2/15/2015 HEALTHCARE ACCREDITATION: WHAT IT MEANS TO YOU HEALTHCARE ACCREDITATION WHAT IT MEANS TO YOU

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1 HEALTHCARE ACCREDITATION: WHAT IT MEANS TO YOU D avid G o u rley, R R T, MH A, FAAR C E xecu tive Directo r, Regulatory Affairs Chilton Hospital Po m p ton Plains, New Jersey HEALTHCARE ACCREDITATION: WHAT IT MEANS TO YOU What is accreditation? History of accreditation Center for Medicare and Medicaid Services (CMS) Medicare Conditions of Participation (CoPs) CoPs Respiratory Services Related CoPs Hospital accreditation Home Medical Equipment accreditation The Joint Commission National Patient Safety Goals HEALTHCARE ACCREDITATION A process in which an entity, separate and distinct from the healthcare organization, usually nongovernmental, assesses the healthcare organization to determine if it meets a set of standard requirements designed to improve quality of care. Organization-wide evaluation of care, processes, and functions Focus on quality of care and patient safety Voluntary process 1

2 Highlights of Hospital Standards Development 1918 ACS sets minimum standards 1945 AOA introduces survey program 1951 Joint Commission forms 1966 AOA granted deeming authority 1986 CoPs expanded 2004 JCAHO launched Shared Vision, New Pathways Federal govt. sets standards of maternity and child care 1946 Hill-Burton Act for hospital upgrades 1965 Medicare legislation enacted 1972 Congress requires validation of JCAHO findings 1997 New CoPs create QAPI program CMS Federal agency that oversees Medicare, Medicaid, and Children s Health Insurance Program (CHIP) Formed in 1965 by President Lyndon Johnson Medicare established to cover those 65 and older Expanded to disabled (2 years or greater) and End stage renal disease (ESRD) in 1972 CMS Health Care Financing Administration (HCFA) established to administer Medicare and Medicaid in 1977 Quality oversight through Peer Review Organization (PRO) implemented in 1982 Prospective Payment System (DRG) implemented in 1983 HCFA renamed CMS in 2001 Medicare Modernization Act signed in 2003 Prescription Drug Plan Competitive bidding for Home Medical Equipment Patient Protection and Affordable Care Act (2010) 2

3 Center for Medicare and Medicaid Services (CMS) President of the United States Barack Obama Secretary of Health and Human Services Kathleen Sebelius CMS Administrator Donald Berwick, MD CMS Organizational Chart MEDICARE CONDITIONS OF PARTICIPATION (COP) Required for hospitals to receive Medicare and Medicaid reimbursement May choose accreditation by deemed agencies or CMS survey CMS survey performed by state licensing agencies (Dept. of Health) Focus on health, safety, and quality Surveys are unannounced and conducted every three years 3

4 MEDICARE CONDITIONS OF PARTICIPATION (COP) Governing Body Patient Rights QA/PI Medical Staff Nursing Services Medical Record Services Pharmacy Radiology Services Laboratory Services Food & Dietetic Services Utilization Review Physical Environment Infection Control Discharge Planning Organ Procurement Surgical Services Anesthesia Services Nuclear Medicine Services Outpatient Services Emergency Services Rehabilitation Services Respiratory Care Services CMS OVERSIGHT The hospital must meet the needs of the patients in accordance with acceptable standards of practice. The following requirements apply if the hospital provides respiratory services. Optional hospital service Comply with acceptable standards of practice (AMA, AARC, ATS) Must be integrated with hospital wide QAPI 4

5 Survey procedures: Determine if the hospital provides any degree of respiratory care services Determine that the type and amount of RC meets the needs of the patients and is delivered in accordance with standards of practice Determine if RC is integrated into hospital-wide QAPI program (a) Standard: Organization and Staffing The organization of the respiratory care services must be appropriate to the scope and complexity of the services offered. Hospital must provide appropriate equipment and qualified personnel Scope of diagnostic and/or therapeutic RC defined in writing and approved by the Medical staff Survey procedures: Review org chart to determine respiratory care s relationship with other services Review P&P to verify scope of diagnostic and therapeutic services is defined in writing 5

6 (a) (1) Medical Director Must be MD or DO Fixed lines of authority and responsibility Knowledge, experience, and capabilities to supervise and administer the service Full time or part time Survey procedures: Verify that director has been appointed and fixed line of authority and delegated responsibility for operations Interview staff regarding role and oversight activities Review director s credentialing file (a) (2) Adequate number of RTs who meet qualifications specified by Medical Staff, and state law Must be sufficient personnel to respond to RC needs of patient population served 6

7 Survey procedures: Interview RT staff regarding services, schedules, availability of staff, assess appropriateness for volume and type of treatments Review sample of RC personnel files to assess qualifications (b) Services must be delivered in accordance with Medical Staff directives. Written policies for delivery of RC services that are developed and approved by the medical staff. Written policies should address specific topics Equipment assembly, operation, and PM Safety practices, IC measures, biohazard waste, gas line ID Handling, storage, & dispensing med. gases CPR Adverse reactions to treatments PFTs Therapeutic percussion & vibration Bronchopulmonary drainage Mechanical ventilation Aerosol, humidification, and gas administration Storage, access, control, administration of meds and med errors Obtaining/analyzing ABGs 7

