Accreditation

How Accreditation Improves

Quality of Care and Patient Outcomes
What is accreditation?

 Accreditation is a voluntary survey process used by

various NONGOVERNMENTAL, INDEPENDENT
EXTERNAL AGENCIES to assess the extent of a
healthcare organization's compliance with applicable pre-
established performance standards set by the agency.
 Accreditation review is CONDUCTED BY
INDUSTRY PROFESSIONALS (e.g., Physicians,
nurses, pharmacists, dieticians, administrators, life
safety code specialists) who, through written reports,
publicly attest to the resulting accreditation status.
 Accreditation is often a VOLUNTARY PROCESS in
which organizations choose to participate, rather than one
required by law and regulation.
What is accreditation?
Accreditation standards are usually regarded as
optimal and achievable.
Accreditation provides A VISIBLE COMMITMENT
BY AN ORGANIZATION to improve the quality of
patient care, ensure a safe environment, and
continually work to reduce risks to patients and
staff.
Accreditation has gained worldwide attention as
an EFFECTIVE quality evaluation and
management tool.
The purpose of accreditation is to IMPROVE THE
SYSTEMS AND PROCESSES of care and, in so
doing, improve patient outcomes.
 Accreditation Is Not An Alternative To
Licensure

Licensure is a process by which a governmental

authority grants PERMISSION TO AN
INDIVIDUAL PRACTITIONER OR HEALTH
CARE ORGANIZATION to operate or to engage
in an occupation or profession.

Licensure regulations are generally established to

ensure that an organization or individual meets
minimum standards to protect public health and
safety
 And Is Not Certification
Certification is a process by which an authorized body,
either a governmental or non-governmental
organization, evaluates and recognizes either an
individual or an organization as meeting pre-determined
requirements or criteria.

Although the terms accreditation and certification are

often used interchangeably, ACCREDITATION
USUALLY APPLIES ONLY TO
ORGANIZATIONS, while certification may apply to
individuals, as well as to organizations.
 Examples of Accreditation Agencies
The joint commission accredits the following types of healthcare
organizations:

Hospitals healthcare networks (managed care plans, preferred

provider organizations' integrated delivery networks, and
managed behavioral health)'.

Home healthcare organizations (home health, hospice, home

infusion' durable medical equipment, personal care, and
support), nursing homes and other long-term care facilities
assisted living facilities, behavioral healthcare organizations,
ambulatory care providers, and clinical laboratories.
Examples of Accreditation Agencies
URAC. Formerly known as the utilization
review accreditation commission,
Det norske veritus (DNV),
National committee for quality assurance
(NCQA)
Accreditation or certification standards for
specific programs (e.g. Disease management
or care management, and certain functions, such
as credentialing).
The Value of Accreditation

Improve the quality of health care by establishing optimal

achievement goals in meeting standards for health care
organizations
Stimulate and improve the integration and management of
health services
Staff effectiveness. Accreditation was cited as contributing
to the effectiveness of organizations' staff in the following
ways: strengthening interdisciplinary team effectiveness;
Establish a comparative database of health care organizations
able to meet selected structure, process, and outcome
standards or criteria
Reduce health care costs by focusing on increased efficiency
and effectiveness of services
The major purposes of accreditation
Provide education and consultation to health care
organizations, managers, and health professionals on
quality improvement strategies and “best practices” in
health care
Strengthen the public’s confidence in the quality of health
care, and
Reduce risks associated with injury and infections for
patients and staff
External credibility,
Organizational learning. Accreditation was cited as
promoting capacity building, professional development,
and organizational learning.
Motivations To Participate In Accreditation Programs

Motivations to participate in accreditation include:.

