BMET: Regulation in the Hospital Environment, basically various AOs you should know

module 3

What does AO stand for?

Accrediting organization

What does CMS stand for?

Centers for Medicare and Medicaid Services

What is CMS? What do they do?

• a federal agency in charge of Medicare and Medicaid Services.

• sets the guideline for healthcare organizations to be approved for the Condition of Participation (CoP) for accessing Medicare/Medicaid (VERY important, most hospitals rely on it to stay open)

What does TJC stand for?

The Joint Commission

What is TJC? What does TJC do?

• a nonprofit organization that accredits and certifies healthcare organizations and programs in the US through a rigorous evaluation process.

• facilities accredited by TJC are recognized as meeting CMS’s Conditions of Participation (CoPs)—> allows hospitals that are accredited by it to participate in Medicare/aid

What does HFAP stand for?

Healthcare Facilities Accreditation Program

What is HFAP? What does it do?

• a national organization authorized by the Centers for Medicare and Medicaid Services (CMS) to accredit healthcare facilities—> allows hospitals that are accredited by it to participate in Medicare/aid

• provides accreditation and certification services to hospitals, ambulatory surgery centers, clinical laboratories, etc.

• offers surveys that evaluate all aspects of healthcare delivery

• focuses on ensuring compliance with federal regulations and industry best practices

How does HFAP impact hospitals?

It helps facilities maintain compliance with federal requirements, enhances patient trust, and improves overall quality of care.

What is DNV Healthcare? What do they do?

• an international accreditation organization

• focuses on quality management and patient safety

• offer programs that address regulatory requirements for hospitals and provide guidance and best practices for clinical specialty organizations

• In 2008, DNV Healthcare was granted deeming authority by CMS (and accredit hospitals for medicare/aid)

  • DNV’s program: National Integrated Accreditation for Healthcare Organizations (NIAHO®), combines ISO’s standards with CoP

What does CAP stand for?

College of American Pathologists

What is CAP? what do they do?

• an organization that accredits hospital laboratories (for high standards of safety, quality, accuracy, in lab testing)

  • provides a laboratory accreditation program

• Focus is on quality and accuracy: ensures that the laboratory’s test results are accurate and reliable, supporting proper patient diagnosis and treatment

• CMS-approved: labs accredited by CAP meet the requirements of the Clinical Laboratory Improvement Amendments (CLIA), which regulate laboratory testing for Medicare and Medicaid patients

How does CAP Accreditation Work?

• CAP conducts rigorous on-site inspections every two years (test procedures, documentation, staff training, etc.)

• Labs must participate in CAP’s proficiency testing program: testing accuracy is regularly evaluated by comparing their results to standard benchmarks

• Labs are provided with resources and recommendations to continuously improve their operations and adopt the latest advancements in laboratory medicine

Why is CAP important to hospitals?

• it is the the “gold standard” for clinical laboratories

• ensures that hospital labs provide high-quality diagnostic testing

What does AABB stand for? What was its old name?

Association for the Advancement of Blood & Biotherapies, formerly American Association of Blood Banks

What is AABB? does AABB do?

• an international organization focused on advancing and accrediting hospitals on the practice and standards of blood banking, transfusion medicine, cellular therapies, and related biomedical services (blood stuff)

• meeting the Clinical Laboratory Improvement Amendments (CLIA) requirements. This makes AABB-accredited facilities eligible for Medicare and Medicaid reimbursement

• provides education and guidance to healthcare professionals and advocates for policies that promote safety and innovation in transfusion medicine and biotherapies

What is the accreditation process for AABB?

• Facilities are inspected every two years to ensure compliance with AABB standards and identify opportunities for improvement

• conducts detailed assessments of hospital blood banks and transfusion services

Why is AABB accreditation important to hospitals?

it demonstrates a hospital’s commitment to maintaining high-quality blood and transfusion services, enhancing patient safety and trust

What does DPH stand for?

Department of Public Health

What does DPH do? What is it?

• a state-level agency responsible for safeguarding and enhancing the health and well-being of residents

  • Their regulations and standards vary from state to state

• licenses and monitors healthcare facilities, ensuring they comply with state health regulations and standards

• implements programs aimed at disease prevention, health education, and emergency preparedness

• collects and analyzes health data to inform policy decisions, track health trends

What does the DPH impact hospitals?

• Hospitals must adhere to DPH regulations and are subject to inspections to ensure compliance

  • failure to comply can result in penalties, including fines or loss of licensure

• Hospitals are required to report certain health data to the DPH

• Hospitals often collaborate with the DPH on public health initiatives, such as vaccination campaigns

What are AHJs? What do they do?

Authorities Having Jurisdiction

• they determine whether hospitals meet the necessary standards to participate in Medicare and Medicaid programs

• can influence hospitals' financial viability and operations

• ensure hospitals meet essential safety and quality standards

What is a Deemed Status organization?

• Organizations authorized by the Centers for Medicare & Medicaid Services (CMS) to assess whether a hospital complies with CMS's Conditions of Participation (CoPs).

• Accreditation by these organizations allows hospitals to participate in Medicare and Medicaid without undergoing separate CMS inspections.

What can happen to a hospital if they fail to meet AHJ organization standards?

• Reduced funding from CMS programs.

• Financial strain, as hospitals rely heavily on reimbursements for operational costs.

• Damage to the hospital's reputation, potentially reducing patient trust and admissions.

What does complying with AHJ standards affect hospitals?

• Financial stability changes, many hospitals depend on Medicare and Medicaid for a substantial portion of their income

• Changes to allocation of resources to meet AHJ standards, like upgrades to equipment, staffing levels, and procedural workflows

• makes hospitals invest in quality improvements, training, and compliance initiatives,

  • improves patient outcomes

  • but increase operational costs

What are some examples of AHJs?

TJC, HFAP, DNV Healthcare

What are 3 tips to pass an accreditation survey?

1. Maintain a comprehensive and precise inventory of all medical equipment managed by HTM

2. Establish well-documented policies and procedures to eliminate any ambiguity

3. Ensure that your written policies and procedures are actively followed in practice.