accreditation q106

8/6/2019 Accreditation Q106

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What is accreditation?y Accreditation is a process in which an entity,

separate and distinct from the health careorganization, usually nongovernmental, assessesthe health care organization to determine if itmeets a set of requirements designed to improvequality of care.



y Accreditation is often a voluntary process in whichorganizations choose to participate, rather than onerequired by law and regulation.

y Accreditation has gained worldwide attention as aneffective quality evaluation and management tool.



A ccreditation Is Not A nAl ternative To Licensure

y L icensure is a process by which a governmentalauthority grants permission to an individual

practitioner or health care organization to operate orto engage in an occupation or profession.



y L icensure regulations are generally established toensure that an organization or individual meets

minimum standards to protect public health andsafety.



A nd Is NotCertification

y C ertification is a process by which an authorized body,either a governmental or non-governmental

organization, evaluates and recognizes either anindividual or an organization as meetingpredetermined requirements or criteria.



y Although the terms accreditation and certification areoften used interchangeably, accreditation usually

applies only to organizations, while certification may apply to individuals, as well as to organizations.



y Accreditation provides a visible commitment by anorganization to improve the quality of patient care,ensure a safe environment, and continually work toreduce risks to patients and staff.

y Improve the quality of health care by establishingoptimal achievement goals in meeting standardsfor health care organizations.

y

Stimulate and improve the integration andmanagement of health services.



y E stablish a comparative database of health careorganizations able to meet selected structure,process, and outcome standards or criteria.

y Reduce health care costs by focusing on increasedefficiency and effectiveness of services.



y P rovide education and consultation to health careorganizations, managers, and health professionals

on quality improvement strategies and bestpractices in health care.

y Strengthen the public s confidence in the quality of health care, and Reduce risks associated withinjury and infections for patients and staff.



A ccreditation Standardsy Accreditation standards are usually regarded as

optimal and achievable.y Accreditation standards are typically developed by

a consensus of health care experts.y Standards are published and reviewed and revised

periodically in order to stay current with the state-of-the-art thinking about health care quality,advances in technology and treatments, andchanges in health policy.



Compliance With Standards



A ssessing of comp liance withStandards focuses on:

y Actual performance ("performance-based") ratherthan capacity to perform.

y P rocesses and outcomes, not simply structure;y P atient care issues related to quality and safety;y The organization's efforts to manage patient care

and to support process improvements that resultin good patient outcomes.



A ssessment Of Comp liancey M ost accreditation agencies use one or more of the

following means to assess compliance with applicablestandards:

-Review of documents that demonstrate compliance;-Onsite observations by surveyors;.-Verbal information gained by surveyors through

interviews;-E xamples of standards implementation;.-Review of medical/health records;.-Assessment of service/support systems;-Integration of performance measure data in scoring.



y Identify an administrative team of key leaders andmanagers to coordinate and oversee ongoingcompliance and survey planning efforts.

y E stablish on-going interdisciplinary teams (orutilize appropriate existing teams) at each site or foreach important function) to meet at least quarterly,reviewing compliance with appropriate standards.



y Identify a medical/professional staff, or medicalgroup team of clinical leaders who will be inauthority at the time of the surveyor will berequired to participate as medical directors,department chairs, etc.



Identify the Ro le of the Qua lity professiona lsy The quality, utilization, and risk managers need to

work with the medical staff/group coordinator toreview compliance with applicable standards andreport to the selected leadership team.



Remain Current with Standardsy D istribute the current Standards and

Guidelines, with any other appropriate

explanatory materialy Annually identify any changes in standardsy Annually identify any changes in survey

process,.y Remain current on patient safety issues standards



P revious Survey Reportsy Review the previous two full survey reports, as well as

any interim random survey reports, looking for areasof vulnerability in the organization (patterns).



Focused Survey Reportsy Review any focused survey reports and any written

progress reports submitted subsequent to corrective

action plans.y D id the corrective action take place and is it still in

place and effective?



Organizationa l Concernsy Review current organizational concerns, data, etc. to

compare current compliance with the past and toidentify any new compliance issues, includingNational P atient Safety Goals.



Continuous measurement

and monitoring of compliance are tracked retrospectively



Qua lity Management/ P erformanceImprovement A ctivities

y Review the current status of all quality management/performance improvement activities.

y S urveyors will look backwards ( the past 12 months) atstatistics and the Performance Improvement Projects



Committee Minutesy Review minutes and other records of teams and

committees, as well as medical staff departments, if applicable, looking for missed improvementopportunities (while there is still time to dosomething).