True commitment to improvement in quality of patient
care and services .
Willingness to be held accountable/to be compared to
like organizations.
Enhancing confidence of the public/consumers.
Condition of payment
Requirement for contracting to provide services and
receive reimbursement
Requirement for residency programs in academic
medical centers
DEEMED STATUS
For a healthcare organization to participate in and receive
payment from the CMS or Healthcare Insurance Marketplace
programs, it must be certified as complying with the
standards, called CONDITIONS OF PARTICIPATION
This certification is usually based on an onsite survey conducted
by A STATE AGENCY on behalf of CMS or the CMS
regional office.
However, if a national accrediting organization enforces
standards meeting the federal Conditions of Participation,
CMS MAY GRANT THE ORGANIZATION "DEEMING"
AUTHORITY TO CONDUCT THESE TYPES OF
SURVEYS and "deem" each subsequently accredited health
care organization as meeting the CMS certification
requirements
DEEMED STATUS
CMS retains the authority to conduct random validation
surveys and complaint investigations for certified
organizations. CMS has planned for 5% of the
hospitals and organizations that receive federal
reimbursement for healthcare will still require
validation by CMS after an onsite accreditation
survey by a deemed agency. This number has
increased since 2014
The regulations provide a mechanism by which
accrediting agencies may apply to become authorized
to confer deemed status. The accrediting agencies
release survey information to CMS after each survey if
deemed status is granted. CMS may release
information from accreditation surveys if applicable to an
enforcement action; otherwise, CMS keeps survey reports
confidential.
Compliance With Standards

Standards in healthcare accreditation have become or are

becoming more practical in the sense of:

Assessing actual performance ("performance-based") rather than

capacity to perform;.

Focusing on:- Processes and outcomes, not simply structure;

Patient care issues related to quality and safety;-

The organization's efforts to manage patient care and to support

process improvements that result in good patient outcomes.
Compliance With Standards

Most agencies will accredit an organization if it is in

"substantial" or "full" compliance (expectations met) with
the standards overall, even if not with each individual
standard.
The better an organization meets the performance
measure expectation compared to peer organizations,
the higher the rating for that portion of the process.
Achieving compliance with the accreditation/regulatory
standards and then maintaining survey readiness is the
goal for healthcare organizations.
Assessment Of Compliance

Most accreditation agencies use one or more of the

following means to assess compliance with applicable
standards:

Review of documents that demonstrate compliance;

Onsite observations by surveyors;.

Verbal information gained by surveyors through interviews;

Examples of standards implementation;.

Review of medical/health records;.

Assessment of service/support systems;

Integration of performance measure data in scoring

Assessment Of Compliance

If a SURVEYOR FINDS ANY CONDITION EXISTING

THAT POSES A THREAT TO PUBLIC OR PATIENT
HEALTH OR SAFETY, the surveyor may notify the chief
executive officer of the organization and recommend denial of
accreditation.

Any recommendation of denial is reviewed by the accrediting

agency before a final decision is made.

The organization is offered an opportunity to discuss areas of

noncompliance, to submit documentation to demonstrate
compliance or progress, and, with some accrediting agencies, to
request a face-to-face interview or even a "validation" resurvey.
Accreditation Survey
Readiness
Preparedness/Continuous Readiness
The individuals who are coordinating the effort must be very
Familiar With The Regulatory Requirements and
elements of performance.
Deemed accrediting agencies make available the
Standards And Rationale To Organizations That Choose
This Method. Online and paper handbooks are available for
purchase.
The CMS regulations are online for download. There are
seminars and educational meetings conducted by various
organizations.
Read the guidelines very carefully and look for time
related words such as Annual, months, and minutes. The
organization is either in compliance or out of compliance.
For example, the joint commission has a regulation in the
comprehensive stroke regulations stipulating the time in
minutes to get a patient from the helipad to the emergency .
Preparedness/Continuous Readiness

Most accreditation agencies use one or more of

the following means to assess compliance with
applicable standards:
Accreditation/Regulatory Readiness Team
Review of documents demonstrating compliance
Onsite observations by surveyors
Verbal information gained by surveyors through
interviews
Examples of standards implementation
Review of medical/health records
Assessment of service/support systems
Integration of performance measure data into scoring
Accreditation/Regulatory Readiness Team

