Pharmacists Role in Health-System Accreditation

Medicare

-federally funded program

-benefits elderly and disabled

-participants pay deductibles and part of coverage costs

Medicaid

-state and federally funded program

-benefits pregnant women, people with disabilities and low income

-participants pay little or nothing for coverage

inpatient prospective payment system (IPPS)

How is reimbursement done?

value-based programs

additionally reward high quality cost and effective care

CMS met (centers for medicare and medicaid services)

What are hospitals required to have?

joint commission

-Independent, non-profit organization since 1951

-Accredits & certifies over 22,000 U.S. health care organizations & programs

-TJC accreditation recognized as a symbol of quality performance standards

-Sets standards and establishes elements of performance based on CMS standards

-be a member

-pay a fee

What are the 2 things you have to as a hospital to be in the certification process of the joint commission?

mission of the joint commission

To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value

vision of the joint commission

All people always experience the safest, highest quality, best-value health care across all settings

-Patient Safety & Quality

-Infection Prevention & Control

-Suicide Risk Reduction

-Workforce Safety & Well-Being

-Health Equity

-Emergency Preparedness

-Care Quality & Risk Reduction

-Data Analytics & AI

-Responsible Use of Health Data

What are some of the things that the joint commission focuses on?

An organization-specific on-site, data-driven process, focused on safety and quality through evaluation actual care processes and technology

What is the joint commission survey process?

objective of the survey of the joint commission

-Evaluate the organization using standards and elements of performance (CMS Conditions of Participation)

-Provide education and "good practice" guidance that will help staff continually improve the organization's performance

Preparation for survey

-continuous readiness

-mock surveys

-staff education and training

continuous readiness

-Since surveys are often unannounced, organizations are encouraged to maintain continuous compliance with TJC standards

-This is essential for demonstrating that high-quality care is always delivered, not just in preparation for a survey

mock surveys

Some organizations conduct internal mock surveys to simulate the real survey process and identify potential areas for improvement

staff education and training

Staff are trained regularly on TJC standards and patient safety protocols to ensure compliance during the survey

initial accreditation survey

for organizations seeking accreditation for the first time

triennial survey

Conducted every three years (unannounced, between 18-36 months since previous survey) for already accredited organizations

unannounced survey

Most surveys are unannounced to ensure the organization maintains continuous compliance

specialty surveys

May be conducted for specific programs (e.g., stroke centers, cancerprograms, specialty care)

-initial accreditation survey

-triennial survey

-unannounced survey

-specialty survey

What are the types of surveys?

surveyor team

A team of TJC surveyors—which may include doctors, nurses, pharmacists, and other healthcare professionals—conducts the survey

tracer methodology (key feature to the process)

-Surveyors select specific patients and follow their care journey throughout the organization, from admission to discharge

-This process involves interviews with staff, observation of care, and review of medical records, aiming to assess how well the organization integrates TJC standards into daily operations

document review

-Surveyors review key documentation, including policies, procedures, quality improvement initiatives, and medical records, to verify compliance with TJC standards

-The organization's performance improvement plans, infection control protocols, and medication management systems are scrutinized

interviews and observations

-Surveyors conduct interviews with leadership, staff, and patients to understand processes, challenges, and improvements

-They may also observe staff as they provide care

on-site feedback

Surveyors provide on-site feedback at the end of each day and may give immediate recommendations for areas that need improvement

-surveyor team

-tracer methodology

-document review

-interviews and observations

-on site feedback

What are the parts of the on site survey?

-preliminary reporting

-plan of correction

-accreditation decision

What is the post-survey process?

preliminary reporting

-Highlights areas where the organization meets standards and where improvements are needed (often during exit conference)

-Organizations can clarify or dispute any findings at this stage

plan of correction (POC)

-Non-compliance needs to be addressed within 60 days on requirements for improvement (RFIs)

-Steps are provided to correct deficiencies and meet TJC standards

-Some deficiencies may require immediate action, while others may be resolved over time and reported via an evidence of standards compliance (ESC) report

accreditation decision

An organization's official accreditation decision is publicly posted to the Quality Check®website within one business day

accredited

full compliance

accredited with follow up

follow up visit required on minor deficiences

preliminary denial of accreditation

serious deficiences

denial of accreditation

fails to meet core standards or take corrective action

medication management tracers

Expect questions and observations on storage/security (unit inspections, ADCs, night cabinets), beyond-use dating/labeling, override practices, high-alert meds, crash carts, formulary controls, and med-use data in QAPI

transitions of care and med rec

Surveyors will follow how the best possible med history is obtained, reconciled, and handed off at discharge, including patient education

compounding and sterile practice

Expect verification of policies, competencies, and environmental controls aligned to your organization's scope and TJC survey activities

event management

Know your sentinel-event policy and RCA process; TJC encourages (but does not require) external reporting of sentinel events

CMS (centers for medicare and medicaid services) and joint comission

Who ensures standards are met?

CMs

Goal is to provide "a high-quality health care system that ensures better care, access to coverage, and improved health"

Department of health and human services

HHS

administers of medicare, medicaid, the children's health insurance program

CHIP

CMS

-Collects and analyzes data, produces research reports, works to eliminate instances of fraud and abuse

-Designated as the organization responsible for certification of hospitals, deeming them certified and meeting established standards

conditions of participation

CoPs

conditions for coverage

CfCs

Conditions of Participation (CoPs) and Conditions for Coverage (CfCs)

CMS develops these that health care organizations must meet in order to participate in the Medicare and Medicaid programs

because up to a third of all hospitals, especially those located in rural areas did not seek the voluntary accreditation programs, such as TJC

Why were CoPs and CfCs established?

-evidence based measurement

-consumer decision making

-value based payment and purchasing

-reduction in variability in core measures

-decreased provider collection and burden

What is being evaluated by CMS?

-accountable care organization/patient centered home/primary care

-behavior health

-neurology

-orthopedics

-pediatrics

What are the CQMC core sets with full maintenance review?

-cardiology

-gastroenterology

-human immunodeficiency virus/ hepatitis C

-medical oncology

-obstetrics and gynecology

What are the CQMC core sets of light maintenance review?

cardiovascular measures

-heart failure

-HTN intervention

-ischemic heart disease/coronary heart disease

-atrial fibrillation

-primary/secondary prevention

-acute myocardial infarction

-angioplasty and stents (PCI)

-implantable cardiac defibrillators

-pediatric heart surgery

-valve replacement