Joint Commission, Healthcare Facilities Accreditation Program (HFAP), and Det Norske Veritas Healthcare, Inc (DNV)
Receive reimbursement from Medicaid and Medicare as third-party payers.
Undergo a CMS survey conducted by the state
Every 3 years for TJC and HFAP, and annually for DNV
1951, Result of efforts by the ACS to create standardization w/in hospitals
2002 w/expected compliance in 2003
To focus on issues identified as areas of concern/root causes for sentinel events.
Patient Safety Advisory group
Critical access hospital
Home medical equipment, orthotics and prosthetics, and medical supply services
The long-term care component to be surveyed with the hospital.
Office-based surgery accreditiation
Primary Stroke Center (PSC)
Every 3 years
Every 2 years
Minimum Standards for Hospitals
Conditions of Participation
Shared Visions-New Pathways
Mark R. Chassin
Criticality level 1 (worst-highest)
Criticality level 1 – Immediate jeopardy
Criticality level 2 – Situational Decision Rules
Criticality level 3 – Direct Impact Requirements (corrected w/in 45 days of survey)
Criticality level 4 – Indirect Impact Requirements (corrected w/in 60 days of survey)
From the census
Second Generation Tracer
The Center for Transforming Healthcare
ORYX, HCAHPS,e-APP data
1 Jul 2010
It allows the hospitals to receive reimbursement from Medicaid and Medicare as third-party payers.
Accreditation evaluates quality of work against stds…every 3 years Certification evaluates an individual, institution…every 2 years
EP (elements of performance) level
Inoperable fire alarm
Adult strength meds on pediatric cart
Lack of master alarms for medical gas system
Pts w/known antibodies rcvg transfusions w/out units being typed for the corresponding antigen
Facility w/out licensure
Individual w/out a license when a license is required
Failure to implement LSC corrective actions
Care processes affcting pt quality/safety
Planning/evaluation of care processes
Individual (Pt)/Second Generation (High risk/criticality)
Systems (Medication mgmnt/infection control/data use/emergency mgmnt)
Aimed at: clarifying stds language ensures stds are program specific deleting redundant/nonessential stds consolidating stds
Lengthy mid-cycle self-assessment tool to promote continuous std compliance.
MEC – Oversees the functions/duties of the medical staff
OMS – Develops/adopts/amends medical staff by-laws
Evaluations must be documented by a qualified individual to administer anesthesia w/in 48 hrs of inducing. Must include:
Anesthesia plan of care
Must be documented w/in 48 hrs after the pt is brought into recovery. Should include:
The hospitals governing body accepts physicians into its medical staff and grant privileges after thorough examination.
Expects the care to be the same regardless of who provides it
Requirement for Improvement
Egress issues, fire protection, and protection of individuals
PTS RIGHT…Key:WHEN PAIN IS ID’d…PLAN of CARE
Comprehensive pain assessment is consisitent w/pts condition and treatment plan Pain assessmenets are pt-centered
Action is taken and pain is reassessed
Pain is treated or pt is referred
Combines assessment, care planning, education, and shift documentation into one document
Caused by aging facilities………..
Risks to pts, staff, visitors
Safety and security
Mxs of written inventory of all operating components of utility systems
Initial assessment w/in 24 hrs of pts admission
Hospital defines info to be collected
Functional/nutritinal screen w/in 24 hrs
Care planning/Multidisciplinary approach to care
Pour and Label
FPPE – Providers seeking privileges or for current practitioners seeking the addition of new privileges
OPPE – Monitor and improve care and that the indicators are approved by the medical staff.
The information is used for during the re-credentialing process
Review – Identifies significant event that would ordinarily require analysis by physician peers to determine cause, effect, and severity.
Rule – Represents general rule, std, or generally recognized professional guideline or accepted practice of medicine where individual variation does not directly cause adverse pt outcomes.
Rate – Identifies cases/events that are aggregated for statistical analysis prior to review.
Obtain and document a patient’s current medications
Decide what info is needed in outpt setting (IN WRITING)
Compare home meds to on order meds
Give pt written med info/provide education