Each organization should have an Accreditation/ Regulatory

Readiness Team or committee that has created a survey
preparedness plan
This group is responsible for the implementation and
improvement of processes in terms of existing and new
accreditation and regulatory standards.
This team most often consists of Key Leaders And Managers
who coordinate and oversee continuous readiness and survey
planning efforts.
The Team Members Must Have Decision-making Authority
in the organization
The Quality Council, the administrative council, or a
senior leadership survey team that includes key QM/PI
leaders and sponsors/champions may assume the role.
Accreditation/Regulatory Readiness Team
Routine meetings are set to review Environmental Rounds,
to establish a method of inspecting and following patients and
processes through the care settings , to communicate
accrediting agency and regulatory information, and to plan for
dissemination of information.
For example, in 2014 The Joint Commission (TJC) issued a
New Patient Safety Goal Regarding The Use Of Monitors
With Alarms. TJC has given organizations two years to
implement this patient safety goal before they will begin
to survey it in January 2016.'
Specific senior leaders (president, vice presidents, chief
nursing officer, administrative directors) should be designated
to ensure compliance with the standards applicable to the
areas for which they are responsible.
In provider organizations, these leaders participate in
regularly scheduled (announced or unannounced)
environmental rounds.
 Accreditation/Regulatory Readiness Team
Activities/Process Improvements
Establish ongoing interdisciplinary teams
Structure: Approximately three-five members
Each Team Meets Routinely, Such As Quarterly, To
Review Compliance with the appropriate
standards/regulations, improvements, and policies. The
team members conduct patient and organizational
TRACERS to identify areas of weakness or areas for
improvement related to the standards.
The team leaders and members are well versed in the
pertinent standards, operational policies, procedures, and
practices and are able to identify compliance deficiencies.
System problems found during environmental rounds, tracer
activities (patient or process), or data tracking that are
linked to standards should be followed up by the leader
responsible for compliance.
 Accreditation/Regulatory Readiness Team
Activities/Process Improvements
The administrative team (leadership) is the most effective in
performing periodic walk-around inspections of all settings,
departments, and services, focusing on selected standards
each time.
Provide a grid or log sheet that outlines, for each standard,
where/in what form appropriate documentation may be found to
prove compliance.
This log will serve the administrative and clinical teams, but
also will provide support to each person participating in the
survey.
System changes often require the work of a quality
improvement team over time
A GOOD ALTERNATIVE OR ADDITION TO THE WALK-
AROUND IS TO ESTABLISH INTERVIEW/FOCUS GROUPS
for each important function or category of standards and each
organization-wide required review process.
Accreditation/Regulatory Readiness Team
Activities/Process Improvements
Types of team activities:
Track tracer, mock survey, or other self-assessment
results with appropriate software to look for trends,
quick-fixes, system issues
Track the findings (teams, committees, departments )
from specific performance measurement activities
Intervention:
If it is planned to have an outside pre-survey performed,
schedule it to allow time possible for implementation of
recommendations
Review the QM/QI/PI processes,
Be certain that the organizationwide QM/QI/PI approach
is understood
 Learning the Regulations
Once the team members have been identified, the initial steps
involve compiling a listing of the requirements and then
performing A GAP ANALYSIS (SELF-ASSESSMENT) to
clarify what is in place and what has yet to be compiled or
developed. Next, assign people to help fill the gaps.
Handling Of The Documents Electronically Or Paper
Work has also been successful External surveyors
appreciate receiving information in a succinct and
organized manner. Your organization's ability to achieve this
will set the tone for success for the whole survey process.
All through the preparation process, it is wise to build in
Educational Opportunities With Leaders, Managers,
Physicians, Staff Members, And Patients when possible.
Maximize those teachable moments that occur. Presenting the
material in a variety of ways also helps the learners retain the
information and makes it more interesting.
Learning the Regulations
If it is planned to have an outside agency conduct a mock
survey, it should be Scheduled To Allow The Maximum
Time Possible For Implementation Of Their
Recommendations. As much as possible, the mock
survey should incorporate all standards that will be in effect
at the time of the actual survey. However, most
organizations do not need to hire a consultant or other
group to perform the mock survey.
Different Departments In The Organization Could
Survey Other Departments. It is important to note
that staff should not survey their own department, as
a "new set of eyes" will see what the staff would
miss. If the organization is part of a larger healthcare
system, then like facilities in the system could be utilized
to survey another facility.
 Document Preparation
There are some specific documents that surveyors will want to see
during the visit. The accreditation and regulatory agencies typically
provide Survey Activity Guides listing the specific documents.
These will need to be collected prior to the survey.
