Accreditation Susan Proctor RN BSN MBAHCM Why Accreditation CMS grants Accrediting Organizations deeming authority to certify compliance with Conditions of Participation CoP An organization that is accredited by a deeming authority has deemed status ID: 573966
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Slide1
HealthcareAccreditation
Susan Proctor, RN, BSN, MBA/HCMSlide2
Why Accreditation?
CMS grants Accrediting Organizations “deeming authority” to certify compliance with Conditions of Participation (
CoP
)
An organization that is accredited by a deeming authority has “deemed status”
Deemed status – not subject to routine CMS certification surveys
No deemed status – under State Authority
Medicare/Medicaid paymentSlide3
Accreditation Options
The Joint Commission (all services)
DNV GL Healthcare: National Integrated Accreditation for Health Care Organizations (
NIAHO
)- Hospital & ISO 9001- any service
Healthcare Facilities Accreditation Program (HFAP) – Hospital
CIHQ (deemed 2013) – Hospital
Accreditation Commission for Health Care (ACHC)– Home Health
Accreditation Association for Ambulatory Health Care (AAAHC) – Leading Clinic/Medical Home Accreditor
CMS does not allow deeming for LTC & Dialysis
Laboratory Point of Care – MO DHSS CLIA certification or CAPSlide4
Disease Specific Certifications
Services must be TJC accredited to qualify for TJC certification
No literature to support cost/benefit advantage
A program can implement best practice without the cost of formal certification
DNV GL certifications
: Comprehensive/Primary
Stroke,
Managing Infection
Risks,
Orthopedic
,
Ventricular Assist
Device.
Diabetes and
Heart Failure
under development for DNV GLSlide5
What is the Culture of Accreditation?
Creates a lot of fear for the hospital staff
Punitive thinking
“Preparing” for the survey – ramp up.
The Accreditation Exercise
“Just Fix It” thinking
Not being able to sustain improvements
made
“
We are what we repeatedly do;
excellence, then, is not an act but a habit.”
-
AristotleSlide6
What is DNV GL
Risk Management company founded in 1864 – Manage risk in 10 industries worldwide
United States since 1898
One of the World’s Top 3 certification bodies
DNV GL Healthcare located in Ohio
CMS Deeming authority 2008 with recent recertification 2014 through 2020Slide7
Reported Outcomes: Transformation
Paradigm shift - gaining accreditation to constant improvement
Outcomes focused & Organization driven
Improved communication between leaders, physicians, and staff
Accreditation becomes a management asset for quality, patient safety, and customer satisfaction improvement instead of the burden of “something more to do”Slide8
What does DNV GL do differently to enable change?
Stable standards, infrequent change
Annual Surveys
Gradual introduction to the ISO 9001:2015 standards
Focus on sequence/interactions of all hospital
processes
Demeanor of survey team
No tipping point (number of survey findings)
Not just the basics but a focus on the fundamentals rather than the extraordinary
There are different ways of meeting requirements
Rationale for the standardSlide9
What is the benefit of annual surveys?
Accreditation and the assessment of the organization is a snapshot
Refocusing resources of the organization
Corrective and Preventive Actions / Internal Audits facilitating this process
Continual improvement
Fostering the habit and more sustainabilitySlide10
ISO MYTHS
ISO 9001 IS applicable to hospitals
ISO 9001 IS all about quality improvement
ISO 9001 is NOT about
an “ISO Format/Structure”
ISO 9001 is NOT a bureaucratic nightmare
ISO 9001 is NOT very costly and time-consuming to put in place
ISO 9001 ENCOURAGES creativity and innovation
ISO 9001 SUPPORTS Lean and Baldrige CPE implementationSlide11
Focus on sequence and interaction of process,
all hospital processes…
Understanding the processes – from paper to reality
Support processes seem to get lost in the survey process
Helps
in breaking down the silo effect?
The basic premise of ISO 9001…
Document what you do
(Policies, Procedures, Protocols, Work Instructions)
Do what you document
(How we carry out these processes?)
Prove it
(How have we demonstrated we follow what we say we will do?)
Improve it
(How do we change, fix, enhance, innovate?)Slide12
The DNV GL Survey Team
They are people and
they
look for certain qualities beyond the credentials (Qualified)
They are approachable (Demeanor)
They want to help not hinder (Engage)
They do care about your staff and your patients
Being a partner not adversarySlide13
No Tipping Point/Accreditation Status
Labeling of the accreditation
Conditional Accreditation, Preliminary Denial… What is the difference?
DNV GL findings (nonconformance) include:
NC-1 CL (Condition Level)
NC-1
NC-2
Findings require corrective action plans, no matter the number
Findings… optimist or pessimist perspective
Prioritizing the importance of attention of the organization is done by category
Some actions require some additional time but something has to be done in the interim
Follow
up
Reducing the anxiety to increase the openness. Slide14
CMS
CoPs
and ISO Integration=NIAHO Standards
Because of ISO 9001 . . . NIAHO connects
compliance
and
quality
into one seamless activity.
A systematic approach to managing quality
Evolved from a set of ‘Conformance’ requirements into an effective ‘
Business Management
’ process
Focus is now on Continual
Improvement
ISO is about Consistency, Customer, (patient) focus & Continual Improvement not
PERFECTION
DNV-GL is looking for compliance to the standards;
they are
not coming to play “
Gotcha
” games
Survey findings are not necessarily a bad thing
Once issues have been identified they can be improved
The actions you take should impact your patients’ care and experience in a positive way
Develop your system in a way that works for you, your staff, your medical staff and your patient’s,
NOT
just to please a survey team.Slide15
Nationwide momentum: A
few
of our customers
400+ hospitals
106 ISO certified
Harris
Health System
Florida
Hospital
Sentara
Health System
The Methodist
Hospital System
St. Luke’s
Episcopal Health System
Upstate
University Hospital (SUNY)
Lee Memorial
Health System
Advocate
Trinity Hospital
Hoag
Memorial Hospital Presbyterian
Phoebe Putney
Health System
Jersey City
Medical Center
North Vista
Hospital
Hays
Medical Center
Seattle
Children’s Hospital
Asante Rogue
Regional Medical Center
Mountain Vista
Medical Center
Holy Cross
Hospital
Madison
Memorial Hospital
Campbell County
Memorial Hospital
Henry Ford
West Bloomfield Hospital
North Memorial
Medical Center
Bellin
Memorial Hospital
Ingalls
Memorial Hospital
Iowa
Lutheran Hospital
Landmark
Hospital
PeaceHealth
Medical Center
Forrest General
Hospital
Olympia
Medical Center
Verdugo Hills
Hospital
Ridgecrest
Regional Hospital
Phelps
Memorial Health Center
McAlester
Regional Medical Center
Jordan Valley
Medical Center
Hardin
Medical Center
ContinueCare
Hospital
Union
Hospital
Premier
Surgical Institute
Pikes Peak
Regional Hospital
Lovelace
Medical Center
San Juan
Regional Medical Center
Flagstaff
Medical Center
Exeter
Hospital
ACCREDITATION
PRIMARY STROKE CENTER
ISO 9001
COMPREHENSIVE STROKE CENTER
Ridgeview
Medical Center
Univ
of Utah
Clinton Hospital
Umass
MemorialSlide16
QUESTIONS