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Accreditation of Healthcare Organization

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Chelsea Lamb

on 23 February 2014

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Transcript of Accreditation of Healthcare Organization

Accreditation of Healthcare Organization
design by Dóri Sirály for Prezi
Accreditation: Mandatory or Voluntary
Board Certification for Physicians
vs. Accreditation for Hospitals
The process of Board Certification for Physicians is
very thorough. It involves extensive testing and peer evaluation that is given by specialists in the respective
field of medicine the physician is testing for.



Increases Doctor retention
Patient confidence
Quality of care, and more

Hospitals often elect to participate in hospital accreditation programs as a way of distinguishing their services. Accreditation can help hospitals identify internal problems, and correct potential pitfalls before they become bigger issues.

Obtaining hospital accreditation
is usually a matter of hiring an accreditation service to perform an assessment.
Hospitals that choose to participate open their doors to scrutiny, and invite the accreditation assessors to investigate any hospital happening.
Most of the time, the accreditation service will send a team of inspectors to the hospital to observe for a period of weeks or months.
Inspectors are usually medical experts, hospital safety advisers, or others with expert knowledge of how hospitals should be run.
Hospital accreditation is a
voluntary
ranking and assessment program that gauges hospital safety, staff competency, and overall quality of patient care.

Accreditation is not typically required for hospitals to operate, or even for them to receive government funding, but it can be an asset.

Board certification
is the process
by which a physician (MD or DO)
in the United States
demonstrates
through either written, practical,
and/or simulator based testing, a
mastery
of the basic knowledge
and skills that define an area of
medical specialization
.

Board Certification is maintained by keeping up with advances
in their field of specialty
and demonstrating good
practices overall for ethics,
patient safety, and
communications.

What is Accreditation?
Accreditation is typically granted or denied by independent accrediting agencies who are unaffiliated with either the hospital or any sort of official government body. The agencies conduct objective studies of how participating hospitals work. If granted, accreditation acts as a sort of “seal of approval” for hospitals.

There are
24 boards that

certify
medical specialists in the United States and there is
no legal requirement to attain it.
Some hospitals may demand that physician's must be board certified to get privileges.
Benefits of Accreditation:
Hospitals
Improves risk management and risk reduction.
Accreditation standards focus on state-of-the-art performance improvement strategies that help health care organizations continuously improve the safety and quality of care, which can reduce the risk of error or low quality care.
May reduce liability insurance costs.
By enhancing risk management efforts, accreditation may improve access to and reduce the cost of liability insurance coverage.
Provides deeming authority for Medicare certification.
Some accredited health care organizations qualify for Medicare and Medicaid certification without undergoing a separate government quality inspection.
Provides education and tools to improve business operations

Benefits of Accreditation: Hospitals
Benefits of Accreditation: Physicians

Enhances staff recruitment and development.
Accreditation can attract qualified personnel who prefer to serve in an accredited organization.
Provides professional advice and counsel, enhancing staff education
Provides practical tools to strengthen or maintain performance excellence
Accredited organizations also provide additional opportunities for staff to develop their skills and knowledge.
Process of Board Certification for Physicians
The process of Board Certification for Physicians is very thorough. It involves extensive testing and peer evaluation by specialists in the respective field of medicine the physician is testing for.
Pre-requisites for becoming Board Certified: - four years of premedical education in a college or university-a course of study leading to an MD or DO degree from a qualified medical school -three to five years of full-time experience in an accredited residency training program

Each physician earns their Board Certification by a written exam that is created by the Member Board of that physician’s certain specialty. In some cases physicians also have to pass an oral exam as well.
Board Certification is maintained by keeping up with advances in their field of specialty and demonstrating good practices overall for ethics, patient safety, and communications.

