HCA 622NATIONAL UNIVERSITY

GROUP 2ALFRED AMOO, CAMILLE INFANTE,

TRELLOR FRAITES, STEPHANIE TAPIA

FEBRUARY 25, 2014

The Role of Accreditation Organizations

The Role of Accreditation Organizations

What is ACCREDITATION? As defined by Ransom, E., Joshi, Nash, and Ransom, S.

(2008), “Accreditation is a process by which an entity external to the organization providing goods or services evaluates that organization against a set of predetermined requirements or desirable attributes and publicly attests to the results” (p.433).

The roles of healthcare accreditation organizations have grown to establish standards for healthcare quality in the United States. These organizations ensure the quality of healthcare provided to each patient seeking medical treatment.

The Role of Accreditation Organizations

According to Stump, Krauss, Pavlinac and Robinson (2000), healthcare organizations seek accreditation for several reasons besides improving the quality of care. These include: Regulatory forces demanding organizations to meet

standards set by the state Medicare and Medicaid certification Good standing in the eyes of the community Lower liability insurance premiums Access to additional managed care contracts that

require these facilities to be accredited Additional learning tool for staff.

Accreditation Organization in the Past

Organizations used on-site inspection, review of reports and policies, and interviewing patients and staff as their means to determine whether or not organizations were compliant with the established rules and regulations.

Accrediting organizations did not collaborate with each other which led to duplication of measures and standards, and thus a waste of revenue.

Limited information to the public in terms of the quality and safety of care being provided; accredited organizations were recognized as passed or failed but never mentioned those who did not seek accreditation.

Accreditation Organization in the Present

Presently, accreditation organizations work with the National Quality Forum (NQF). Main objective: To ensure health care quality and safety in the

United States of America. Many challenges exist despite the development of

accrediting bodies such as: Skepticism of surveyors of organizations who approve

organizations who have yet to be accredited; value of accreditation is minimized

Competition Organizations who choose not to participate for various reasons

including financial reasons, fear of failure, unwillingness to contribute the time and effort to go through the accreditation process; does not reflect a true picture of the standard of care due to missing data of non-participants

Accreditation Organizations in the Future

Most accreditation of hospitals focus on inpatient care; accreditation must adapt ways to include other additional service areas including ambulatory and ancillary care

Accrediting bodies must develop ways to provide meaningful data that addresses the needs of the public as demands in transparency and accountability in healthcare rise

Continued participation with the regulatory bodies and the NQF to establish standardized measures should continue success in accreditation organizations

THEIR ROLE IN THE ACCREDITATION PROCESS

Joint Commission of Accreditation of Healthcare

Organization (JCAHO)

About the JCAHO

Commonly referred to as “The Joint Commission (TJC)”

Established in 1951Private, independent, not-for-profit

organizationAccredits 18,000+ organizationsOldest and largest accrediting bodyFocus: to provide safe, quality care for public

Mission Statement

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 Statement

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

Accreditation by JCAHO

Accredits various healthcare organizations: Hospitals Ambulatory and Behavioral healthcare Critical Access Hospital Home Care Nursing Care Center Laboratory Services

Cost- ~ $33,000 trienniallyDecision Process- TJC Board of CommissionersSupport include but not limited to:

website access (www.jointcommission.org) Consultation e.g. standards interpretation, performance reviews Advisories e.g. sentinel alerts Electronic manuals

Accreditation Process

Based on analysis of data collected using : Conditions of Participation (CoP) by CMS ORYX performance measurements Tracer methodology Annual self-assessments

On-site reviews every three years Exception (laboratories, every 2 years) Unannounced from 2006

Competent surveyors Healthcare experience Undergoes certification Continuing education

Results of Accreditation Process

Performance measures evaluation: satisfactory, partial, insufficient

Categories of Accreditation “Accredited”

Compliant with ALL standards Receives TJC’s Gold Seal of Approval™

“Provisional” Failure to provide evidence of compliance with all standards within specified

time, usually 45 days “Conditional”

Noncompliant with specific standards which require a follow-up onsite review “Preliminary Denial”

Justification to deny accreditation based on findings, subject to review and appeal

“Denial” Accreditation denied, review and appeals exhausted

References

Meldi, D., Rhoades, F., Gippe, A. (2009). The Big Three: A Side by Side Matrix Comparing Hospital Accrediting Agencies. National Association Medical Staff Services (NAMSS). Retrieved from http://www.namss.org/portals/0/advocacy/namss_synergy_janfeb09_accreditation_grid.pdf. Accessed February 6, 2014.

