Survey Activity
Accreditation is an official authorization or approval, or recognition of conforming to standards. Is accreditation required?
Accreditation is voluntary and granted by private sector organizations.
What is the SAFER Matrix?
A report from the Joint Commission that provides organizations with the information they need to prioritize resources and focus corrective action plans in areas that are most in need of compliance activities and interventions.
How soon after an accreditation survey should you prep for the next survey?
12 months after the last onsite survey
True or False:
After having a College of American Pathologists (CAP) survey, facilities can be surveyed by CMS to validate the program.
True. Because CMS granted the this program deeming authority, facilities have the potential for a CMS validation survey.
A scientific and educational association of surgeons that was founded in 1913 to improve the quality of care for the surgical patient by setting consensus-driven standards.
American College of Surgeons (ACS)
This strategy frequently used during survey follows the experience of care, treatment, or services for several patients through the organization's entire healthcare delivery process.
Tracer methodology
What is the y axis on the SAFER Matrix?
Likelihood to harm a patient/staff/visitor (low, moderate, high, immediate threat to health or safety)
What model is ideal for survey preparation?
Continuous survey readiness (CSR)
True or False:
State-specific laws and regulations supersede federal laws and regulations if more stringent.
True. This includes licensure, privacy of medical records, durable power of attorney, certificate of need, and mandated healthcare coverage.
Accredits a variety of laboratory settings from complex university medical centers to physician office laboratories. It covers a complete array of disciplines and testing procedures. CMS granted the this program deeming authority. It is also recognized by TJC and can be used to meet many state certification requirements. This program provides laboratory accreditation to forensic drug-testing facilities, biorepository facilities, and reproductive laboratories, in collaboration with the American Society for Reproductive Medicine.
College of American Pathologists (CAP)
How long does the organization have to follow-up on activity and corrective action?
60 days
What is the x axis on the SAFER Matrix?
Scope (limited, pattern, widespread)
Continuous readiness programs include all of the following except:
a. organizational assessment
b. survey readiness oversight
c. requirements and standards oversight
d. survey process (preparation, survey outcomes and post-survey activities)
e. none of the above
e. none of the above
Bills passed by both houses of Congress and signed by the U.S. president, passed over the president’s veto, or allowed to become law without the president’s signature are what type of laws?
Federal laws
Granted for collection, processing, testing, distribution, and administration of blood and blood components; hematopoietic progenitor cell activates; cord blood activities; perioperative activities; relationship testing activities; and immunohematology reference laboratories.
Association for the Advancement of Blood and Biotherapies
The healthcare quality management professional can expect to contribute to the development of survey processes for all the following EXCEPT
a. accreditation
b. safety policy
c. governance
d. licensure
c. Governance
The healthcare quality management professional contributes to the development of survey processes for accreditation, safety policy, and licensure. He does not necessarily get involved with survey process for governance, unless specifically required to do so.
What does SAFER Matrix stand for?
Survey Analysis for Evaluating Risk (SAFER)
Some organizations create work groups for related clusters of accreditation standards and others have a single multidisciplinary group to evaluate readiness on the standards across the entire organization. Departments consistently requiring representation include what?
1. Quality
2. Nursing
3. Medical Staff
4. Pharmacy
5. Plant Operations
6. Environmental Services
7. Infection Control
The Patient Protection and Affordable Care Act (ACA) has how many fundamental elements for an effective compliance program?
7
1. Implementing written policies, procedures, and standards of conduct
2. Designating a compliance officer and a compliance committee
3. Conducting effective training and education
4. Developing effective lines of communication
5. Conducting internal monitoring and auditing
6. Enforcing standards through well-publicized disciplinary guidelines
7. Responding promptly to detected offenses and undertaking corrective action
A private, not-for-profit organization that screens, trains, and certifies organizations that collect or audit data for health plans and providers.
National Committee for Quality Assurance (NCQA)
How long is our Joint Commission survey cycle?
3 years
What is listed on the SAFER Matrix?
Organizations that are not far along in the journey to high reliability may employ this model for survey preparation.
Just-in-time regulatory or accreditation readiness models.
This model come with great financial and personnel costs. When organizations use just-in-time programs with ramp-up activities in the months prior to anticipated surveys, tremendous additional resources are required to demonstrate regulation or standard compliance. Extra staff, consultants, external resources, or extra time are required for self-assessments or gap analyses; for corrective actions to assure compliance; for meetings to discuss policy revision approvals; and for frontline staff education on policy revisions, operational process improvements, and expected survey procedures.
According to the American Hospital Association, providers must comply with how many regulatory requirements across nine domains?
629
A private, not for profit formed in 1979. It's standards advance and promote patient safety, quality care, and value for ambulatory healthcare through peer-based accreditation processes, education, and research.
The Accreditation Association for Ambulatory Health Care (AAAHC)