Accreditation

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Accreditation Insider, March 9, 2017

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Comparison Element  Center for Improvement in Healthcare Quality  (CIHQ) Det Norske Veritas Healthcare, Inc. (DNV) Healthcare Facilities Accreditation Program (HFAP) The Joint Commission (TJC)
Organizational Focus CIHQ is a nationally recognized accrediting organization approved by CMS to deem acute acute hospitals to be in compliance with the Medicare Conditions of Participation.  CIHQ' focus is to partner with accredited hospitals in improving the quality and safety of patient care by providing a survey process that is educational, collegial, and value-added. DNV’s corporate purpose is safeguarding life, property, and the environment. DNV received deeming authroity for hospitals from CMS on September 26, 2008. The HFAP is a nationally recognized accreditation organization with deeming authority from CMS. Its mission is to advance high quality patient care and safety through objective application of recognized standards. TJC has collaborated with healthcare organizations for more than half a century to focus on safe, quality care for the American public through a voluntary independent evaluation process. Healthcare is the sole industry served.
Organizational Structure CIHQ is a privately-held limited liability company with its corporate headquarters located in McKinney, TX. CIHQ has been in existence since 1999 and provides accreditation and consulting services to over 300 hospitals across the United States. DNV Healthcare, Inc. is an operating company of Det Norske Vertas. DNVHC corporate offices are in Houston, Texas and Cincinnati, Ohio. DNV has been operating in the United States since 1898. HFAP is a not-for-profit organization dedicated to helping healthcare organizations maintain the highest standards in patient care and comply with ever-changing government regulations and a constantly evolving healthcare environment. TJC is a not-for-profit organization dedicated to providing the highest value service to healthcare organizations
Number of Accredited Hospitals Since receiving deeming authority from CMS in July of 2013, CIHQ has accredited more than 20 hospitals, and is scheduled to have more than 30 hospitals by the end of 2015. Since receiving deeming authority from CMS in September 2008, DNV has accredited more than 27 hospitals and will be listed soon on the DNV Web site Nearly 200 hospitals and more than 200 other healthcare facilities as well as laboratories are listed on the HPAP Web site. Nearly 5,000 hospitals and approximately 10,000 other healthcare organizations are accredited or certified by TJC.
History Formed in 1999 as a consulting company, CIHQ became the nations 4th deeming authority for acute care hospitals in 2013. Today, in addition to being a deeming authority, CIHQ continues provides a wide-range of accreditation and support services to hospitals through its consulting arm - Accreditation Resource Services. DNV has a worldwide reputation for quality and integrity in certification, standards development, and risk management in a wide range of industries, including extensive international healthcare experience. The HFAP has been accrediting healthcare facilities for more than 60 years and under Medicare/ Medicaid since its inception. HFAP is also authorized to survey clinical laboratories under CLIA. The Joint Commision was established by healthcare professionals to improve the delivery of patient care and has been conducting accreditation of healthcare organizations for more than 50 years. Unique deeming authority was awarded in 1966.
Governance & Leadership CIHQ senior staff have over 75 years of combined clinical and executive-level hospital leadership experience. DNV is managed by a dedicated group of degreed professionals, each with many years of experience in their respective field of healthcare management, clinical services, health law, ISO certification and engineering. The accreditation management team has extensive healthcare operational experience in the United States and understands the dynamics of a complex healthcare  organization. The AOA Bureau of Healthcare Facilities Accreditation is a panel of physicians and administrators from family practice, surgery, internal medicine, pathology, obstetrics and gynecology, hospital administration, colleges of osteopathic medicine and the American Academy of Osteopathy. HFAP is represented in all major healthcare and quality improvement forums as a key player in the shaping of healthcare policy. TJC’s Board of Commissioners is comprised of physicians, nurses, healthcare leaders and professionals, and public representatives. TJC leadership helps influence national healthcare policy, funding priorites, performance measurement, and future legislation alongside other key stakeholders and influencers.
