Pharmacy News

Accreditation Options Broaden for Acute Care Hospitals

[November 1, 2013, AJHP News]

Cheryl A. Thompson

BETHESDA, MD 15 Oct 2013—Acute care hospitals wanting to demonstrate their compliance with the Medicare conditions of participation through accreditation by a national organization recently gained a fourth option: the Center for Improvement in Healthcare Quality.

The 14-year-old membership-based, privately held company on July 26 obtained approval from the Centers for Medicare and Medicaid Services (CMS) to serve as one of its national accrediting organizations for hospitals.

"We started as a consulting organization," said Rick Curtis, chief executive officer of the Center for Improvement in Healthcare Quality, with headquarters in Texas.

The company, he recounted, had identified a need among hospitals to have more than a "mock survey" in preparing for an official survey by a state agency or CMS-recognized national accrediting organization.

To meet that need, the Center for Improvement in Healthcare Quality offered a consultative service "designed to partner with hospitals over the long term," Curtis said.

Hospitals that partnered with the company for the consultative service became members. Likewise, he said, hospitals that now undergo the accreditation process with the company become members.

Playing field. Although hospitals can demonstrate their compliance with the Medicare conditions of participation through certification by a state health agency, most opt for accreditation.

About 84% of the acute care hospitals participating in the Medicare program have had a national accrediting organization deem they meet the conditions of participation, according to CMS’s most recent financial report.

The Joint Commission dominates the field. In 2010–11, the report states, 90% of hospitals with so-called deemed status obtained it from the Joint Commission. The rest of the hospitals split almost evenly between the Healthcare Facilities Accreditation Program of the American Osteopathic Association and Det Norske Veritas Healthcare Inc.’s program, known as National Integrated Accreditation of Healthcare Organizations.

Hospitals elect, for different reasons, to contract with the various national accrediting organizations having deeming authority, said Bona E. Benjamin, director of medication-use quality improvement at ASHP. "It depends on the needs of the individual hospital."

All four national accrediting organizations offer resources and fee-based support to help hospitals comply with the Medicare conditions of participation, said Lee B. Murdaugh, director of accreditation and medication safety at CardinalHealth Innovative Delivery Solutions.

Murdaugh is a coauthor of the current edition of ASHP’s book Assuring Continuous Compliance with Joint Commission Standards: A Pharmacy Guide.

Unlike the Center for Improvement in Healthcare Quality, she said, the three other CMS-recognized national accrediting organizations have standards that "go above and beyond" the Medicare conditions of participation.

For example, the Joint Commission incorporates its ORYX core quality measures and sentinel event management into the process of surveying hospitals. The Healthcare Facilities Accreditation Program includes the National Quality Forum’s "Safe Practices for Better Healthcare" and information from the Institute for Healthcare Improvement and the Agency for Healthcare Research and Quality. Det Norske Veritas Healthcare focuses on health care processes and the International Organization for Standardization’s quality management standards.

"There’s an advantage to the patient," Murdaugh said, when the accrediting organization focuses on the safety and quality of care.

Validation surveys. The Center for Improvement in Healthcare Quality’s standards for accreditation, according to the organization’s website, are based "almost solely" on the Medicare conditions of participation. In addition, the requirements under each standard are based on the interpretive guidelines published by CMS for use by state agencies when surveying hospitals.

Curtis said the advantage of obtaining accreditation from his company is its focus on the federal regulations.

Accreditation by his company, he asserted, puts a hospital in a good position to "withstand" a survey by federal or state personnel.

Normally, hospitals with deemed status do not have to undergo a routine survey by CMS. But federal regulations allow CMS to validate the accreditation process of national accrediting organizations.

CMS said it does this by having state health agencies survey a representative sample of each organization’s accredited hospitals and visit hospitals in response to substantial allegations of noncompliance with the Medicare conditions of participation.

In fiscal year 2011, the representative sample was 2%, or 73 hospitals. CMS reported that at 44% of these hospitals the state agency cited a serious deficiency not described in the report from the national accrediting organization. This serious deficiency usually pertained to the hospital’s physical environment.

As for the other type of validation survey, CMS conducts 3500–5000 "complaint" surveys every year and finds "significant problems" in 4–6%, according to the Joint Commission.

The findings of a validation survey have meaning for more than the national accrediting organization. If a validation survey determines a hospital is out of compliance with any Medicare condition of participation, current federal regulations state that the hospital "may be subject to termination of the [Medicare] provider agreement."

Communication. Murdaugh said all of the national accrediting organizations solicit and receive feedback from their client hospitals.

In addition, the Joint Commission conducts field reviews of proposed accreditation standards before finalizing them and enlists a group of health care practitioners to provide advice.

Those health care practitioners constitute the Professional and Technical Advisory Committee for hospitals.

The committee’s pharmacist member and an alternate are appointed by ASHP, said Benjamin, who communicates with the Joint Commission about its medication management standards, emerging issues, and members’ concerns.

ASHP’s chief executive officer, she added, serves on the Joint Commission’s Patient Safety Advisory Group. And, at the Joint Commission’s request, ASHP in the past year recommended members to serve on the expert panel for pediatric standards and task force on advanced certification in stroke care.

"We don’t have the opportunity for that type of dialogue with the other [hospital-accrediting] groups," Benjamin said.


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