable in specific area

• american board of medical specialties (ABMS) is recognized as leader in setting gold standard for physician specialty certifications

practitioners

• act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area

• state governments issue licenses based on regulations specific to healthcare practices

• facilities evaluated on an annual basis by the state health department

• is illegal for organizations and professionals to provide healthcare services without

licensure

• preparation for accreditation and licensure processes cannot be accomplished a few weeks before the organization is due for review

• solid accreditation and licensure infrastructure must be built and maintained so that the organization is ready for an inspection at any time

• some are scheduled; others are unannounced

accreditation and licensure surveys

t/f: there is no standard review process

true

___ are more flexible and tailored to the organization

___ tend to be more bureaucratic

voluntary processes, governmental processes

• assess the alignment of an institution’s practices, policies, procedures, and documentation with its standards of performance

• 270 standards and roughly 2,000 elements of performance

JC accreditation standards

site visit every ___ with midpoint self-assessments that include correction action plans (JC accreditation process)

3

surveyors will come with knowledge of the organization - what 4 points?

• midpoint assessment action plan

• any consumer complaints

• previous accreditation data

• core measure data

• outline the schedule of activities

• identify individuals to be interviewed

• leaders are expected to provide an overview of the organization’s mission and vision, strategic goals and objectivities, current experiences and outcomes, performance monitoring, and improvement activites

step 1. opening conference (JC survey process)

what is the second step in the JC survey process?

survey team then develops preliminary report of onsite survey, noting any deficiencies

what is the last step in the JC survey process?

exit conference

• summarize findings and explain any deficiencies

• report probably accreditation decision

who may be part of the survey team (depending on the size of the organization)?

• physician

• administrator

• registered nurse

• other masters-level clinicians

• state licensing agency rep

• 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)

• 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 processes

• focuses on patient care at the point of care

• patients selected based on current census of patients that have a typical case mix

• high-risk process or systems areas

  • medical management

  • infection control

  • data management

  • restraints

tracer methodology

organization has complied with all performance standards (category)

accredited

organization is not in compliance with specific standards and requires a follow-up survey within 30 days to 6 months (category)

accreditation with follow-up survey

organization did not meet all of the standards at the time of the on-site survive and had a level of standards non-compliance and RFIs in excess of the published levels for the year (category)

contingent accreditation

organization is in significant noncompliance with standards in multiple performance areas (category)

preliminary denial of accreditation

this results when all available appeal procedures have been exhausted, and the organization has been denied accreditation (category)

denial of accreditation

• requires hospitals submit >60 measures in addition to hospital consumer assessment of healthcare providers and systems (HCAPHS) survey results

• also require measures for long-term care, physician services, dialysis centers, some ambulatory care settings

CMS CoP certified

• health care organizations that want to participate in and receive 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

  • CMS lists organizations with deeming authority

  • health care organization would be exempt from federal inspections to ensure compliance with CMS requirements of participation

• demonstrates that an organization not only meets but exceeds expectations for a particular area of expertise

deemed status

what are the CMS conditions of participation?

• unannounced surveys

• survey team drops in on an annual basis or in response to complaints from patients or employees

• surveyors usually from state department of health, however one to two medicare officials from the regional office may be present

• process like state licensure surveys

• usually unscheduled reviews

• two surveyors who come from nursing, pharmacy, dietetic, or clinical laboratory background

• look for evidence of three trigger issues

  • excessive percentage of patients suffering from dehydration

  • decubitus ulcers in low-risk residents

  • fecal impaction

certification and licensure of long-term care

• three surveyors

• flexible survey process

• tailored to patient care services and community of interest of the organization

psychiatric and rehabilitative care: CARF (commission on accreditation of rehabilitation facilities) accreditation

• opening conference

  • must be accessible to all communities of interest

    • payers, staff members, referring agencies, members of the community, patients

opening conference (CARF survey process)

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

document review (CARF survey process)

interviews with program staff and patients

• validate info gathered from the document review

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

interviews with program staff and patients (CARF survey process)

exit interview with organization leaders

• identify any deficiencies

• present an overall summary of findings

exit interview with organization leaders (CARF survey process)

• offers the national integrated accreditation for healthcare organizations (NIAHO), which incorporates international organization for standardization (ISO 9001) quality management standards

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

• granted deeming status from CMS 2008

DNV-GL healthcare accreditation