Some healthcare entities organize their documents in an
annually updated file box or notebook binder categorized with
labeled dividers. Either way, the goal is to be able to present the
documents in an organized and timely manner. It is a good practice
to have two identical boxes or binders
It is a good practice to have Two Identical Boxes Or
Binders - one to give to the surveyor for review and the other
one to keep In The Command Center so that the organization
survey team sees exactly what the surveyor has been given to
review.
Review of the document box or binder prior to the survey by a
senior leader, manager, or risk manager is necessary to prevent
outdated or potentially inappropriate materials from seeping into
the document compilation.
 Tracers
A tracer is A Record Used To Assess The Movement Of A
Patient Through The Health System. From entry to
discharge the record is reviewed for completeness,
individualized care planning, pain assessments, individualized
education, patient involvement in goal setting, communication
with the care team, discharge planning, and other components
pertinent to the patient.
For a patient who entered via the Emergency Department, a
tracer might include assessing the time it took to be seen
by a physician, how long it took to be admitted, and
anything else that might have delayed their care
Tracers examining system processes such as medication use
and information flow will also occur during the survey process.
When conducting mock surveys and tracers, use fresh
eyes to look at your organization as if you had never seen it
before. Put yourself in the place of the surveyor.
Education of Staff, Leaders, and Practitioners
When making rounds and conducting tracers ask staff to
'show you' that, so they know the answers. For
example, staff frequently will answer a question about a
resource saying that they can find it on the computer; but
when put to the test, they cannot actually find it.
Slide presentations are particularly helpful to teach
regulatory compliance Information.
Presenting regulatory compliance information via printed
materials allows the reader to refer back to the document.
Newsletters on the subject are available via many sources.
Many Other Educational Media are available or can be
developed by the organization. While email is used
frequently to send out updates, there is no guarantee that
the emails are even opened.
The organization's electronic education system is
a wonderful means of conveying information if the
system is used. Crossword puzzles, fill in the
blank games, and scrabble puzzles are easy to
make or can be purchased from multiple sources.
organization chose a Wizard of theme. As the
team members were talking with staff throughout
the organization, they would ask the staff
questions. If the staff member got the correct
answer, or could find the correct information in
their department/unit, they were awarded with a
sticker. The sticker was placed on a card with a
Yellow Brick Road on it
 Knowledge Readiness
Distribute the current Standards and Guidelines
(NCQA), with any other appropriate explanatory material
[for The Joint Commission, use the "Applicability of the
Standards" matrices
Review the previous two full survey reports and any interim
random survey reports
Review any focused survey reports and any written progress
reports submitted subsequent to corrective action plans.
Annually identify any changes in standards and evaluate
need for associated change in organization policy
Annually identify any changes in survey process, such as
how the increased emphasis on patient safety
 Knowledge Readiness
Review current organizational concerns, data, etc. to compare current
compliance with the past and to identify any new compliance issues,
including annually revised National Patient Safety Goals
Review the current status of all quality management/performance
improvement activities
Remain current on patient safety issues-standards, national reporting
requirements, National Patient Safety Goals
Remain current on compliance with organization ethics and anti-
fraud policies.
Review minutes and other records of teams and committees,
Review the organization's last quality management/performance
improvement program evaluation report.
Review the current year's quality management/quality improvement
plan, objectives, and any Strategic Quality Initiatives.
Review and revise all policies and procedures associated with the
standards
 Communication
Review all QM/QI/PI communication, reporting,
and feedback processes and improve as appropriate
Is each staff member, clinician, and governing body
member able to identify at least one strategic initiative
and one successful improvement within the last six
months?
Is each staff member able to identify the patient safety
practices for which he/she is responsible?
Consider organizationwide information/
communication improvements that make
readiness/compliance easier
Provide reminders concerning key (or
problematic) compliance issues via email, screen
savers, flyers, newsletters,
Regulatory Compliance Leaders Meetings
Conducting ongoing monthly or bi-monthly
regulatory compliance meetings keeps the
regulatory emphasis in the forefront with
department leaders as well as senior
leadership.
This approach provides another layer of staff
involvement in the survey preparation process.
During the meetings, section leaders provide a
short presentation for the group on a particularly
challenging or troublesome regulation and lead
a discussion on how to approach adherence to
the requirement. The results of the above
listed activities can also be discussed at these
meetings.
 Preparations for the Days of Survey