Ransom, E.R., Joshi, M. S., Nash, D. B., and Ransom, S.B. (2008). Healthcare Quality Book: Vision, Strategy, and Tools (2nd Ed.). Chicago: Health Administration Press.

The Joint Commission. About the Joint Commission. Retrieved from http://www.jointcommission.org/about_us/about_the_joint_commission_main.aspx. Accessed February 22, 2014.

THEIR ROLE IN THE ACCREDITATION PROCESS

The National Committee for Quality Assurance (NCQA)

NCQA Background

Private, non-profit organization.First established in 1990.Located in Washington, D.C.Funded by the Robert Wood Johnson

Foundation, the largest philanthropy dedicated to health care.

NCQA Mission Statement

Mission Statement: “The mission of the National Committee for Quality

Assurance is to improve the quality of health care and to provide information so that patients, payers, physicians, hospitals, and other interested parties can better judge how health plans and health care facilities compare on the basis of quality and therefore make more informed decisions among health plans specifically health management organizations and preferred provider organizations.” (Swenson 2000)

NCQA Accreditation Programs

Offers a variety of programs for organizations to win business , meet regulatory requirements and distinguish themselves from other institutions.

Programs for health plans: Health Plan Accreditation (HPA) Disease Management (DM) Case Management Accreditation (CM) Wellness & Health Promotion (WHP) New Health Plans (NHP)

NCQA Accreditation Process

The National Committee for Quality Assurance uses sets of programs and measurements to evaluate healthcare quality.

Strictly voluntary, participation is not required.

Notable performance measurement systems: Healthcare Effectiveness Data and Information Set

(HEDIS) Consumer Assessment of Healthcare Providers and

Systems Survey (CAHPS)

Healthcare Effectiveness Data and Information Set (HEDIS)

This performance measurement tool is designed to assist purchases and consumers in evaluating managed care plans and to hold health care plans accountable for the quality of their services that they provide.

HEDIS includes performance measures related to dozens of important health care issues. Selected measures include, but are not limited to: Advising smokers to quit Antidepressant medication management Breast cancer screening Cervical cancer screening Children and adolescent access to primary care physician Children and adolescent immunization status Comprehensive diabetes care Controlling high blood pressure Prenatal and postpartum care

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is divided into eight domains for performance measures. These domains include: 1. Effectiveness of care2. Access and availability of care3. Satisfaction with care experience by current

members4. Cost of care including premiums, deductibles, and

coinsurances fees5. Health plan stability6. Informed health care choices7. Use of services and lastly8. Health plan descriptive information

History of HEDIS

September 1991 – Version 1.0 of HEDIS was introduced by three employers: Xerox, Digital and GTE as well as other representatives of the health industry where it was originally called HMO Employer Data and Information Set.

October 1993 - the NCQA undertook development for HEDIS for version 2.0 with a more comprehensive revision and expansion to one hundred measures where it was renamed to the Health Plan Employer Data and Information Set

1997 – Version 3.0 was created and changed to Healthcare Effectiveness Data and Information Set with new revisions. “HEDIS 3.0 focuses on outcome as well as process to measure quality; includes measures for Medicare and Medicaid populations in addition to commercially insured groups, thereby bringing private and public measurement efforts together; covers a fuller spectrum of health care, notably illness as well as preventive care; standardizes the member satisfaction survey process; and addresses implementation issues, notably the requirements for management information systems,” (Spoeri 1997).

Consumer Assessment of Healthcare Providers and Systems Survey (CAHPS)

Created in 1997These surveys cover topics that are important to

consumers and focus on aspects of quality that consumers are best qualified to assess, such as the communication skills of providers and ease of access to health care services,” (CAHPS 2014).