Accreditation Requirements CIHQ standards are closely aligned with the Medicare Conditions of Participation at 42CFR. Requirements are based on the interpretive guidance provided to CMS State enforcement agencies in the State Operations Manual (SOM). Because the Conditions of Participation address minimum standards of care, CIHQ has developed additional standards that address key quality and patient safety challenges faced in today’s healthcare environment. CIHQ' standards are clear, understandable, and designed to allow hospitals maximum flexibility in developing compliance strategies. DNV standards are directly related to the CMS Conditions of Participation (CoPs) and apply to any size hospital. Standards are less prescriptive and the survey process supports CMS quality initiatives, focus on continual improvement prioritized by the organization, and allows organizational innovation to determine the most effective means for compliance using best practices. HFAP standards include CMS and other nationally recognized standards, as well as evidence-based best practice and selected patient safety initiatives. Standards are realistic, understandable, measurable, beneficial, and achievable. The standards exceed the Conditions of Participation (CoPs). Leading healthcare practice standards and National Patient Safety Goals are developed in concert with healthcare professionals, the public, and other key stakeholders. The standards exceed the Conditions of Participation (CoPs) and are directly relevant to the current delivery of healthcare.
Survey Process The survey process is a highly collaborative and educational in approach utilizing tracer methodology and CMS survey procedures. CIHQ requires hospitals to only undergo a survey for services and sites of care billed under the hospital's Medicare CCN. CIHQ does not require entities to be surveyed just because of a relationship with the hospital. The NIAHOSM and ISO surveys are done together through Tracer Methodology, as well as staff and patient interviews. Tracer Methodology has been a staple of ISO 9001 surveys since ISO’s inception in 1987. All areas of the hospital are surveyed, both clinical and non-clinical. Tracer Methodology is a tool to identify and document effective processes. Comprehensive, non-biased and thorough reviews of patient-centered processes within the facility are conducted in the least disruptive way possible. Educationally focused reviews also offer non-prescriptive recommendations for corrective measures for deficiencies found. With guidance from the healthcare field, TJC developed the tracer methodology to follow and evaluate the quality of a patient’s healthcare experience. This offers a patient-centered and process focused survey rather than a paper- intensive process.
Survey Frequency (All surveys are unannounced) DNV performs an annual on-site survey. HFAP performs on-site surveys of hospitals once every three (3) years. TJC performs on-site surveys of hospitals every three (3) years. As part of the TJC Intracycle Monitoring requirements, he accredited organization is required to complete a Focused Standards Assessment (FSA).
• Initial Survey - Full survey conducted within 4 months of initial application  
• Mid-Cycle Survey - One or two day survey approximately 18 months into survey cycle 
• Triennial Survey - Full survey every 36 months. Occurs between 34 – 36 month of cycle
Surveyors All CIHQ surveyors are clinicians with extensive hospital experience and survey full time. All surveyors undergo a rigorous training program and proctoring. In addition, CIHQ is the only accrediting organization that requires their surveyors to be nationally certified as healthcare accreditation professionals (HACP). Surveyors must complete continuing education on an ongoing basis. All DNV surveyors must successfully complete NIAHO Surveyor didactic training and separate ISO 9001 Lead Auditor didactic training. HFAP surveyors are not employees of the organization, but are paid volunteers. Frequently recruited from HFAP-accredited facilities, survey teams include physicians, nurses, and administrators with years of experience. They represent leadership in their own facilities and bring a current understanding of the healthcare industry to the survey process.  
Surveyors include physicians, registered nurses, and the PE Specialists come with a facilities and safety background. All surveyors must complete 45 hours of continuing education in their discipline within every three (3) year period. All surveyors are employees of TJC and have extensive healthcare experience; many are currently employed in hospitals or private practice. Surveyors must pass a certification exam. Training is continuous and collaborative. TJC is the first and only accrediting body to certify its surveryors. TJC is the first and only accrediting body to certify its surveyors.
Surveyors must participate in annual surveyor training, as well as other courses offered throughout the year by DNV and DNVHC staff. Surveyors have a strong educational background and receive continuing education to keep them up to date on advances in quality-related performance evaluation.