Board Certification for Physicians
International Organization of Standards (ISO)
ISO- is the worlds Largest developer of voluntary International Standards
ISO is a network comprising the national standards institutes of 163* countries
ISO Standards make positive contributions to the world we live in. They promote quality, ecology, safety, reliability, compatibility, interoperability, efficiency and effectiveness

International Organization of Standards (ISO) Health Standards
Industry
- ISO Health standards ensure consistency. Healthcare providers , national governments and manufacturers benefit from not having to comply with multiple specifications and requirements for different markets. ISO standards are strategic tools for business to gain a competitive advantage through products and services that are safe, reliable, and trustworthy.
Regulators
- ISO standards provide tools to assess and evaluate conformity, providing a technical base for health legislation. Regulators can rely on trusted internationally harmonized solutions, which are continually reviewed and improved to provide a technical basis for market- friendly regulations that meet citizens’ expectations.
Consumer
- ISO standard safeguard consumer interests by ensuring good quality care and safe reliable products and services

ISO 9001-2008
Take a look at This
Madison Memorial Hospital is a nationally recognized, regional nonprofit healthcare facility and clinics.
In Idaho, MMH is the only self sustaining community owned non-critical access hospital.
MMH serves the communities of Rexburg, Rigby, and into West Yellowstone.

Madison Memorial
450 E. Main St.
Rexburg, Id 83440

Dr. Rachel Gonzales, CEO
Madison Memorial Hospital
CEO, Madison Memorial Hospital
Nonprofit; 501-1000 employees;
2012– Present (2 years)
Adjunct Faculty, University of Phoenix
2002– Present (12 years)
Adjunct Faculty, Capella University
2010– 2012 (2 years)
COO, Madison Memorial Hospital
2009– 2011 (2 years)
Interim Administrator, Teton Valley Health Care
October 2007– April 2008 (7 months)
Chief Nursing Officer, Teton Valley Health Care
1998– 2008 (10 years)

Madison Memorial Hospital Accreditation
After much consideration, Madison Memorial Hospital chose to pursue accreditation through DNV, through its NIAHO (the National Integrated Accreditation for Healthcare Organizations) program. DNV is a registrar with a strong focus on quality, innovation, and continual improvement.
Madison Memorial Hospital is also certified by DNV to ISO 9001:2000 standards, a quality management system.
Hospitals seeking deeming by DNV are required to be conforming to the ISO 9001:2000 standard within two years after their initial survey. Registration to ISO 9001:2000 is not dependent on participation in the NIAHO accreditation program but the organization must be conforming to the requirements of the ISO 9001:2000 standard.

Why Madison Memorial chose ISO 9001
ISO 9001:2008 sets out the criteria for a
quality management system

(QMS)
and is the only standard in the family that can be certified to (although this is not a requirement). It can be used by any organization, large or small, regardless of its field of activity. In fact ISO 9001:2008 is implemented by over one million companies and organizations in over 170 countries.


Dr. Rachel Gonzales, CEO
Madison Memorial Hospital
News Anchor:
“A lot of changes are taking place in the healthcare industry, and one change that’s more local is Madison Memorial hospital in Rexburg has just named a new CEO. Sasha Zimmerman just met with her to find out what’s next for the hospital in Rexburg.”
Sasha Zimmerman:
“After almost 10 months of searching and interviewing Madison Memorial hospital has named Rachel Gonzales their new Chief Executive Officer.”
CEO Rachel Gonzales:
“I’m quite excited. I’ve been in this position or have worked for Madison Memorial for the last three and a half years. I am really excited for our future.”
Sasha Zimmerman:
“Gonzales has lived in Idaho since 1998 and before she came to Madison Memorial she worked at Teton Valley hospital. The new CEO started her healthcare career as a nurse and has since moved into other positions including COO and interim CEO.”
CEO Rachel Gonzales:
“We have a few new service line expansions that we are looking at, that we’ve started over the last 10 months. We’ve had an expansion of our infusion therapy services, for example. We are looking forward to a labor and delivery remodel which will begin in about 30 to 60 days. We’re excited for that and our new moms.”
Sasha Zimmerman:
“Right now the hospital has 69 beds and the administration is focusing on quality improvement and cost effectiveness for the future.”
CEO Rachel Gonzales:
“In reality I’m here because of the physicians, because of the directors, because of the board of trustees; everything we do here is a team effort, so there is a piece of that, that I wish the entire hospital, the five hundred and two employees, could get the recognition at the same time.”
In Rexburg, Sasha Zimmerman, KPVI News 6.