CAHPS surveys ask patients to evaluate their experiences during their stay at hospitals, home care facilities, and physician offices.

To be qualified by the NCQA, participating health organizations must submit their results in their collected surveys just like the HEDIS surveys.

References

CAHPS. (2014). The CAHPS Program. Retrieved from https://www.cahps.ahrq.gov/aboutcahps/cahps-program/index.html.

NCQA. (2014). About NCQA. Retrieved from http://www.ncqa.org/AboutNCQA.aspx.

Ransom, E. R. (2008). The healthcare quality book: vision, strategy, and tools. 2nd ed. Chicago:Health Administration Press.

Spoeri, R. K., & Ullman, R. (1997). Measuring and reporting managed care performance: Lessons learned and new initiatives. Annals Of Internal Medicine, 127(8), 726-732.

Swenson, M. (2000, 06). NCQA: Advancing The Quality Agenda In Managed Health Care. In SEMINARS IN MEDICAL PRACTICE (Vol. 3, No. 2).

THEIR ROLE IN THE ACCREDITATION PROCESS

Healthcare Facilities Accreditation Program

(HFAP)

About the HFAP

Governed by the America Osteopathic Association (AOA)

Created in 1945Private, independent, non-profit organizationCurrent Accredited organizations – 438

207 hospitals 231 other healthcare facilities and laboratories

First accrediting body recognized by CMS in 1965

Mission Statement: To advance high quality patient care and safety through objective application of recognized standards

Accreditation by HFAP

Accredits various healthcare organizations: All hospitals and affiliated clinical laboratories Mental health facilities Substance abuse facilities Physical rehabilitation facilities Clinical laboratories Critical access hospitals

Certifies the following disease management programs or Centers of Excellence: Primary Stroke Center Certification

Cost- $25,000 triennially (accreditations) $7,050 biennial (stroke center certifications)

Accreditation by HFAP

Survey process methodology: CARE Data collected using

record reviews (open and closed), data analysis, observations, staff interviews, as well as review of patient treatment processes

Standards are measured by their impact on patient care Survey team evaluates compliance with the standards Measures the facility’s ability to deliver high-quality patient

care consistently Surveys performed in the least disruptive process possible. Offers educationally focused reviews.

Decision Process- AOA Bureau of Healthcare Facilities Accreditation Reviews and address survey reports Designates accreditation level

Accreditation Process

Basis for survey standards: CMS Conditions of Participation (CoPs) The National Quality Forum’s “Safe Practices for Better

Healthcare” The Institute for Healthcare Improvement The Agency for Healthcare Research and Quality The National Fire Protection Association’s “Life Safety Code”. Standards are closely aligned and “Crosswalked” to CMS CoPs

On-site reviews every three years Exception (Primary Stroke Center Certification, every 2 years) Unannounced, however blackout dates allowed

Trained quality volunteer surveyor teams A physician (lead), registered nurse, and a hospital administrator Not employees of HFAP, but paid professional volunteers actively

practicing at other HFAP accredited healthcare facilities

Results of Accreditation Process

Categories of Accreditation “Full Accreditation”

Satisfies ALL requirements in all quality performance areas. Resurvey within three years after accreditation.

“Interim Accreditation” Satisfies requirements but not in all quality performance areas. Requires further work in order to be compliant Resurvey within twelve months after accreditation.

“Denial of Accreditation” Necessary requirements are not met. Insufficient or no corrective actions taken to address

deficiencies.

References

Accreditation by HFAP. (2014). Retrieved from http://www.hfap.org/WhyHfap/workingwithhfap.aspx. Accessed February 17, 2014

Anaheim General Hospital Receives Full Accreditation from the Healthcare Facilities Accreditation Program. (2011, March 8). Business Wire. Retrieved from http://ezproxy.nu.edu/login?url=http://search.proquest.com.ezproxy.nu.edu/docview/855953634?accountid=25320. Accessed February 17, 2014

CMS-Approved Accreditation Programs. (2013). Retrieved from http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/CMS-Approved-Accreditation-Organizations.pdf. Accessed February 24, 2014

