Accreditation

JCAHO Surveys - Interviews w/ Leaders

-CEO/person responsible for strategic planning and resource allocation -medical staff leaders -nursing leaders -hospital department directors

JCAHO Surveys - Document Review

-committee minutes -reports of measurement and assessment activities -reports to medical staff, hospital committees, and governing body -bylaws, planning documents, and other evidence of performance

JCAHO Activities

-develop performance standards -provide accreditation services -make educational and consultative support available -include outcomes and performance measures into accreditation -disclose performance information to interested parties *Can do mock interviews before *Support available, not free, but good service

CARF Activities

-develop standards that improve programs and services -recognize accredited organizations -conduct accreditation research on outcomes -provide consultation, education, training to support programs -provide info and education to consumers

CMS Survey & Guidance

-drives all surveys and accrediting bodies -no cost to have -surveys provided by state team of surveyors -deemed status authority and insurance -"crosswalks" to follow if deemed status *If very good, prob won't see for another 36 months -diff manuals for diff areas of practice -hard copy and electronic -foundation for all care and reimbursement -dealing w/ complaints

JCAHO Surveys - Visit to Settings

-environment of care -infection control -client care -staff communications -client right issues

What CHAP Accredits

-home health (deemed and non-deemed) -hospice (deemed and non-deemed) -home medical equipment -pharmacy -private duty -infusion therapy nursing -public health -community nursing centers -supplemental staffing services *Only accredits community-based orgs

JCAHO Organizations

-hospitals (general, psych, rehab and peds) -healthcare networks (HMOs, PPOs) -home care -nursing homes and long-term care -critical access hospitals

JCAHO Surveys - Function Interviews

-medication use/nutrition care -anesthesia invasive proc. -infection control -human resources and medical staff credentials -client and family education -performance improvement -client care -ethics -continuum of care -info management

ACHC Info

-only national healthcare accrediting org started at grass-roots level by a few home care providers endeavoring to create viable option of accreditation sensitive to needs of small providers -mid 2000s CMS granted deemed status for home care, hospice and DME providers -surveys similar to JCAHO, CHAP, CARF

JCAHO Surveys - After Process

-organizational reports given electronically after survey and publicly disclosed -Requirements for Improvement (RFIs) -Type I recommendations - unsatisfactory compliance (remedied in given timeframe; submission of acceptable evidence of standards compliance (ESC) plan) -Supplemental recommendations (remedied by next review)

CARF Survey

-similar to JCAHO -team of surveyors examines services -outcomes (3 year, 1 year, provisional, nonaccreditation, preliminary, accreditation w/ stipulations) *If nonaccredited you've lost money and they will come back tougher *These are businesses and you are asking them to eval you

CHAP Survey

-similar to JCAHO and CARF -team of surveyors examines services -outcomes -plan of correction -deemed status -every 3 years

JCAHO Surveys Cont'd

-survey planning session -opening conference and orientation to organization -leadership session -trader methodology -competence assessment process -environment of care session (includes building tour) -exit conference

JCAHO Surveys

-unannounced**18-36 months after full survey three years -always be ready -data drive -client-cenered and evaluating actual care process -demonstrate consistent performance (12 months) -interdisciplinary approach -collaborate w/ consumers, professional organization and colleagues -be prepared for questions

ACHC

Accrediting Commission for Home Care

CHAP Goals

Assist all types of community-based healthcare orgs to: -strengthen internal operations -promote continuous quality improvement techniques and systems -promote consumer safety, satisfaction and outcomes -affirm public trust -meet community health needs in cost efficient and effective manner -maintain the viability of community health practice nationwide *Think triple-aim, the whole initiative of healthcare

CARF

Commission on Accreditation of Rehabilitation Facilities

CHAP

Community Health Accreditation Program

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

JCAHO Standards

Patient-focused functions -rights and organization ethics -assessment -care -education -continuum of care Organizational Functions -improving organizational performance -leadership -management (info, HR, environment) -surveillance, prevention and control of infections *Ethics is current #1 they look for