Health Care Regulatory and Certifying Agencies

Health Care Regulatory and Certifying Agencies

Chapter Objectives

1. Identify health care regulatory and certifying agencies.

2. Explain the nurse’s role in relation to hospital surveys.

3. Define The Joint Commission.

4. Define accreditation.

5. Discuss strategies for implementation of proper procedures for an upcoming hospital survey.

6. Discuss strategies for implementation of proper procedures using appropriate regulatory and certifying agency guidelines.

Determination by an accrediting body that an eligible health care organization complies with applicable standards of The Joint Commission

American Osteopathic Association (AOA)

Osteopathic accreditation program that ensures osteopathic students receive their training with the provision of high-quality patient care

Centers for Disease Control and Prevention (CDC)

Agency charged with the promotion of health and quality of life by preventing and controlling disease, injury, and disability; has created multiple infection control standards that are now part of standard Joint Commission accreditation

To act in accordance with stated requirements, such as standards. Levels of compliance include noncompliance, partial compliance, and substantial compliance

The Joint Commission (TJC)

Accreditation organization that strives to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations

National Institute for Occupational Safety and Health (NIOSH)

Federal agency responsible for conducting research and making recommendations for the prevention of work-related injury and illness. NIOSH is part of the CDC within the U.S. Department of Health and Human Services

Occupational Safety and Health Administration (OSHA)

U.S. Department of Labor agency that ensures the safety and health of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in workplace safety and health

State departments of health and human services

Foster accessible and high-quality health and senior services to help all people to achieve optimal health, dignity, and independence in an attempt to prevent disease, promote, and protect well-being at all life stages and encourage informed choices that enrich quality of life for individuals and communities.

U.S. Department of Health and Human Services (USDHHS)

U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves

REGULATORY AGENCIES

Health care organizations work with a myriad of accrediting and regulatory agencies so that optimum standards of care and delivery of care can be met. Regulatory agencies are charged by federal and state governments to:

• Set standards for the operation of health care organizations

• Ensure compliance with federal and state regulations developed by government administrative agencies

• Investigate and make judgments regarding complaints brought by consumers of the services and the public

Licensing of health care agencies to maintain practice occurs through state departments of health. State departments of health usually oversee outcomes of care within health care facilities, investigate consumer complaints, and deal with issues of importance to the public health. These agencies monitor basic compliance with the specific health care regulations of that state. Compliance with regulatory standards on both national and state levels is mandatory, and fines can be leveled against organizations for noncompliance.

Accreditation agencies evaluate health care organization against a set of standards that have been validated against best practice. Accreditation is voluntary.

ACCREDITATION

Accreditation agencies were initially founded to set a minimum of standard of care. As they have matured, their missions have expanded to “continuously improve the safety and quality of care provided to public” (The Joint Commission, 2009). They have moved from compliance agencies to agencies that hope to drive improvement and quality of care.

Accrediting agencies move beyond basic compliance and look to the continuous improvement of operational systems critical to patient care and safety. While accreditation is listed as a voluntary process, federal reimbursement of health care is dependent on accreditation.

THE JOINT COMMISSION

The mission of The Joint Commission (previously known as the Joint Commission on Accreditation of Healthcare Organizations) is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. The Joint Commission evaluates and accredits more than 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation’s predominant standards-setting and accrediting body in health care. Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements.

The Joint Commission’s evaluation and accreditation services are provided for the following types of organizations:

• General, psychiatric, children’s, and rehabilitation hospitals

• Critical access hospitals

• Health care networks, including managed care plans, preferred provider organizations, integrated delivery networks, and managed behavioral health care organizations

• Home care organizations, including those that provide home health services, personal care and support services, home infusion and other pharmacy services, durable medical equipment services, and hospice services

• Nursing homes and other long-term care facilities, including subacute care programs, dementia special care programs, and long-term care pharmacies

• Assisted living facilities that provide or coordinate personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities, and health-related services

• Behavioral health care organizations, including those that provide mental health and addiction services, and services to persons with developmental disabilities of various ages, in various organized service settings

• Ambulatory care providers, such as outpatient surgery facilities, rehabilitation centers, infusion centers, group practices, and office-based surgery

• Clinical laboratories, including independent or free-standing laboratories, blood transfusion and donor centers, and public health laboratories

Accreditation by The Joint Commission is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain The Joint Commission’s Gold Seal of Approval, an organization must undergo an on-site survey conducted by The Joint Comission at least every 3 years. Laboratories must be surveyed every 2 years.