Who is on the core survey team?

Compile the requested documents.
Who is to be contacted when the surveyors arrive?
Compile a list with cell phone numbers, pagers, etc.
Where will the command center be located?
Where will the surveyor's home room be located? There
must be computer access in this room, and assure that
the door can be locked for security purposes.
Who will tour with the surveyor?
Preparations for the Days of Survey

Who will scribe and take notes during the survey?

Who will be readily available in the command center?
What supplies will be needed in the command center?
Consider having a rolling computer case outfitted
ahead of time with office supplies, laptop, power cord,
flip chart markers, self-adhesive flip chart pages,
organization directory, etc.
For the governing board and members of expected
interviews, prepare example proceedings such as
questions and answers. Running practice interviews
ahead of time is recommended
 SURVEY PROCESS

The actual survey process will vary with different

accreditation agencies, but many of the activities are
similar.
Surveys for all accreditation agencies with deemed
statuses are unannounced, which is becoming the
industry standard.
The number of surveyors is determined by the
accrediting organization, with consideration of facility's
size, types of patients, and services provided.
Most surveys are conducted at least once every
three years, but this is not the standard for all types
of healthcare organizations and accrediting bodies.
Information unique to each type of accreditation program
can be found on their websites.
 Surveyor Arrival
Any overseeing agency can visit an organization at any
time. Any day of the week may be a survey day, even on
the weekends, unless otherwise stated by the agency. A
surveyor might visit at any time of day, even during the
night shift.
When it becomes known that the surveyor is on site
or on the way, it is important to immediately begin
notifying the key members of the survey team and
activate the survey plan.
Surveyors may enter an organization via any entrance.
Sometimes they are easy to spot as they will be in
business dress with rolling computer cases wearing
lanyards with identification. Ideally, staff at information
desks are prepared to greet surveyors. The surveyors
should be asked to have a seat while the administration
or designated individual is notified
 Surveyor Arrival
At the time of arrival, there should be an announcement to
the organization such as, "We would like to welcome
{accreditation/regulatory agency name} to our facility for
their {# of days or type of} survey."
This alerts all the staff and practitioners that there are
surveyors in the building.
This should be done for any type of survey/surveyor
who is in your building, not just for the major accreditation
surveys.
If the organization chooses not to make the overhead
announcement, then the staff and physicians need to be
alerted, by some means, that surveyors are in house.
Everyone needs to be on his or her best behavior
during a survey, but patient safety processes need to
be hard wired into their everyday practice.
 Entrance Interview
The surveyor or team will usually want to sit down for a
few minutes with the organization's designated individuals, to
go over why they are at the organization (triennial survey,
complaint survey, revisit, disease specific certification, initial
survey, etc.) and what the schedule of the day will be. It is
very helpful for the surveyor to have an attendance list with
the names and titles of the attendees so he/she can refer