M inutes reflects theactual work doneand issuesaddressed by thecommittee



Qua lity P rogram Eva luationy Review the previous year's quality

management/performance improvement program

evaluation report.



A re approved recommendationsbeingimplemented?



Current Year Qua lity P lan

y Review the current year's quality management/quality improvement plan, objectives, and any strategicquality Initiatives.



A re the objectives/initiatives being

achieved? In progress?



P o licies and P roceduresy Review and revise all policies and procedures

associated with the standards.

y Be certain that the policies are organizationwide orsystem-wide as appropriate and, most importantly,that all policies and procedures dealing with the

same system, function, or process are consistentacross all settings and areas of the organization.



The Review P rocess 5

y Review the Q M / P I processes, approved approach, andteam activities and determine any revisions or

modifications, or develop a new process if appropriate.



B e certain that theorganization wideQ M /PI approach isunderstood and is

utilized for all quality planning

and qualityimprovement

activities.



P atient Safetyy For patient safety, review the program description and

program components and track data, analysis,reporting, action



Patient safety goals has become part of theaccreditation process Patient S afety has

come priority number surveyors, Nocompromise in standards related to patient safety



Communications Strategiesy Review all QM / P I communication, reporting, and

feedback processes and improve as appropriate



Communicationhas become oneof the patientsafety goals



M edical staff credentials has acquired special importance due to its link to quality of clinical care and patient safety. It is an essential part of any accreditation review process



Medica l Staff Credentia ls

y Review credentials process and files for licensedM edical Staff for timeliness, completeness, andcurrent competency status



H uman Resources

y Review human resource process and files fordocumentation of timely orientation and completionand maintenance of current competencies



It is a must in every survey process toreview human resources files tocheck for completeness and current appraisal

process



Conduct Base line Surveyy A planned self-assessment process will determine the

degree of compliance with the standards and survey preparedness. Also, it helps identify areas forimprovement.



It is a great opportunity to interpret the standardsand get a team perspective to the gaps incompliance



P eriodic Se lf-assessment/ P resurveyP rep.

y A period self assessment is a tool for the team tomeasure progress towards compliance with thestandards. E nough time should be allowed betweenperiodic self assessment. Results should feed into theprioritization process for performance improvement



S ome A ccrediting A gencies such as the JointCommission requires that the organization send the self assessment prior to the actual survey. Theorganization must show how it deals with performance gaps



Mock Surveyy If it is planned to have an outside presurvey

performed, be certain that it is timed to allow themaximum time possible for implementation of recommendations.

y Incorporates all standards that will be in effect at thetime of the actual survey wherever applicable.



Communications and InformationInside the organization

y P utting policy and procedure manuals and forms on line;y P roviding an organizationwide compliance calendar with

review dates, plan/report due dates, etc.;y C omputer sign-on screeny QI/ P I or survey tips, reminders;y F requent emails to staff concerning relevant standards,

P rogress reports,y C ompliance needs.



G et Organized and Take A ctiony develop a binder for each department to focus on

the area specific standardsy E stablish Accountability and responsibility.y E verybody s job is Nobody s joby L ist all improvement activities with all necessary

documentations to prove it.y R emember what is not written is not doney All medical staff has to be involved even if

improvement is in another area.



y

There should be evidence of M

edical Staff participation on at least some of theinterdisciplinary QI, strategic initiative, or bestpractice teams.

y

P rovide specific pre-survey orientation to allpotential interview teams, QI teams that might beparticipating.



Educate, Educate, Educatey E ducate/update each medical staff department chair,

officer, medical director, or medical group:- P revious compliance issues in their area and currentstatus,- C urrent standards and any changes since the last survey;- C urrent monitoring/data collection, analysis, andimprovement processes for their area;- All quality improvement successes within at least the last12 months.



Educate all staff concerning:y The survey process, its importancey E ach pertinent improvement impacting their role,y

Roles and responsibilities in compliance with they standardsy C ompliance with policies/procedures.y D epartment/service, and care and service provisiony

P atient safety y P atient rights and responsibilitiesy E ach person should have in hand the log indicating where

all appropriate documentation is located.



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accreditation q106

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