|
|
|
Accreditation Agencies in
|
|
"The mission of the Joint Commission on Accreditation of Healthcare Organizations is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations." JCAHO |
Similar "quality assurance" standards for five Joint Commission accreditation programs (hospital, psychiatric, long term care, and ambulatory healthcare) were adopted between 1979 and 1981. Revisions were adopted in 1984 to add a requirement for monitoring and evaluation. Then in 1990 the ten-step monitoring and evaluation process was added to the manuals. In 1992 there were major changes with the expansion in language and standards to quality assessment and improvement. In 1994 the hospital standards were reorganized into functional chapters and "performance improvement" language replaced QA & I. The ambulatory care manual was likewise reorganized into functional standards and began using PI terms and processes for improving organization-wide performance in 1996. The home care and "- behavioral health care manual conversions to functional standards took place in 1997.
Beginning in 2003, all accredited organizations must meet all approved National Patient Safety Goals and the accompanying recommendations (as applicable) to avoid a Requirement for Improvement.
A new accreditation process called "Shared Visions-New Pathways" became effective in January 2004. It is intended to shift the focus from survey preparation to continuous improvement. The vision shared with healthcare organizations, oversight bodies, and the public is to "bridge what has been called a gap or chasm between the current state of health care and the potential for safer, higher quality care" [Source: "Facts about Shared Visions-New Pathways," www.icaho.orq/accredited+organizations/svnp ]
The acute hospital Joint Commission standards seem to set the precedent for standards in other settings, and they are now quoted in the judgments of many civil malpractice cases. Conversely, changes in the standards are generally consistent with changes in federal regulation and precedent-setting court cases. Similarly, changes in the standards reflect recent national concerns, as expressed in media coverage (e.g., sentinel events) or major reports (e.g., the 10M report on medical errors). This makes the Joint Commission standards an important resource in establishing quality strategies and performance improvement processes. Hospital standards are referenced in this Handbook the most, as they are the first to change and are the most comprehensive of all the Joint Commission programs. Behavioral Care Program The Comprehensive Accreditation Manual for Behavioral Health Care (CAMBHC) is used for healthcare organizations that provide mental health or chemical dependency/ other addictive behavior services to adults, adolescents, or children; or that provide mental retardation/developmental disability, foster care, corrections, forensic, or other psychosocial services in most settings. Hospitals providing inpatient and/or residential mental health programs for children and adolescents may be surveyed under the CAMBHC if third party reimbursement requires; otherwise, such programs are surveyed under the hospital standards (CAMH). Each facility is evaluated individually for determination of eligibility for survey based on the behavioral health care standards, hospital standards, or a combination.
The long term care program has been in place since 1966. The Comprehensive Accreditation Manual for Long Term care (CAML TC) applies to nursing homes and skilled nursing facilities, as well as facilities now providing sub-acute care. The newer assisted living program began in 2000 and uses standards in the Accreditation Manual for Assisted Living (AMAL).
(Joint Commission or JCAHO) Multiple accreditation programs
The Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) is used for any ambulatory healthcare organization meeting eligibility criteria. Types of ambulatory care organizations include:
| "Our goal is to increase the value of NCQA accreditation both to organizations pursuing accreditation and to the audiences who seek help in assessing the quality of health care provided by those organizations. " Margaret E. O’Kane President. |
The National Committee for Quality Assurance (NCQA) works with managed care organizations, healthcare purchasers, state regulators, and consumers to develop standards and performance measures (Health Plan Employer Data Information Set or HEDIS~ that effectively evaluate the structure and functions of medical and quality management systems in managed care organizations.
In 1990, when JCAHO dropped their Managed Care Accreditation Program, they turned those managed care organizations that were currently accredited over to NCQA. NCQA is now an independent body originally founded in 1979 by the then Group Health Association of America (now the American Association of Health Plans) and the American Managed Care Review Association. Standards were finalized 7/1/91, with revisions approximately every two years since then.
Current NCQA programs:
The AOA accreditation program was developed in 1943 and 1944 and implemented in 1945. Under this program hospitals were surveyed each year. In this manner the AOA was able to assure that osteopathic students received their training through rotating internships and residencies in facilities which provided a high quality of patient care. In 1965 Medicare and Medicaid were introduced and the American Osteopathic Association and the American Osteopathic Hospital Association applied to the Health Care Financing Administration (HCFA), now CMS, for deeming authority to survey hospitals under the Medicare Conditions of Participation. In 1995 the AOA applied for and received deeming authority to accredit laboratories within AOA accredited hospitals under the Clinical Laboratory Improvement Amendments of 1988 (CLIA).