back to it throughout the survey.
The surveyor leads this meeting but usually allows questions
from the group. This meeting is efficient, lasting 15 to 45
minutes, as the surveyor will want to begin the survey process
as soon as possible.
A typical schedule for the day at an acute care hospital might
include visiting clinical units, observing medication administration,
watching a time-out in surgery, assessing moderate sedation,
reviewing prepared documents, visiting an outpatient care area,
and touring the Emergency Department.
 Entrance Interview
If the survey team is from a state agency or CMS, the
expectation is that they should not be allowed to
move through the facility without being accompanied by a
staff member.
There should be a designated escort for each
surveyor to guide them through the facility.
Deemed agency surveyors and other accreditors may
prefer that their surveyors not be accompanied, but the
organization has the right to assign someone as a guide.
Ensure the survey team members have a private
area for their computer set up and document
review. Provision of information on the closest restrooms
and exit doors is essential
Regardless of the oversight entity, patient care
should not be interrupted or unduly affected by the
survey.
 Surveyor Work Room
Escort the survey team to their home room for the
duration of the survey. The ideal room for a survey
team should be locked (to keep their items safe and
protect the confidentiality of their notes), and contains:
a telephone, the ability to connect to the internet, a printer
connection, and a table large enough to accommodate
several people.
Some surveyors prefer to have an empty folder with
their name on it for them to use during the survey.
Some healthcare organizations make it a practice to
provide a few basic office supplies and Kleenex in the
home room. If only one surveyor is in-house, a
smaller empty office can be used. It is a nice touch
to provide creature comforts such as coffee, ice water,
and light refreshments. Keep in mind that CMS
employees may not be able to accept food unless it is
being provided for the staff as well.
 Command Center
There should be a command center established for the
organization's accreditation/regulatory leaders, similar to
that utilized during a disaster. Bring the rolling
computer case with supplies into the room. Be sure
that the command center staff has access to the
regulations either online or in hard copy. Get the
document box or binder that houses the prepared survey
documents. One or two people are usually enough to staff
the command center.
If the surveyor asks for a form, policy, or procedure,
the scribe with the surveyor should contact the
command center to obtain the requested information.
This will prevent the surveyor from getting duplicate
information.
Staff Interviews with the Surveyor
There should be a scribe with the surveyor to note the
surveyor's questions, what policies/forms are looked at,
areas surveyed, staff and physicians spoken to, and
which patient records are reviewed. In virtually every
survey staff members will be involved in talking with
surveyors.
The surveyor will ask caregivers specific questions to
assess their care provided, practices, communication,
and adherence to policies. Staff members may ask a
surveyor to re-state a question if they do not
understand what the surveyor is asking. Most
surveyors are very happy to clarify what they are asking
for and try very hard to put staff members at ease during
interviews
Patient Interviews with the Surveyor

