Exam 1: Accrediting Organizations Regulations

Accreditation

-process by which organizations demonstrate compliance with required standards

-gives official recognition to sanction, authorize to certify, or guarantee meeting required standards

Accreditation is used to...

recognize health care organizations, educational institutions, and professional programs affiliated with those institutions for a level of performance, integrity, and high quality, which entitles them to the confidence of the community and the public they serve.

Accreditation agencies

Commission on Accreditation of Rehabilitation Facilities (CARF)

The Joint Commission (TJC)

Centers for Medicare and Medicaid Services (CMS)

Agency for Health Care Administration (AHCA)

Accreditation Council for Occupational Therapy Education (ACOTE)

Why do we need accreditation?

-consumers make choices

-shows signs of quality

-shows commitment of the organization to continuously improving services, managing risk, and serving the community

Accreditation Council for Occupational Therapy Education (ACOTE)

accreditation council for OT education

self-study process

-standards A-C (D for some programs)

A = administrative and institutional support, strategic planning, and faculty professional development

B = evidence requirements met through coursework and assignments

C = evidence of FW sites

D = project details

addresses the administrative and institutional support; credentials of the OT/OTA faculty, program director, academic fieldwork coordinator; and informational materials.

standard A

requires evidence that the educational requirements are met through specific coursework and assignments.

standard B

focused on the fieldwork education for the OT/OTA student.

standard C

Not included in every self-study submitted by OT/OTA programs. This section, is exclusively designed for programs offering a baccalaureate OTA degree or programs offering a doctoral OT degree—either an occupational therapy doctorate (OTD) or doctor of occupational therapy (DrOT). Provides specific information addressing the baccalaureate project the OTA student must complete as part of the degree requirements.

standard D

ACOTE provides accreditation standards for the following programs...

-entry level OTD

-entry level master

-OTA bachelor

-OTA assistant

Commission on Accreditation of Rehabilitation Facilities (CARF)

accreditation agency for rehabilitation facilities

not required to have CARF accreditation, but looks good to have because reputable

CARF areas of accreditation

1) aging services

-CCRC (continuing care retirement communities)

2) behavioral health

3) employment and community services

-vocational evaluations

-transition services

-independent living

4) medical rehabilitation

5) DMEPOS (durable medical equipment, prosthetics, orthotics, and supplies)

6) opioid treatment programs

7) vision rehabilitation services

8) child and youth services

CARF accreditation standards

consultative accreditation process

specific quality standards for each area

-good business practice

-results of services

-process of providing services

-specific standards for particular programs (i.e. pediatrics, amputee, spinal cord, head injury, etc.)

The Joint Commission (TJC)

oldest and largest private agency for voluntary accreditation

-performance standards

-accreditation service

-education and consultation

-utilizes outcomes and performance measures

-publicly discloses performance evaluations to interested parties

looks at PAIN and PATIENT SATISFACTION

What is The Joint Commission (TJC)?

The oldest and largest private agency for voluntary accreditation.

What services does The Joint Commission (TJC) provide?

Accreditation service, education, and consultation.

What does The Joint Commission (TJC) utilize for evaluation?

Outcomes and performance measures.

What does The Joint Commission (TJC) publicly disclose?

Performance evaluations to interested parties.

What key aspects does The Joint Commission (TJC) focus on?

Pain and patient satisfaction.

T or F: The TJC is the only accrediting organization with the capability and experience to evaluate health care organizations across the continuum of care.

true!!!

(looks at care starting from hospital admission to D/C)

Healthcare organizations seek TJC accreditation because...

-expedites third-party payment

-often fulfills state licensure requirements

-may favorably influence liability insurance premiums (aka better insurance rates)

-enhances access to managed care contracts

-may favorably influence bond ratings and access to financial markets

Bond ratings

-a measure of a healthcare organization's financial health and creditworthiness

-a good bond rating allows an organization to borrow money more easily and at a lower interest rate

-a good bond rating allows an organization to secure bond funding for projects

-a good bond rating gives an organization more financial flexibility to pursue growth opportunities

What does the TJC accreditation focus on?

-processes and functions that most significantly influence care (clinical and organization)

-doing things rights

-doing things well

-promoting safety

-what needs to occur

Centers for Medicare and Medicaid Services (CMS)

a federal agency within the U.S. Department of Health and Human Services that is responsible for Medicare and Medicaid, among many other responsibilities

largest payer of rehab services in the nation because

-growing older population (medicare)

-people below the poverty line (medicaid)

Agency for Health Care Administration (AHCA)

A regulatory agency in Florida created in 1992 under the Health Care Reform Act of 1992 for the purpose of ensuring that efficient quality health care services are accessible to all Floridians.

responsible for licensure of HC facilities and sharing HC data through FL Center for Health Information and Policy Analysis

t or f: AHCA will show up unannounced

true

patients will call them for complaints and then they show up at the facility

Employee safety

regulated by both federal and state governments

Occupational Safety and Health Act of 1970 (OSHA) authorizes....

the federal government to establish and enforce occupational safety and health standards for all places of employment engaging in interstate commerce

Occupational Safety and Health Administration (OSHA)

-the general duty clause states that an employer has an overall obligation to furnish employees with a place of employment from recognized hazards

-inspections are conducted by specially trained agents of the department of labor called compliance officers

-violation may results in a citation to the employer, and/or criminal and civil penalties

Types of professional regulations

-licensure (highest level of accreditation)

-registration and certification

-title protections

Professional regulations are important because they...

-protect consumers from unqualified practitioners

-assure high level of competency and professionalism

Licensure

process by which a government agency grants permission to an individual to engage in a given occupation after the applicant has met the minimal requirements of competence to ensure the public health and safety

Licensure law

legally defines scope of practice

Certifications and registrations

-defined by the State Regulation Board (SRB)

-require OT and OTA to meet specific requirements

-do not specify a scope of practice

Title protection

-legal restrictions around and guidelines for the use of a professional title

-protects the title but not the therapeutic interventions

-does not designate scope of practice

-to date, no state utilizes this practice

Specifies a scope of practice

a) licensure

b) certifications and registrations

a) licensure

does NOT specific a scope of practice

a) title protection

b) licensure

c) certifications and registrations

d) a and c

d) a and c

title protection and certifications and registrations

highest level of accreditation

a) title protection

b) licensure

c) certifications and registrations

b) licensure