Video Interview Transcription
Caring for us and our loved ones requires so many aspects to meet high standards, from medical equipment to biological evaluation, from testing laboratories to health informatics. ISO’s health care standards provide a world of solutions for manufacturers, regulators, healthcare professionals, and most important of all, for you and me as patients. When it comes to healthcare, confidences has a nickname, ISO.

ISO in Healthcare
At A Glance



Board Certification
Accreditation
Voluntary
Performed by medical experts in the field
Usually a written and oral exam
No legal requirement to attain it
Maintained by keeping up with medical advances in the field
Voluntary
Granted by independent agencies
Ranking and assessment program to evaluate hospital
No legal requirement to attain it
Maintained by internal and external surveys to verify that standards are met
Presented by
Charity Donnelly
Chelsea Lamb
Paige Whittaker
Shae Hildreth

Benefits of Accreditation: Patients
Benefits of Hospital Accreditation
DNV has been granted approval by the Centers for Medicare and Medicaid Services for deeming authority for the NIAHO (the National Integrated Accreditation for Healthcare Organizations) hospital accreditation program to determine hospitals compliance with the Medicare Conditions of Participation. The foundation of DNV’s NIAHO accreditation is the ISO 9001:2000 standard.
MMH has followed these standards since their inception. To stay compliant with DNV standards, MMH continually monitors their progress, and receives periodical audits both in house and by the DNV.
Recently DNV complimented Madison Memorial for exceptional performance improvement. DNV claimed that MMH was one of the only hospitals that had closed almost all corrective actions.

Madison Memorial Hospital Accreditation

In July 2009, Madison Memorial Hospital became the 13th hospital in the US to be certified to ISO 9001:2008. This was the culmination of an interest, study, and push towards accreditation at MMH which began in the late 90’s and early 2000’s
DNV certification and accreditation according to ISO 9001 standards offers an alternative to the specific standards for quality and safety improvement offered by the Joint Commission, which can be prohibitive for smaller hospitals, and allows more autonomy for individual healthcare organizations to uncover areas for improvement and implement their own customized solutions
ISO 9001 focuses on internal process improvement and requires annual surveys conducted by trained volunteers from the accredited organization
Cost benefit analysis – DNV does not charge an annual fee and fees are charged based on quantity of surveyors, size of facility, and complexity of services making the fee structure a Fee-For-Service arrangement more compatible with smaller facilities
MMH chose ISO 9001 QMS because it focuses on continuous process improvement through internal and external surveys to help them achieve their goals of improved patient safety and quality of care, adding service line expansions, and risk management.
ISO 9001: 2008 Internationally recognized standards of quality

The processes of board certification for physicians and accreditation for hospitals have many similarities.
Provides a
competitive edge
in the marketplace. Accreditation may provide a
marketing advantage
in a competitive health care environment and improve the ability to secure new business.
Provides a customized, intensive review.
The standards are specific to each accreditation program.

Helps organize and strengthen patient safety
Strengthens community confidence in the quality and safety of care, treatment and services.
Achieving accreditation demonstrates a commitment to providing the highest quality services.

The Big Four: Healthcare Accreditation Organizations in US
Joint Commission (JC) www.jointcommission.org
DNV Healthcare Inc. DNVHC www.dnvaccreditation.com
American Osteopathic Association www.osteopathic.org
Center for Improvement in Healthcare Quality www.cihq.org


Joint Commission (JC)
Began offering voluntary accreditation in 1953
Granted deeming status from CMS in 1965
Accredits more than 20,000 healthcare organizations, such as ambulatory care facilities, behavior healthcare facilities, critical access hospitals, home care organizations, hospitals, clinical laboratories, and nursing care centers
Annual fees range from $1,500 to $38,000, depending on facility size and patient volume
Its program addresses performance, quality, and patient safety, and it offers
specific requirements
for quality and safety improvement
Joint Commission (JC)
Yes- Offers ISO Certification
Yes- Performs annual surveys
Yes- Performs surveys every three years
Yes- Accredits and deems healthcare facilities in addition to hospitals
Yes- Surveyors are employees of accrediting agency
No- Surveyors are trained volunteers from accredited organizations