Another valuable source of information for

surveyors comes from the patients and their
families. Who better to interview than someone
who is experiencing the care first hand?
Because of personal healthcare information
confidentiality, the surveyor will ask permission to
speak to the patient. Topics that are bound to come
up during the interview include pain control,
communication, medication reconciliation, and
individualized education.
 End of the Survey Day
It is typical for the survey team to hold a
debriefing meeting at the end of each day or at the
beginning of the next day to discuss how the
survey is going. Managers and others should then
be informed of what was found and what was
troublesome to the surveyor. This will allow the staff
to be more prepared and obtain needed information for
the next day
In some organizations, a senior leader will send a
summary email communication to selected
members of the leadership team at the end of each
survey day. This keeps the leadership apprised of
the daily findings, helps educate, and provides a
means of support and encouragement for the team.
Stress levels are naturally high during the survey
process and this is one way to alleviate some of that
stress and connect with one another.
At the End of the Survey
When the survey has been completed, the surveyor or
survey team will hold an exit conference with the
organization's leadership team to review preliminary
findings. The CEO is typically asked who he/she wants
at the exit conference. The official findings and citations
will be provided in a written report from the surveying
agency in approximately 10 days.
After the exit conference is over and the surveyors
leave, a summary of the preliminary findings should be
communicated as appropriate throughout the facility. It is
common for a senior leader to send out a summary
email to selected members of the leadership team.
Regardless of the results, the organization should
celebrate. If there is still more to be done, celebrate the
work done so far, then in the next few days continue the
journey to accreditation or regulatory compliance.
After the Surveyors Leave
For a CMS or state survey, the organization receives a
Statement of Deficiencies also known as a 2567
form. The organization then completes a detailed
corrective action plan identifying the changes that will
be made, who is responsible for oversight, timelines,
monitoring of the performance, and reporting structure
within the organization.
There is a tight timeframe for response associated with
citations.
The time varies with the accreditation/regulatory
agency, however. Usually there is a set number of
calendar days specified, in which the organization must
submit action plans. Do not miss submission dates.
Common Correction Plan Questions to
Answer
What was the main issue identified by the
surveyor?
What was the underlying cause of
noncompliance?
What specific steps will be taken to prevent
this from happening in the future?
Who is the senior leader responsible to
monitor that the action plan is completed?
What timeframe is being established?
What data will be collected to assess
compliance?
Common Correction Plan Questions to
Answer
What are the data numerator and denominator definitions?
What are the inclusion and exclusion criteria?
What is the % goal for performance?
Will a sample be monitored or will there be 100%
monitoring?
If a sample is used, how will the sample be chosen?
How will progress toward compliance be monitored?
Are progress reports going to be made to organizational
committees or leaders?
What steps are in place to ensure sustainability of
improvements?
 Continuous Improvement and
Sustainability
Identifying the root causes of a process failure,
implementing changes, and monitoring the success of
those interventions necessitates the use of an ongoing and
structured performance improvement model (e.g., plan,
do, check, and act).
Making changes can be done quickly in some
instances, but maintaining performance improvement is
more challenging.
It would be a shame to develop a process that leads
to desired outcomes, then to later slide back into old
inferior patterns and habits that caused the underlying
problems in the first place, Being able to sustain
improvements is imperative.
 Disease Specific Certification
Becoming certified as a disease specific provider is
very popular and can do much to enhance a
healthcare organizations' reputation in the community.
Several agencies, as described below, offer certifications
including in areas such as stroke, acute myocardial
infarction, heart failure, hip/knee replacements, vascular
disease, dialysis, and many more.
Also, some state agencies offer certifications in stroke
care and ST-elevated myocardial infarction care.
Specific information on the certification standards can
be found on the appropriate certification agency's
website
Hospital Accreditation Organizations with
Deemed Status
At the time of this writing these four (4) CMS approved
hospital accreditation organizations can provide deemed
status. They are :
1. The Joint Commission (TJC)
2. Det Norske Veritas Healthcare (DNV Healthcare)
3. American Osteopathic Association/Healthcare Facilities
Accreditation Program (AOA/HFAP)
4. Center for Improvement in Healthcare Quality (CIHQ)
Standards are developed based on evidence for
practice, expert opinion and consensus, or research.

Standards are published and reviewed and revised

periodically in order to stay current with the state-of-
the-art thinking about health care quality, advances in
technology and treatments, and changes in health
policy.
Standards may focus on the infrastructure of the
organization, the processes of care delivery, or the
outcomes of the care delivery system
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https://www.youtube.com/watch?v=8FWgMT-GETc
https://www.youtube.com/watch?v=xCNCbUy4hBo
https://www.youtube.com/watch?v=K6Ah8ojVPiQ
https://www.youtube.com/watch?v=5MqWox5U9I0
https://www.youtube.com/watch?v=DbGlwoQ53Gc