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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.

Joint Commission releases annual report on quality and safety

The Joint Commission has released its 2013 annual report on quality and safety, which also recognizes 1,099 hospitals as “top performer” organizations.

The report provides a summary of 3,300 Joint Commission-accredited hospitals on 47 accountability measures of evidence-based care processes.

The annual report can be found online here.

ASHE publishes comparison of accreditation organizations

The American Society for Healthcare Engineering (ASHE) has put together a nice piece on the various accreditation options available to hospitals following their annual conference in Atlanta. The ASHE piece cleanly discusses the existing options for accreditation with a strong engineering and life safety slant.

Editor’s note: the ASHE piece was published just moments prior to the CMS announcement that CIHQ had also received deeming authority for hospital accreditation, and the new accrediting body was not included in the original article.

You can find the original article on ASHE’s website here.

Live from New York at Executive Briefings!

Checking in from the 2014 Joint Commission Executive Briefings. Are you in attendance? Keep an eye out for your local AHAP representative…

The morning session provided a great wrap up of the year’s most problematic standards by Pat Adamski and George Mills in their annual side by side presentation. Ron Wyatt, MD, medical director for The Joint Commission’s Division of Healthcare Improvement wrapped up the first half of the day with a superior presentation on OPPE and FPPE. It was intriguing to see medical staff chapter issues represented as a focus at this year’s conference. The final session today will look at strategies to engage physician leaders and medical staff also.

More to follow as the day progresses!

FTC issues complaint over lack of information security

The Federal Trade Commission (FTC) released a complaint against LabMD, Inc. The complaint alleging that a lack of information security was an unfair practice under Section 5 of the FTC Act. The complaint stems from two incidents: personal information for approximately 9,300 consumers became available on a peer-to-peer or P2P file sharing network when a billing department manager installed the software on his computer for personal use; and law enforcement agents also found the personal information of hundreds of patients in the hands of identity thieves.

For more information on this incident, click here. 

Joint Commission leaders call for high reliability in hospitals

Too many hospitals and healthcare leaders currently experience serious safety failures as routine and inevitable parts of daily work, according to an article published last week in The Milbank Quarterly. In the article, authors Mark R. Chassin, MD, FACP, MPP, MPH, president and CEO of The Joint Commission; and Jerod M. Loeb, PhD, executive vice president for healthcare quality evaluation at The Joint Commission, urge hospitals to make the substantial changes necessary to achieve the ultimate goal of zero patient harm by adapting lessons from high-risk industries.

To prevent the harm that results from failures, which affects millions of Americans each year, Chassin and Loeb offer a framework for major changes involving leadership, safety culture and robust process improvement. The framework is designed to help hospitals make progress toward high reliability—defined as extremely high levels of safety maintained over long periods of time, and comparable to levels demonstrated by the commercial air travel and nuclear power industries, among others.

For more information, visit the Joint Commission’s website.

Standards proposed for new blood management certification program

The Joint Commission’s Laboratory Accreditation program announced earlier this month that it is developing a Patient Blood Management certification program for Joint Commission-accredited hospitals. The process of patient blood management involves bringing a patient-centered approach in the hospital to to the blood utilization activities as well as blood conservation.

For more information, visit here. 

CMS renews HFAP deeming authority

The Healthcare Facilities Accreditation Program (HFAP) has received its continued status as an accrediting organization for hospitals through CMS. The notification was posted in the August 28 Federal Register and goes into effect September 25, 2013.

Accrediting organizations must reapply for deeming authority at least every six years. This decision provides HFAP with deeming authority through September 25, 2019.

The decision can be seen here. 

Ten California hospitals fined for patient safety issues

The California Department of Public Health (CDPH) issued ten penalties this week to California hospitals–and fines totaling $675,000–after investigations found the facilities’ noncompliance with licensing requirements caused, or was likely to cause, serious injury or death to patients.

The penalties range for lack of compliance for everything from telemetry monitoring to cardiac catheterization processes, respiratory care and general patient safety.

Find more on the CDPH site here. 

Patient dumping scandal may cost accreditation

The Joint Commission has issued preliminary denial of accreditation for Rawson-Neal Psychiatric Hospital, a mental health facility in downtown Las Vegas, over a patient dumping scandal.

State officials with the Nevada Department of Health and Human Services have expressed disappointment in The Joint Commission’s decision, stating: “We are disappointed by the Joint Commission’s decision to move for a Preliminary Denial of Accreditation, which appears to be based on outdated survey information and is not an accurate reflection of the hospital’s current practices and policies.”

For more on this story, click here.