8 (b) (1) Personnel qualified to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures must be designated in writing Written policies to address: Type of RC services provided Qualifications, including job title, licensure, education, training, experience, and whether with or without supervision Type of personnel qualified to supervise Survey procedures: Review treatment logs, job descriptions, and policies and procedures Determine: Duties and responsibilities of staff Qualifications and education, licensure Specialized training or experience (b) (2) If blood gases or other clinical laboratory tests are performed in the RT unit, must meet applicable requirements for lab services specified in CoP Refer to guidelines for independent laboratories 8

9 (b) (3) Services must be provided only on, and in accordance with, orders of MD or DO. Review medical records of patients receiving RC services to verify that services are provided only upon the orders of a physician, and that services are provided in accordance with those orders RELATED COP S (e) Governing Body Contracted Services All contracted services must be in compliance with CoPs Mechanism must be in place to evaluate quality Must be integrated into QAPI Delineation of contracted services needed RELATED COP S (d) Governing Body Confidentiality of Patient Records Posted information must not be accessible to visitors or non-hospital staff Medical records must be not be accessible to visitors or non-hospital staff Clinical information must not be left at bedside 9

10 RELATED COP S (c) Medical records content Medical records must contain: Description of patient response to medications Description of patient response to services, such as interventions, care, and treatment RELATED COP S (b) (2) (i) All drugs and biologicals must be kept in a secure area, and locked when appropriate Secure area means stored in a manner to prevent unmonitored access by unauthorized individuals Areas with restricted access would be considered secure Mobile medication carts must be locked in a secure area when not in use Hospital Accreditation 10

11 HOSPITAL ACCREDITING BODIES The Joint Commission (TJC) Based in Oakbrook Terrace, Illinois Accredits approximately 88% of hospitals in U.S. American Osteopathic Association (AOA) Based in Chicago, Illinois Accredits approximately 5% of hospitals in U.S. Det Norske Veritas (DNV) Based in Oslo, Norway Accredits approximately 7% of hospitals in U.S. THE JOINT COMMISSION (TJC) Established in 1951 Largest healthcare accrediting body in the world Deemed in original Medicare legislation to accredit for CMS (formerly HCFA) Accredits hospitals, home care, long term care, ambulatory care, behavioral health, laboratory services AMERICAN OSTEOPATHIC ASSN. (AOA) Healthcare Facilities Accreditation Program Established in 1945 Deemed by CMS since 1966 to accredit hospitals, clinical laboratories, and other healthcare facilities One NJ hospital system accredited Kennedy Memorial Hospital (3 locations) 11

12 DET NORSKE VERITAS (DNV) Healthcare division granted CMS deeming privileges in 2008 Six NJ hospitals accredited Meadowlands Hospital Saint Joseph s Regional Medical Center Columbus Hospital LTACH South Jersey Healthcare System (2 hospitals) Acuity Specialty Hospital HOME MEDICAL EQUIPMENT (HME) ACCREDITATION Required by CMS since Sept Ten accrediting organizations approved by CMS Based on CMS DMEPOS Quality Standards Unannounced survey process Accreditation in effect for three years HOME MEDICAL EQUIPMENT (HME) ACCREDITATION Accreditation Commission for Healthcare American Board for Certification in Orthotics and Prosthetics Board of Certification/ Accreditation International Commission on Accreditation of Rehabilitation Facilities Community Health Accreditation Program Healthcare Quality Association on Accreditation National Association of Boards of Pharmacy The Compliance Team The Joint Commission National Board of Accreditation for Orthotic Suppliers 12

13 THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Released by The Joint Commission, starting in 2003 Based on sentinel events identified and reported Applicable to all sites of care, as appropriate Reviewed annually Some goals become embedded in TJC standards THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Identify patients correctly Use at least two forms of identification Must be performed for all medication administration and testing/treatments Room number cannot be used Specific procedure for blood transfusion THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Improve staff communication Critical tests/critical values Identify critical tests Specify critical values (panic values) Establish appropriate timeframe for MD to be notified Document MD notification Monitor compliance 13

14 THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Medication safety Label all medications Includes syringes, basins, cups Anticoagulation therapy THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Prevent infections Comply with hand hygiene guidelines Implement guidelines for resistant infections, central line infections, and surgical site infections THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Medication reconciliation (effective 7/1/11) Document medications on admission Assess for therapeutic duplication Prevents missed doses Provide list to next caregiver upon transfer Provide list to patient/family on discharge 14

15 THE JOINT COMMISSION (TJC) NATIONAL PATIENT SAFET Y GOALS Identify patient safety risks in the environment Suicide risk (Hospital) Home fires with oxygen (Home care) HEALTHCARE ACCREDITATION Questions??? 15

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