BENEFITS OF JOINT COMMISSION ACCREDITATION

There are many benefits to accreditation, but those specific to health care accreditation include:

• Leads to improved patient care

• Demonstrates the organization’s commitment to safety and quality

• Offers an educational on-site survey experience

• Supports and enhances safety and quality improvement efforts

• Strengthens and supports recruitment and retention efforts

• May substitute for federal certification surveys for Medicare and Medicaid

• Helps secure managed care contracts

• Facilitates the organization’s business strategies

• Provides a competitive advantage

• Enhances the organization’s image to the public, purchasers, and payers

• Fulfills licensure requirements in many states

• Recognized by insurers and other third parties

• Strengthens community confidence

STANDARDS AND PERFORMANCE MEASUREMENT

The Joint Commission standards address the organization’s level of performance in key functional areas, such as patient rights, patient treatment, and infection control, and the standards focus not simply on an organization’s ability to provide safe, high-quality care but also on its actual performance. Standards set forth performance expectations for activities that affect the safety and quality of patient care. If an organization does the right things and does them well, there is a strong likelihood that its patients will experience good outcomes. The Joint Commission develops its standards in consultation with health care experts, providers, measurement experts, purchasers, and consumers. See Box 7-1 for an overview of The Joint Commission’s Hospital Accreditation Standards.

Box 7-1 THE JOINT COMMISSION HOSPITAL ACCREDITATION STANDARDS OVERVIEW

Patient-Focused Functions

• Ethics, rights, and responsibilities

• Provision of care, treatment, and services

• Medication management

• Surveillance, prevention, and control of infection

Organization-Focused Functions

• Improving organization performance

• Management of the environment of care

• Management of human resources

• Management of information

Structures with Functions

• Medical staff

© Copyright 2007, The Joint Commission. JC Hospital Accreditation Standards 2007 Manual.

There are also disease-specific certifications such as The Joint Commission’s certificate of distinction for primary stroke centers. This certification program was developed in collaboration with the American Stroke Association. Other disease-specific certifications of The Joint Commission include those for asthma, heart failure, and trauma. Disease-specific care certifications focus on:

• Creating an organized comprehensive approach to disease-specific performance improvement

• Using comparative data to evaluate disease-specific program processes and patient outcomes

• Evaluating the patients’ perception of care quality

• Maintaining data quality and integrity

The Joint Commission survey is considered a “rite of passage” for any new nurse manager. Before 2008, the survey would occur every 3 years and was announced. On the eve of the announced visit, there would be much preparation and energy invested in the satisfactory completion of the survey. In 2008, The Joint Commission started making unannounced visits. This change requires that all health care institutions be in a state of “constant readiness.” Changes in The Joint Commission accreditation process are summarized in Box 7-2.

Box 7-2 THE JOINT COMMISSION’S SHARED VISIONS—NEW PATHWAYS

Shared Visions—New Pathways includes the following changes in the accreditation process

• A substantial consolidation of the standards was undertaken to reduce the paperwork and documentation burden associated with the accreditation process. The intent of this change is to increase the organization’s focus on patient safety and health care quality by improving the clarity and relevance of the remaining standards.

• A midcycle, periodic performance review (PPR) is now required, during which the organization must evaluate its compliance with TJC standards. If noncompliance is noted, a plan of action must be developed and reported. Validation of PPR findings and corrections will be reviewed by TJC during the organization’s next on-site survey.

• A priority focus process (PFP) is used to design each organization’s on-site survey. The PFP uses the organization’s core measures data, previous recommendations, demographic data related to clinical service groups, complaints, sentinel event information, and MedPar data to design a survey that is relevant to that organization’s patient safety and health care quality issues.

• On-site evaluation is now focused on compliance to the standards in relation to the care experiences of actual patients in the facility. This process is known as the tracer methodology.

• Individual organizational performance reports have been revised to provide “Quality Reports,” which include specific organizational performance information.

• Surveyors actively seek the engagement of physicians and other direct caregivers during the accreditation process.

From Yoder-Wise, P. S. (2006). Beyond leading and managing nursing administration for the future. St. Louis, MO: Mosby, 2006:381.

The importance of the nurse’s role in ensuring patient safety and delivering quality care is emphasized through key nursing activities such as:

• Influencing improved design of care processes

• Creating a nonpunitive environment to enhance error reporting

• Participating in error reporting and analysis

The importance of the nurse’s position is further elaborated by her or his leadership role in complying with the necessary standards for medication management, infection control, pain management, and the environment of care.

As a nurse, daily adherence to the standards is of the utmost importance. During a site visit from the accrediting agencies, you will be asked to participate in interviews or team meetings with representatives from the accrediting bodies.

One of the most common standards of The Joint Commission that affects nursing care deals with the management of pain. The standard includes the following:

• Documentation of assessment of pain

• Documentation of the relief of pain

• Use of therapeutics to manage pain

• Assessment of use of therapeutics

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Tags: Nursing Delegation and Management of Patient Care

Dec 3, 2016 | Posted by admin in NURSING | Comments Off

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