Scoring Process All standards and attendant requirements are scored as “pass / fail”. There are no percentages or categories. The closer a standard is to assuring the provision of safe quality care, the higher the expectation of compliance will be. The goal is to strike a proper balance between focusing on meaningful issues versus technical and isolated lapses in compliance. DNV does not aggregate the scoring of the survey. The organization is responsible for developing and implementing corrective action plans to address all noncomformities identified. Surveyors report discrepancies to the HFAP Office. The facility is then sent a comprehensive report. The facility then submits a Plan of Correction within 30-60 days. Elements of Performance are evaluated as compliant or non-compliant.  TJC utilizes the Survey Analysis for Evaluating Risk (SAFER) approach to provide organizations with a visual depicting the risk level of each observation to assist organizations in prioritizing findings and focusing corrective actions.  All observations are assigned a single time frame of 60 days for corrective action. For observations which have a higher risk level in the matrix, additional information will be required to demonstrate sustained corrective action.
Accreditation Categories  • Accredited - Fully meets all CIHQ accreditation policies and requirements • Accredited - Noncomformities resolved pursuant to DNV accepted corrective action plan • Full Accreditation • Accredited- Hospital is in compliance with all applicable standards at the time of survey or has successfully addressed all requirements for improvement.
• Accreditation at Risk - Violation of key CIHQ policies / survey requirements • Jeopardy Status- Organization fails to meet corrective action plan requirements • Interim Accreditation • Provisional- Hospital fails to successfully address all requirements for improvement within a specified timeframe.
• Accreditation Withdrawn / Denied - There are two reasons why accreditation would be denied 1. Failure to ultimately address an “accreditation at risk” issue 2. Refusal to permit CIHQ to conduct a survey and/or access to necessary information • Not Accredited • Denial • Conditional- Nature of the Requirements for Improvement requires an onsite follow-up survey
      • Preliminary Denial - Severity of findings justifies denial of accreditation. Decision is subject to review and appeal.
      • Denial- Accreditation has been removed or denied and appeals have been exhausted.
Cost of Accreditation CIHQ Charges a flat annual fee, based on licensed bed capacity. This fee includes full and mid-cycle surveys as well as travel expenses. In addition, there is NO additional fee for follow-up  and complaint surveys (two per year). Hospitals pay only travel expenses. CIHQ has a low price guarantee and will meet or beat the overall cost of other accrediting organizations DNV does not charge for the NIAHOSM Standards, Interpretive Guidelines or Accredidation Process for non-commercial use The cost of the survey is based on the number of surveyors and the length of the survey. Size of the facility, average daily census, number of FTEs, complexity of services offered, type of survey to be conducted and whether special care units or off-site clinics or locations will factor into the cost of the survey. A “Quick Quote” can be submitted to the DNB via the Web site. The average annaul cost for DNV services is $23,100. These fees include all travel expenses. The average cost for HFAP services averages The average cost for TJC services is $33,000 for three (3) years; a survey is required once every three years. However, individual hospital costs vary by size and complexity.
$25,000 for three years. Individual facility costs vary by size and complexity
Accreditation Decision Process Authority for granting, modifying, or removing a hospital's accreditation status rests with the Chief Executive Officer of CIHQ. If a hospital wishes to appeal an accreditation decision, CIHQ  will convene a independent Accreditation Review Board (ARB). The decision of the ARB is final. NIAHOSM Accreditation. If appropriate, the organization may receive a three (3) year certification for meeting the ISO 9001 Quality Management System requirements. If a hospital is dissatisfied with an accreditation decision, it may appeal to the “Standards and Appeals Board” (SAB). The SAB is an independent body chartered by the DNV Board of Directors to hear accreditation appeals. The decision of the SAB is final.   Adverse accreditation decisions are primarily based on non-compliance with requirements that have a direct impact on patient safety and quality of care.
