DMEPOS/HME, Hospice, Home Health, Hospital Services

Doctor and Staff

Today’s healthcare environment is becoming more focused on accreditation and continual compliance.  Public and Private health plans now demand that any provider organization seeking accreditation first earn accreditation from one of the nationally recognized accreditation bodies.

Earning Accreditation

For a healthcare organization to earn accreditation it must first comply with a rigorous set of compliance standards focusing on “Patient Safety.”  Accreditation bodies that have deeming authority by Centers for Medicare and Medicaid Services (CMS) have CMS quality standards integrated into their existing standards.

Most accreditation bodies follow the same format and categories of standards:

  • Infection control
  • Human resources
  • Environment of care
  • Performance improvement
  • Leadership or governance
  • Provision of care
  • Record of care
  • Patient/Employee rights and ethics
  • Equipment management
  • Life safety
  • Laboratory
  • Waive testing
  • Medication management, etc…

An aspiring healthcare organization must implement all quality standards that are applicable to their organization type as defined by their accreditor:

  • Developing and implementing policies and procedures to comply with each standard
  • Develop policies and procedures for all internal and external processes
  • Training and orienting all staff on areas defined by the quality standards (infection control, patient safety, HIPAA, etc…)
  • Track and document all accreditor defined activities such as (patient complaints, service delivery, equipment maintenance, disaster drills, patient falls, infections, incidents, staff training, etc…)
  • Conduct internal audits and performance reviews to ensure continual compliance

Once implemented, the organization must begin working as if they are accredited for a period of time (usually 4 months) prior to their accreditation survey.

Initial Accreditation Survey

One the day of the survey their chosen accreditation organization’s surveyors/auditors will arrive onsite to perform the accreditation audit.  They typically use two techniques when conducting a survey; Patient Tracer and System Tracer.  Both processes reveal many things about your organizations compliance system or quality management systems effectiveness.

Patient Tracer

At the center of any healthcare organization lies the patient.  This is where your surveyor/auditor will begin to understand how your quality management system works.  By examining the patient chart/record, a surveyor can begin to piece together the entire encounter from admission to discharge.  In all cases patient charts/records are reviewed to determine total compliance with all regulations and quality standards.  The chart will point the surveyor in many directions and all departments whether they made direct contact with the patient or not.  This method is used extensively by accreditors like “The joint Commission” as well as in “ISO 9001” audits.  To learn more about Patient Tracer methodology visit IBNLearning.com