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Healthcare Quality and Accreditation

The issue of safe, high-quality care is foremost in the minds of healthcare consumers and healthcare workers across all settings. For more than a decade, a vigorous national effort has attempted to better define care processes and outcome measurements that are predictive of quality. This endeavor has been advanced through the work of expert panels convened by the Institute of Medicine, as well as the contributions of the National Quality Forum and other expert consortia.

Healthcare workers know that the essential structural components of high-quality care must be better quantified, continuously evaluated and strongly enforced. Healthcare structure refers to various components of the settings in which providers deliver care. Those components include: material resources (electronic health records), human resources (staff expertise, staffing levels) and organizational structure (hospitals, home health).

Healthcare Quality: The right care for every person every time has become the widely accepted definition of quality since it was adopted by the federal Centers for Medicare and Medicaid Services.

How is quality of care measured? In the United States, the primary mechanism for evaluating quality of care is the accreditation process required by the Centers for Medicare and Medicaid Services (CMS). This system is administered by a variety of public and private accrediting bodies working across many healthcare settings. CMS has defined the specific criteria that guide the evaluation of safety and quality. These standards are known as the Conditions of Participation (CoPs) and the Conditions for Coverage (CfCs). These minimum health and safety requirements are the foundation for improving quality and protecting the health and safety of care recipients. In order to participate in Medicare or Medicaid, healthcare facilities must meet (or exceed) the conditions specified in these federal regulations. The CoPs for hospitals can be found at: http://www.access.gpo.gov/nara/cfr/waisidx_04/42cfr482_04.html. The CfCs for all other healthcare settings are at: http://www.cms.hhs.gov/CFCsAndCoPs/06_Hospitals.asp.

While participation in Medicare and Medicaid is voluntary, not-for-profit care providers are required to serve Medicare and Medicaid beneficiaries as a condition for receiving federal tax exemptions granted for providing healthcare to the community. Medicare and Medicaid account for 56 percent of all care provided by hospitals, and Medicare payments provide about 20 percent of hospitals’ revenue and 70 percent of long-term care hospitals’ revenue. Consequently, very few hospitals elect not to participate. Organizations seeking Medicare approval may choose to be surveyed either by state survey agencies on behalf of CMS, or by a private accrediting body such as the Joint Commission (formerly, the Joint Commission on Accreditation of Healthcare Organizations).

In 1965, at the time the Medicare and Medicaid insurance programs were established, Congress determined that agencies other than CMS would be allowed to perform accreditation surveys. Through a process known as “deeming,” CMS ensures that the standards of the private accrediting organizations that it recognizes meet or exceed the Medicare criteria. While the primary responsibility for safety and quality of care ultimately lies with CMS, all accrediting organizations have a responsibility to Congress to assure that any facilities receiving Medicare or Medicaid reimbursement are in compliance. State agencies do not conduct routine surveys to recertify facilities with “deemed” status unless a complaint is registered or a severe quality issue arises. However, all states do have their own licensing regulations that healthcare facilities must meet and which are often very similar to those found in the federal CoPs. In essence, then, all facilities must meet federal and state requirements at a minimum, in addition to the standards developed by private accrediting organizations. As a result, there is a hierarchy of regulations and standards against which each facility can be evaluated: federal, state and private. And, at each level, the standards must always meet or surpass the level above.

Where quality concerns arise, nurses and other healthcare workers may want to report their facility to the appropriate state agency or accrediting body. Reporting such issues is something that should be done in concert with other personnel in the facility or in conjunction with a local bargaining unit, rather than as an individual. Status as a part of a larger group, or as part of a union, will provide some measure of protection against retribution. Contact information to help you find your own state regulations for hospital licensure and to make those reports is listed in the resources section of this document.

Accrediting Organizations:

There are currently three organizations with deeming authority to accredit hospitals, although there are additional organizations that accredit other types of healthcare facilities. Unlike the federal CoPs, accreditation standards for each of these organizations are not publicly available—making it difficult for healthcare workers to know if their facilities are in compliance with their accrediting organization. Unfortunately, the regulations within the CoPs are not proscriptive. However, those conditions are the minimum requirement and can be reviewed, along with state regulations, as a basis for determining the need to report a facility when staff members become aware of quality issues.

The Joint Commission
(formerly the Joint Commission on Accreditation of Healthcare Organizations)
The Joint Commission is a private, not-for-profit accrediting organization that provides standards, survey evaluations, sentinel event alerts and professional consulting services to healthcare organizations, and accredits a majority of hospitals (over 90 percent) nationwide. Overall, the commission evaluates and accredits approximately 18,000 healthcare organizations, including hospitals, ambulatory surgery centers, healthcare networks and clinical laboratories. Facility accreditation through the Joint Commission is based on the standards contained in the organization’s Comprehensive Accreditation manual. Accreditation surveys are conducted every one to three years, and the Joint Commission’s deeming status is in effect until July 2014. For more information, follow this link: http://www.aft.org/pdfs/healthcare/jcahoupdate05.pdf.

American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP)
Originally created in 1945 to conduct an objective review of services provided by osteopathic and allopathic hospitals, HFAP has maintained its deeming authority continuously since the inception of CMS in 1965. The program meets or exceeds the standards required by CMS/Medicare to provide accreditation to all hospitals, ambulatory care/surgical facilities, mental health facilities, physical rehabilitation facilities, clinical laboratories, critical access hospitals and stroke centers. Over 200 hospitals have HFAP accreditation. HFAP surveys are unannounced and take place every three years. Accredited hospitals are listed at: http://www.hfap.org/AccreditedFacilities/index.aspx?FacilityType=HOSPN.

Det Norske Veritas
Det Norske Veritas (DNV) is the newest healthcare accreditation business and a newly approved accreditation alternative. DNV received its deeming status from Congress in 2008. DNV has a relatively small share of hospital subscribers (fewer than 30) and has developed the National Integrated Accreditation for Healthcare Organizations (NIAHO℠) program survey standards, which combine ISO 9001 quality management (international standards) with Medicare’s CoPs for Hospitals. Hospitals subscribing to DNV undergo annual accreditation evaluations. DNV’s deeming status is in effect until Sept. 26, 2012. More information can be found at http://www.dnv.us/industry/healthcare/hospital_accreditation/index.asp.

Resources :

For state agency contacts to find state licensing regulations or to report unsafe conditions, visit: http://www.cms.hhs.gov/SurveyCertificationGenInfo/Downloads/State_Agency_Contacts.pdf.

To report a complaint to the Joint Commission about an unsafe condition in one of its accredited hospitals, follow this link: http://www.jointcommission.org/GeneralPublic/Complaint/.