The AOA has also developed accreditation requirements for ambulatory care/surgery, mental health, substance abuse, and physical rehabilitation medicine facilities. HFAP Recognition
The AOA program has been granted "Deeming Authority" to conduct accreditation surveys of acute care hospitals by the Centers for Medicare & Medicaid Services (CMS). (Section 1865 of the Social Security Act and implementing regulations 42 CFR 488.5.) This means that a hospital accredited by the AOA is deemed to comply with the Medicare Conditions of Participation for Hospitals as published by CMS.
The AOA program has been granted "Deeming Authority" from CMS to survey hospital laboratories under the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as published in the Federal Register, Vol. 60, No. 140, page 37657, Friday, July 21, 1995. The program is a recognized alternative to accreditation by CMS or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The laboratory accreditation program is a recognized alternative to accreditation by the College of American Pathologists (CAP) or JCAHO. According to the National Committee for Quality Assurance, "NCQA does not require managed care organizations (MCOs) to accept specific accrediting bodies. An MCO makes the final determination about which accrediting bodies are acceptable." An MCO can decide to accept the AOA as their preferred accrediting agency.
The Council on Accreditation (COA) is an international, independent, not-for-profit, child- and family-service and behavioral healthcare accrediting organization. Founded in 1977 by the Child Welfare League of America and Family Service America, COA partners with human service organizations worldwide to improve service delivery outcomes by developing, applying, and promoting accreditation standards. In 2004, COA accredited or was in the process of accrediting more than 1,500 private and public organizations that serve more that 7 million individuals and families in North America, England and the Philippines.
As the leader in ambulatory health care accreditation, the Accreditation Association for Ambulatory Health Care (Accreditation Association/AAAHC) has been setting the standard for quality in ambulatory health care for over 25 years. The AAAHC accreditation certificate has become a symbol that an organization is committed to providing the highest level of quality health care possible.
The Accreditation Association currently accredits over 2200 organizations in a wide variety of ambulatory health care settings, including ambulatory and office based surgery centers, managed care organizations, as well as Indian and student health centers, among others. With a single focus on the ambulatory care community, the Accreditation Association offers organizations a peer-based, relevant, and cost-effective approach to accreditation.
The AABB Accreditation Program strives to improve the quality and safety of collecting, processing, testing, distributing and administering blood and blood products. The Accreditation Program assesses the quality and operational systems in place within the facility. The basis for assessment includes compliance with Standards, Code of Federal Regulations and federal guidance documents. This independent assessment of a facility’s operations helps the facility to prepare for other inspections and serves as a valuable tool to improve both compliance and operations. Accreditation is granted for collection, processing, testing, distribution, and administration of blood and blood components; hematopoietic progenitor cell activities; cord blood activities; perioperative activities; parentage testing activities; immunohematology reference laboratories and SBB schools. Contact the Accreditation Department at accreditation@aabb.org or call (301) 215-6492.
Developed by experts from the professions of health, law and corrections, separate standards exist for health care delivery in jails, prisons, and juvenile detention and confinement facilities. The areas covered by the Standards include:
- Facility governance and administration
- Maintaining a safe and healthy environment
- Personnel and training
- Health care services support
- Inmate care and treatment
- Health promotion and disease prevention
- Special inmate needs and services
- Health records
- Medical-legal issue
• The U.S. Department of Health and Human Services (USDHHS) is the most important federal actor in health care.
• Other federal agencies with major health services roles include:
- Department of Veterans Affairs
- Department of Defense
- Department of Agriculture (nutrition policy, meat and poultry inspection, food stamps)
- Environmental Protection Agency
- Department of Labor which administers
Occupational Safety and Health Act
Protect and promote the health, social and economic well-being of all Americans and in particular those least able to help themselves—children, the elderly, persons with disabilities and the disadvantaged—by helping them and their families develop and maintain, productive, and independent lives. (1996)
Administration for Children and Families (ACF)
Administration on Aging (AoA)
Agency for Healthcare Research and Quality (AHRQ)
Agency for Toxic Substances and Disease Registry (ATSDR)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare & Medicaid Services (CMS)
Food and Drug Administration (Food and Drug Administration)
Health Resources and Services Administration (HRSA)
Indian Health Service (IHS)
National Institutes of Health (NIH)
Program Support Center (PSC)
Substance Abuse and Mental Health Services Administration (SAMHSA)
The Centers for Medicare & Medicaid Services (CMS) administers the
Medicare program and works in partnership with the States to administer:
• Medicaid,
• The State Children's Health Insurance Program (SCHIP), and
• Health insurance portability standards.
