Accreditation
Accreditation Participation Requirements
For an organization seeking accreditation for the first time, compliance with most of the Accreditation Participation Requirements (APR) is assessed during the initial survey.
Core Measure Sets
-These are what the joint commission evaluates very closely.
-there are certain treatment plans and methods to take to treat these conditions.
Hospital Outpatient Department
Hospital-Based Inpatient Psychiatric Services
Substance Use
Tobacco Treatment
what is the mission of the joint commission?
to improve patient welfare.
APR
Accreditation Participation Requirements
specific requirements for participation in the accreditation process and for maintaining an accreditation award.
When seeking accreditation for the first time, compliance with most of the (APR) is assessed during the initial survey.
How to prepare for a survey
Examine:
-current processes
-current policies
-current procedures relative to standards of care
-improve areas not in compliance
For a health care organization to be accredited...
-it should meet specific quality standards.
-standards are broad and cover different aspects of the care services.
Standards surveyed:
clinical services provided
managerial process
the outcomes of services
the qualification of providers and the patient's satisfaction
True or False?
Accreditation and Certification are very similar in their purpose.
True.
Accreditation attempts to determine if an organization has met requirements of an accrediting body while Certification attempts to confirm that requirements have been met by a certifying institution.
CTS
“Care, Treatment, and Services” reflect the flow of care, treatment, or services as they are provided in behavioral health care and human services organizations. They fall into (3) categories:
1. Standards that are applicable to all behavioral health care and human services settings.
2. Standards that are applicable to specific programs/services.
3. Standards that are applicable to specific populations with unique needs, including the following:
- Individuals with addictions
- Children/youth, including children receiving child welfare services
- Individuals with eating disorders
- Individuals with intellectual and developmental disabilities
- Individuals in opioid treatment
After the Survey
-Report of survey posted on JC website
-If no requirements for improvement (RFI), accreditation is official
-If RFI's, organization makes changes and submits them in a report
-Quality Checks allow consumer to see if facility is accredited
-Unannounced surveys can occur any time between 18-36 months after announced survey
-May give short term notice for larger facilities
Accreditation
A voluntary review process that monitors performance, provides guidelines, determines whether providers will receive gov't funding, a form of recognition.
Standards cover:
-patient rights and education
-infection control
-medication management
-preventing medical errors
-qualifications and competencies for HC providers
-preparation for emergencies
What are the (6) domains of healthcare quality?
safe - effective - patient centered - timely - efficient - equitable
HRM
Human Resource Management
addresses the organization’s responsibility to establish and verify staff qualifications, orient staff, and provide staff with the training they need to support the care, treatment, or services the organization provides.
Fire Safety: RACE
R—Rescue anyone in immediate danger
• A—Activate the fire code and notify appropriate person
• C—Confine the fire by closing doors and windows
• E—Evacuate patients and other people to safe area
What happens if you lose accreditation?
Loss of accreditation = loss of funding
What is HCAHPS?
Hospital Consumer Assessment of Healthcare Providers and Systems
-to provide a standardized survey instrument and data collection methodology for measuring patients' perspectives on hospital care
what does the Joint Commission do?
they observe, review, track, and audit everything within a HC facility.
What are (3) specific National Patient Safety Goals?
- ID patients correctly (2 identifiers)
- Prevent infection (Hand hygiene)
- ID patient safety risks (suicide assessment)
Sentinel events are?
something that happened due to a safety issue that caused the death of a patient.
To earn and maintain The Joint Commission's Gold Seal of Approval...
an organization must undergo an on-site survey by a Joint Commission survey team at least every three years.
How often are hospitals surveyed by the joint commission?
Hospitals are surveyed every three years.
What is "The Joint Commission"
non-profit, independent organization that accredits and certifies health care organizations and programs in the US.
Examples of Infection Control Standards (IC)
identifies risks for acquiring and spreading infections
organization sets goals to minimize the possibility of spreading infections
organization has an infection prevention and control plan
Fire Safety: PASS
how to use a fire extinguisher, which stands for:
Pull the pin
Aim the nozzle
Squeeze the lever
Sweep from side to side