Det Norske Veritas (DNV) Healthcare
Began offering voluntary accreditation in 2008
Granted deeming status by CMS in 2008
Accredits more than 350 hospitals
There are no annual fees. Survey costs vary based on quantity of surveyors, length of survey, size of facility surveyed, and complexity of services offered.
DNV’s program, National Integrated Accreditation for Healthcare Organizations (NIAHO), incorporates the ISO 9001 quality management system (QMS) standard
ISO 9001 requires hospitals to create, document, and enforce a QMS, the goal of which is continuous quality improvement.

Det Norske Veritas (DNV) Healthcare
Yes- Offers ISO Certification
Yes- Performs annual surveys
No- Performs surveys every three years
No- Accredits and deems healthcare facilities in addition to hospitals
No- Surveyors are employees of accrediting agency
Yes- Surveyors are trained volunteers from accredited organizations

American Osteopathic Association (AOA)
AOA offers accreditation through their Healthcare Facilities Accreditation Program (HFAP)
Began reviewing osteopathic hospitals in 1945
Granted deeming status by CMS in 1965
Accredits nearly 200 hospitals, as well as clinical laboratories, ambulatory care facilities, mental health facilities, substance abuse facilities, physical rehabilitation facilities, and critical access hospitals
Three year accreditation averages less than $9,000 annually
HFAP standards are overseen by both allopathic and osteopathic healthcare professionals
HFAP standards link closely to corresponding Medicare CoPs, and accreditation is based on the correction of any deficiencies uncovered during inspection.

American Osteopathic Association (AOA)
No- Offers ISO Certification
No- Performs annual surveys
Yes- Performs surveys every three years
Yes- Accredits and deems healthcare facilities in addition to hospitals
No- Surveyors are employees of accrediting agency
Yes- Surveyors are trained volunteers from accredited organizations

Center for Improvement in Healthcare Quality (CIHQ)
Began offering voluntary accreditation in 2009
Granted deeming status by CMS in 2013
Counts more than 200 hospitals among its members
Annual fees range from $5,000 to $22,000, based on quantity of beds in the facility
Member based organization consisting of acute care and critical access (less than 25 beds) hospitals.
Focuses nearly exclusively on the Medicare CoPs as a basis for its standards, and its few additional standards exist to “address gaps in the [CoPs] in the areas of patient safety and quality care” says CIHQ

Center for Improvement in Healthcare Quality (CIHQ)
No- Offers ISO Certification
No- Performs annual surveys
Yes- Performs surveys every three years
No- Accredits and deems healthcare facilities in addition to hospitals
No- Surveyors are employees of accrediting agency
Yes- Surveyors are trained volunteers from accredited organizations

The
Big
Four
Accreditation and Centers for Medicare and Medicaid Services (CMS)
Section 1865(a)(1) of the Social Security Act (the Act) permits providers and suppliers "accredited" by an approved national accreditation organization (AO) to be exempt from routine surveys by State survey agencies to determine compliance with Medicare conditions.
Accreditation by an AO is voluntary and is not required for Medicare certification or participation in the Medicare Program. A provider’s or supplier’s ability to bill Medicare for covered services is not impacted if it chooses to discontinue accreditation from a CMS-approved AO or change AOs. Section 1865(a)(1) of the Act provides that if the Secretary finds that accreditation of a provider entity by a national accreditation body demonstrates that all applicable conditions are met or exceeded, the Secretary may deem those requirements to be met by the provider or supplier. Before permitting deemed status for an AO's accredited provider entities, the AO must submit an application for CMS review and approval.

Board Certification for Physicians
vs.
Accreditation for Hospitals
Note: Data based on a small, random sample of HRC (Health Risk Control) members. Percentages do not add up to 100 due to rounding.
Full transcript