November 20, 2013 | | Comments 0
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A look at the future of accreditation

AHAP’s own Jodi Eisenberg was recently interviewed on the changing world of accreditation. AHAP has been given permission to reprint the contents of that Q and A below.

Q: The fall is always a big, looking-ahead period in accreditation as The Joint Commission holds its annual Executive Briefings conferences. What do you anticipate will be big topics in 2014 for The Joint Commission and other accrediting bodies?

JE: I’m hopeful there won’t be many substantive standards changes, and I anticipate that most of the changes will be to the survey process. I believe The Joint Commission has been working hard to streamline its survey processes and ensure consistency from surveyor to surveyor.

For the field, this has been good news. Over the years, the annual meeting has evolved from reporting changes to standards into a forum to discuss problematic standards. This is an opportunity for those of us in the field to provide input into potential resolutions to the problems, and for the accrediting bodies to share best practices and processes that have helped move organizations to compliance.

For example, there continues to be findings under Life Safety relative to firewall penetrations. Organizations that have taken the hint and fully implemented an “above ceiling work permit” process have seen the number of penetrations drop, getting closer to overall control of the process. These standards are written for organizations of all sizes, and it is important for larger organizations with more resources to share their knowledge with smaller organizations. By doing this, we are collectively improving healthcare across the country. This annual meeting is a good forum for us to provide and receive that information.

As for the other accreditation agencies, I think they are all looking at each other, as well as to CMS, to identify ways to differentiate themselves in a positive way as accrediting leaders in the field. In the end, it all boils down to the CMS Conditions of Participation. My hope is that we will continue to hear how these accrediting bodies are working with CMS to align standards, patient safety initiatives and survey processes so that “bottom line” patient care is provided in a safe and effective manner.”

Q: There have been a lot of big changes in the field in the past year. How do you think the increased number of accrediting organization options has altered the landscape of hospital accreditation?

JE: My hope is the more accrediting bodies that connect with and work with CMS and healthcare organizations to advocate for safe and effective care, the better it will be for all patients in any healthcare setting. The ultimate goal is to push healthcare organizations to embed foundational standards and continuous survey readiness into their organizations and daily operations so that accreditation is seen as less of an event and more of a validation of the safe and effective care organizations provide every day.

Additionally, the more accrediting bodies in the field … the hope would be that we would continue to see positive changes at CMS due to the advocacy of these accrediting bodies. Some of our federal regulations and many of our state regulations are antiquated and in need of update. The more voices pushing and advocating for current regulations – and regulations that support safe, efficient and effective patient care – the better.

Q: Disease-specific program accreditation has come a long way in the past few years. How do you feel these programs and options have changed or improved since they first arrived on the scene?

JE: I’m a bit ambivalent about the disease-specific certification programs. I’m not entirely convinced that they bring added value to the organization. But, do we need a certification survey to push us to do the right thing for our patients? I would encourage organizations to take a strong look at whether the disease-specific program (DSP) is necessary and adds value. For those DSPs that are tied to reimbursement, such as Ventricular Assistive Device Certification and Lung Volume Reduction Surgery Certification, the value is in the qualification to be reimbursed. Advanced Primary Stroke and Comprehensive Stroke Certification are programs where the market is primarily driving certification. Again, organizations have to determine individual value and return on investment.

Having said that, I do believe these DSP standards can bring a level of consistency in practice across organizations, which is a good thing and of benefit to patients. Therefore, regardless of whether an organization is going to move forward with DSP or not, I think it is valuable to use the standards to establish a foundation for new programs or to assess the status of an existing program. As a result, organizations will also strengthen their overall compliance with hospital regulations and standards, helping to build compliance into operations across and throughout their organization.

Q: We’ve seen a real culture shift in The Joint Commission’s approach to surveys in the past few years. How has this impacted your work as an accreditation specialist?

JE: Culture shift or response to their customers? I believe The Joint Commission is listening to healthcare organizations. I also believe that healthcare organizations are more vocal. They have limited resources and most are in this business to take care of patients safely, effectively and efficiently. Culture shift or not, this is a positive change and in my mind the biggest benefit will be directed toward the patient. This shift can also be attributed to the fact there are more deeming authorities and healthcare organizations have more of a choice.

To be honest, this particular aspect hasn’t impacted my work significantly as an accreditation specialist. While it has likely opened up opportunities for communication and collaboration between healthcare organizations and The Joint Commission, and this can be viewed as a definite benefit to accreditation specialists, I believe that each and every day, we need to be ready to care for patients regardless of who is accrediting our organization.”

Q: What do you perceive as the biggest challenge moving forward for accreditation specialists?

JE: The healthcare regulatory front is changing rapidly; keeping up with the changes is challenging. Over the past three to five years, I have seen more changes from CMS relative to the Conditions of Participation than I have in the 10 years prior. Keeping track of the changes; implementing changes to policies and practices within healthcare organizations; and helping staff and management understand the reasons, benefits and the impact of these changes is always challenging. Organizations across the country are trying to balance limited resources to ensure they are being utilized effectively and efficiently – accreditation is just one aspect of operations.

Jodi Eisenberg, MHA, CPHQ, CPMSM, CSHA, is the program manager of accreditation and clinical compliance at Northwestern Memorial Hospital in Chicago. She is responsible for leading the full range of Joint Commission and other accreditation and regulatory compliance activities, including organization of continuous compliance activities for Joint Commission and other regulatory agencies. Eisenberg has authored, co-authored, edited and contributed to several HCPro, Inc. books and training programs including The Joint Commission Survey Coordinator’s Handbook. She has also served as an expert trainer for Accreditation Specialist Boot Camp. Eisenberg’s evolution in healthcare administration began in medical staff services and quality. She holds a master’s degree in Healthcare Administration from the University of St. Francis.

Note: The ideas and opinions expressed in this article are in no way linked to those of Northwestern Memorial Hospital.

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About the Author: Matt Phillion is the director of the Association for Healthcare Accreditation Professionals and a Senior Managing Editor at HCPro, Inc., where he is the editor of the monthly publication Briefings on The Joint Commission.

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