HFAP Overview. (2014). Retrieved from http://www.hfap.org/about/overview.aspx. Accessed February 17, 2014

Thompson, C. A. (2013). Accreditation Options Broaden for Acute Care Hospitals. American Journal of Health-System Pharmacy, 70(21), 1868, 1870. http://dx.doi.org/GALE%7CA350337707&v=2.1&u=nu_main&it=r&p=AONE&sw=w&asid=44b9afe23555b679d2ac3116e1cf7fa0

Center for Improvement in Health Quality (CIHQ)

PROUDLY SERVING HEALTHCARE ORGANIZATIONS SINCE 1999

About CIHQ

Newest accreditation provider approved by CMS

Membership-based organizationComprised of 275 general acute care and

critical access hospitalsAssures hospitals comply with the Medicare

Conditions of Participation and improve the quality of care, treatment, and service in their communities

Offers disease specific certification for stroke (primary), hip/knee surgery, and heart failure.

Mission, Vision and Values

Mission: To create a regulatory environment that enables healthcare organizations to effectively deliver safe, quality patient care

Vision: CIHQ will be viewed by its members as an indispensable alley in their accreditation and regulatory compliance efforts

Values: Integrity Accountability Collegiality and Openness Stewardship

CIHQ Three Divisions

Hospital Accreditation Division (July 2013)

Accreditation Resource Services (Consulting Division, Est. 1999)

Professional Certification Division (HACP)

CIHQ Hospital Accreditation Division

Survey Process- Combines CMS survey procedures with tracer methodology: Open conference Document review Visits to patient care and support areas Building tour Open and closed medical record review Credential and personnel file reviews Daily briefings and exit conference

Survey Process

Full Surveys Initial Surveys

Conducted the first time an organization applies for accreditation

Triennial Surveys This survey is conducted for existing accredited

organizations. 36 months after the organizations last full survey

Focused Surveys Mid-Cycle Surveys

Conducted 16-20 months from the organizations last full survey. Focuses on the organizations compliance to new or revised standards as well as standards that address high-risk patient care processes.

Survey Process continued…

Complaint Survey Performed in response to a complaint received about an

accredited organization from a patient or surrogate decision maker.

Designed to validate the accuracy and substance of the complaint

Follow-Up Survey Conducted when the following occur:

The organization sustains an immediate threat to health and safety deficiency.

The organization sustains a condition level deficiency.

Accreditation Status

AccreditedAccreditation at Risk

Reasons why accreditation would be at risk Fails to submit a required corrective action plan Fails to notify CIHQ of substantive changes to their application Makes false public claims regarding accreditation Violates CIHQ policy on falsification and misrepresentation

Accreditation Withdrawn/Denied Reasons why accreditation would be denied

Failure to ultimately address an “accreditation at risk” issue Failure to pay your accreditation fees Refusal to permit CIHQ to conduct a survey and/or access to

necessary information

References

Center for Improvment in Healthcare Quality. About CIHQ. Retrieved February 21, 2014, from Center for Improvement in Healthcare Quality: cihq.org

Summary

Accreditation organizations ensure safe and quality healthcare for patients One means for healthcare organizations to be held

accountable Some reasons for being accredited:

to meet state and national level standards to lower insurance premiums to ensure Medicare financial reimbursements

Four (of 8) Recognized “Deemed Authorities” Joint Commission (JCAHO) . National Committee for Quality Assurance (NCQA) Healthcare Facilities Accreditation Program (HFAP) Center for Improvement in Health Quality (CIHQ)

Summary (cont’d)

Characteristics: Private non-for-profit organizations Accreditation is based on CMS Conditions of Participation

(CoPs). 3-year Accreditation Cycle; Site survey visits are unannounced. Survey Process Methodology: ORYX, Tracer, CARE, HEDIS and

CAHPS. Levels of accreditations vary – depends on requirements

met 3 Groupings: fully accredited, partially accredited, and denial

Cost for accreditation ranges varies depending on size and complexity $23,000 to $33,000, with JCAHO being the highest.

JCAHO is accrediting more than 18,000 facilities; other three are cost effective options for healthcare providers.