In addition to these programs, CMS has other responsibilities, including:
• The administrative simplification standards from the Health Insurance
Portability and Accountability Act of 1996 (HIPAA),
• Quality standards in health care facilities through its survey and
certification activity, and clinical laboratory quality standards.
o Medicare
o Medicaid
o State Children’s Health Insurance Program (SCHIP)
o The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
o Clinical Laboratory Improvement Amendments (CLIA)
Medicare (Title XVIII) is a social insurance a program for people age 65
and older and for some disabled people under 65
Mandated by 1965 Social Security Act and administered by DHHHS
Components:
- Part A – Hospital Insurance – pays for medically necessary inpatient hospital
care, inpatient care in a skilled nursing facility after a hospital stay,
home-health care, and hospice care
- Part B – Outpatient Care
The Medicaid Program
Medicaid eligibility is limited to individuals who fall into specified
categories:
• Pregnant women,
• children and teenagers,
• individuals who are aged, blind, or disabled.
The rules for counting income and resources vary from State to State and from group to group.
States have a wide degree of flexibility in designing their programs.
The portion of the Medicaid program that is paid by the Federal Government is
known as the Federal Medical Assistance Percentage.
Certification under Medicare/Medicaid
Certification and/or recertification means that an agency can bill Medicare
and/or Medicaid for the services provided if the patient is covered by Medicare
and/or Medicaid (publicly funded insurance programs)
The federal regulations become the standards that an institution must meet if it wishes to participate in Medicare and /or Medicaid programs
The standards are known as the Conditions of Participation
The Conditions of Participation are part of the Code of Federal Regulations, last revised by HCFA in 1986 (final rule published June 17, 1986, in the Federal Register, Volume 51, No. 116, pp. 22010-22052).
Hospitals must meet the Conditions established by Medicare and Medicaid to receive reimbursement for treating program beneficiaries.
The Conditions of Participation are part of the Code of Federal Regulations, last revised by HCFA in 1986 (final rule published June 17, 1986, in the Federal Register, Volume 51, No. 116, pp. 22010-22052).
Hospitals must meet the Conditions established by Medicare and Medicaid to receive reimbursement for treating program beneficiaries.
Conditions related to these services or functions must be met by all
hospitals participating in Medicare and Medicaid programs:
• Governing body
• Patients' rights
• Quality assessment and performance improvement
• Medical staff
• Nursing services
• Medical record services
• Pharmaceutical services
• Radiological services (contract service OK)
• Laboratory services (contract service OK)
• Food and dietetic services (contract service OK)
• Utilization review
• Physical environment
• Infection control
• Discharge planning .
Conditions for optional services are applicable if the institution offers
such services:
- Organ, tissue, and eye procurement
- Surgical services
- Anesthesia services
- Nuclear medicine
- Outpatient services
- Emergency services
- Rehabilitation services
- Respiratory care services
Swing beds (between acute and skilled services)
Special conditions apply to psychiatric hospitals, related to
• Medical record requirements
• Staffing requirements
The conditions:
o Surveyors of health care facilities are concerned with three aspects of
standards:
o Capacity concerns the physical plant—the professional and nonprofessional
staff and equipment
o Performance refers to how the capacity of the facility is used and is a much
more complex judgment for the surveyor than capacity
o Product is based on the maintenance of the patient’s well-being
• Granted “deemed status” to any hospital accredited by the Joint Commission
on Accreditation of Hospitals.
• Deemed status is a legal term meaning in accordance with federal law, agencies
accredited by certain bodies are in automatic compliance with all the conditions
of participation in the Federal Registry for that particular type of agency.
• The Joint Commission is the only organization with deemed status for the
accreditation of hospitals.
• Accreditation is a voluntary process.
• DHHS conducts validation surveys on 10% of all Joint Commission accredited
hospitals each year.
•
http://www.cms.hhs.gov/quality/hospital/
Ask a question and we will answer it within the next 48 hours. If you
have no questions, please review the answer to the questions asked by others:
Question: Does the section on AOA tell us that AOA does not go out and do the accreditation visits and does it tell us that COA does the accrediting of psychiatric facilities for AOA? Thank you Answer: Unfortunately, the instructor for this course is not available until the summer to answer the questions posted on the web.
Question: Explain how licensure, certification (for Medicare) and accreditation for healthcare organizations are similar and how they are different? Answer: Please take a look at http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=5338434&query_hl=3
You can add your suggestions or read below suggestions made by others:
Suggestion: The lecture provided easy to understand background material and specialization of US accrediting agencies as well as highlighted in a summarized format the most important quality improvement programs in healthcare.
Suggestion: What worked very well for me was the script provided with the audio. Last week I was furiously taking notes. As I am a visual learner it is very hard for me to just listen to a lecture; I printed off the script first and then followed along with the audio and added notes and highlighting as needed; great, thank you! Information complete yet succinct.
|
