Making Sense of Regulatory Entities

Transcription

1 Making Sense of Regulatory Entities Diane Bradley, PhD, RN, NEA-BC, CPHQ,FACHE, FACHCA Regional Chief Clinical Officer HealthTech Management Services

2 Objectives The participants will be able to: Compare and contrast the CMS deeming authorities. Understand the importance of meeting standards relative to quality and patient safety. Develop a plan for continual readiness versus emergent readiness.

3 Who provides Health Care Accreditation? The Joint Commission (TJC) American Osteopathic Association s Healthcare Facilities Accreditation Program (HFAP) Center for Improvement in Healthcare Quality Det Norske Veritas (DNV)

4 Hierarchy Health & Human Services CMS CIHQ TJC DNV HFAP

5 Centers for Medicare & Medicaid Services A department of Health & Human Services Responsible for issuing the Medicare Conditions of Participation (CoPs) as a standard of care Hospitals are responsible for meeting the CoPs to obtain reimbursement for care rendered to Medicare beneficiaries

6 Deeming Authorities TJC DNV HFAP

7 The Joint Commission Oldest of the accrediting bodies; began in 1951 Standard development dates back to the early 1900s when the American College of Surgeons created its Hospital Standardization Program Formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Name changed in 2007 to The Joint Commission

8 Healthcare Facilities Accreditation Program (HFAP) Created in 1945 by the American Osteopathic Association specifically for osteopathic hospitals Extended their reach to include nonosteopathic hospitals

9 Det Norske Veritas DNV Healthcare (True North) Developed by Norwegian DNV which began in 1864 as a global entity Approved by CMS as a deeming authority in 2008 DNV Healthcare is an international accrediting body Surveys done annually Headquarters near Katy, TX

10 State Health Department Agency No requirement to be surveyed by one of the agencies outside of your respective State State agencies survey according to the CoPs to determine certification to participate Use the Medicare State Operations Manual (SOM) to determine compliance with minimal standards

11 New Accrediting Body Center for Improvement in Healthcare Quality (CIHQ) Granted deeming status July 26,2013 Formerly a consulting company for accreditation and regulatory compliance support established in 1999 Can accredit acute and critical access hospitals Headquartered in Round Rock, TX

12 TJC Goal The goal is to help hospitals become high reliability organizations for delivering safe, effective care. The Joint Commission helps hospitals help patients to achieve continual progress toward quality healthcare.

13 TJC s CAMH Chapters Accreditation Participation Environment of Care Human Resources Infection Prevention Information Management Medication Management Medical Staff Nursing Provision of Care Performance Improvement Patient Rights Emergency Management Life Safety National Patient Safety Goals Record of Care Transplant Safety Waived Testing

14 What s special about TJC? The Joint Commission (TJC) 1. Well known since Fulfill regulatory and payer requirement 3. Provide education and guidance 4. Improve risk reduction 5. Marketing 6. Enhance patient safety

15 Considerations Cost (around $33,000) Poorly aligned with the CoPs Proprietary Standards, e.g. NPSG Prescriptive standards Complex scoring methodology with aggregate scoring that may impact the organization s accreditation status

16 DNV Goals 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.

17 DNV s NIAHO* Chapters *National Integrated Accreditation for Healthcare Organizations (DNV 2004) Quality Management System Governing Body Chief Executive Officer Surgical Services Anesthesia Services Laboratory Services Respiratory Care Services Medical Imaging Nuclear Medicine Services Rehabilitation Services Obstetrics Services Emergency Department Patient Rights Medical Records Services Discharge Planning Utilization Review Physical Environment Organ, Eye and Tissue Procurement Outpatient Services Dietary Services Medical Staff

18 What s special about DNV? Det Norske Veritas (DNV) 1. Approved in United States since Fulfill regulatory and payer requirement 3. Provide education and guidance 4. Improve risk reduction 5. Focus on quality outcomes

19 Considerations Cost (around $23,000) Closely aligned with CoPs Have recently added some proprietary standards Survey is completed annually; continual readiness Use ISO9001 in Years 3 & 4

20 HFAP Goal 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

21 HFAP Chapters Compliance with Federal, State and local laws Patient Rights Quality Assessment-PI Medical Staff Nursing Services Medication Administration Medical Record Services Patient Records Rehabilitation Services Respiratory Services Pharmaceutical Services Radiological Services Laboratory Services Food & Dietetic Services Utilization Review Environment Infection Control Officer Discharge Planning Organ, Tissue & Eye Procurement Surgical Services Nuclear Medicine Services Emergency Services

22 What s special about HFAP Healthcare Facilities Accreditation Program (HFAP) 1. Strictly adhere to CoPs 2. Standard changes are infrequent 3. When changes occur, the updates are provided for free to HFAP clients 4. Defined methodology (CARE) 5. Fee is all-inclusive (around $27,000)

23 Considerations Cost Moderately complex scoring system HFAP does not have the brand recognition due to the original focus on osteopathic hospitals Benchmarking data library is lacking

24 Validation Surveys There are two types of validation surveys: 1. surveys conducted on a representative sample basis, which may be either comprehensive surveys of all Medicare conditions or focused surveys on a specific condition or conditions; or 2. surveys in response to a "substantial allegation" generally a complaint. These surveys focus on those Medicare conditions related to the allegations.

25 Pros & Cons PROs Accreditation indicates the organization has met the minimal standards TJC often viewed as the Gold Standard Competition between deeming authorities Continual readiness Continual improvement CONs Are minimal standards sufficient today? Cost dollars and resources associated with preparing for survey Sometimes confusing if there are proprietary standards + CoPs Lack of frequency for State agencies to conduct survey Surveyed too frequently

26 What to do? Discuss what is the consensus in your organization? Remember, compliance with the CoPs is the only requirement Is the financial investment an option for your organization? What does private accreditation mean to your constituents? Do they know who TJC, DNV, or HFAP are?

27 Questions

28 References Centers for Medicare and Medicaid Services. cms.gov The Joint Commission. jointcommission.org Vallejo, BC et al. A comparison of hospital accreditation programs. Jan/Mar 2011 Health Law News. A comparison of hospital accreditation organizations. July 13, 2012 Horty Springer. Question of the week. May 23, 2013