Accreditation Support CIHQ is the only accrediting organization to offer a comprehensive array of support services to its hospitals at no additional cost. Services are provided through CIHQ' consulting division - Accreditation Resource Services (ARS). Services include; organization-wide access to standards and interpretation, a comprehensive resource library of over 400 template documents and tools, monthly webinars on accreditation topics, an electronic reference library, staff training modules, continuing education credits, survey preparation took kits, and complimentary registration for two at CIHQ' annual accreditation and quality summit. Guidelines for Accreditation Process at no charge for non-commercial use. The HFAP provides standards interpretation for its clients. In addition, HFAP accreditation manuals reflect the latest standards and include a comprehensive cross-reference system to CMS standards, as well as scoring guidelines that assist facilities to prepare for surveys Accreditation support includes, but is not limited to, dedicated account representatives, standards interpretation assistance, periodic performance reviews with flexible options, patient safety information and advisories, strategic surveillance system (S3), and electronic manuals.
Public Health Care Advocacy CIHQ works closely with CMS and other key stakeholders in shaping the accreditation and regulatory environment for hospitals in the United States.   While HFAP participates in a variety of federal, state, and local support initiatives to advance patient quality and safety, its primary focus is delivering a high quality, educationally focused survey experience. TJC has been the American healthcare quality advocate for more than half a century with ongoing initiatives such as “Speak Up,” National Patient Safety Goals, Office of Quality Monitoring, Quality Check, Public Advisory Group, Business Advisory Group, Board representation, and public policy initiatives to help consumers and providers of healthcare.
Patient Safety CIHQ has embedded strong principles of patient safety into its standards, and use evidence-based best practices in helping hospitals identify potential risks to patient safety and subsequently develop risk mitigation strategies DNV supports the initiatives that hospitals have developed and implemented to guide safe patient care practices. DNV also supports and fosters innovations through development of hospital best practices but clearly understand that some practices do not suit all organizations. DNV believes that there are different avenues for achieving positive patient safety outcomes and the hospitals know their patient populations and resources best. HFAP incorporates safety standards from a variety of sources to reflect the broad national spectrum. Using the Medicare CoPs as a base and adapting such things as the NQF 30 safe practices and endorsing the Institute for Healthcare Improvement’s “5 Million Lives Campaign” HFAP accreditation standards include current patient safety initiatives throughout. TJC has a proven record of helping thousands of organizations address their patient safety problems, including the review of sentinel events. Collective learning from their experience has been shared with the broader healthcare community of organizations, such as through the publication of Sentinel Event Alerts. 
Goals of Organization CIHQ' goal and mission is to create a regulatory environment that enables healthcare organizations to effectively deliver safe, quality patient care. DNV has two major goals: to access compliance and educate hospitals in best practices. Hospitals can use innovation to develop new methods for producing positive results. DNV holds hospitals accountable to ensure that processes are planned, managed, measured, documented, and continually  improved. The HFAP goal is to continue to help healthcare facilities deliver high quality patient care through the application of its consistent standards while continuing to streamline and improve its survey processes. The goal is to help hospitals become “high reliability” organizations for delivering safe, effective care. TJC helps hospitals help patients to achieve continual progress toward quality healthcare.
Continuous Improvement CIHQ believes that hospitals are in the best position to determine for themselves an approach to continuous improvement. CIHQ does not prescribe a specific performance improvement methodology as a condition of accreditation, or dictate to the leadership of a hospital or medical staff how it will govern itself. DNV utilizes integrated standards from the internationally recognized ISO 9001 quality management system requirements. For more than 60 years, the HFAP has provided healthcare facilities with a reliable system of measurement for improving their processes enabling them to provide their communities with high quality patient care. They continue to evaluate their program to support the ever evolving healthcare environment. The heart of TJC’s “Gold Seal of Approval”™ centers on continuous improvement with employee involvement, enablement, and empowerment. For 50 years, TJC has been working together with healthcare providers on innovative solutions and new processes, such as the Standards Improvement Initiative and the Health Care-Associated Infection Compendium.



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