Building Your Professional Toolkit: The Hospital Quality Director Series
Preparing for Accreditation and Licensing Surveys, Part 1
Welcome to Beyond the Swiss Cheese’s “Hospital Quality Director Series”, aimed at equipping hospital quality directors across the U.S. with tools, resources, and information for professional success in a role that frequently comes without any training or support. Let’s start with preparing for accreditation and licensing surveys.
Introduction to Hospital Accreditation
As a hospital quality director, navigating the complexities of accreditation and licensing surveys is one of your most critical responsibilities. These surveys not only ensure compliance with regulatory requirements but also provide opportunities to enhance patient care, improve safety protocols, and strengthen your organization's overall quality management systems.
Whether you're preparing for accreditation with The Joint Commission, Det Norske Veritas (DNV), the Healthcare Facilities Accreditation Program (HFAP), Center for Improvement in Healthcare Quality (CIHQ), Accreditation Commission for Health Care (ACHC), or any of the Centers for Medicare and Medicaid Services (CMS)-approved accrediting organizations, a systematic approach to preparation can transform what might seem like a daunting task into a strategic opportunity for organizational improvement.
This blog series provides a step-by-step approach to help you successfully prepare your hospital for upcoming accreditation and licensing surveys, drawing on best practices and proven methodologies from healthcare quality experts.
First Things First: Understanding the Accreditation Landscape
Key Accrediting Organizations in the U.S.
Before diving into preparation strategies, it's important to understand the major accreditation players in the healthcare space:
The Joint Commission (TJC): The largest and oldest healthcare accrediting body, accrediting nearly 3,000 hospitals in the United States. TJC accreditation is considered the gold standard by many and has been granting "deemed status" for Medicare participation since 1965.
Det Norske Veritas (DNV): DNV offers the National Integrated Accreditation for Healthcare Organizations (NIAHO®) program which uniquely integrates ISO 9001 quality management principles into its accreditation process, emphasizing continuous improvement.
Healthcare Facilities Accreditation Program (HFAP): Another important accrediting organization that focuses on patient-centered processes through comprehensive, unbiased surveys. (In 2020, HFAP merged with ACHC)
Center for Improvement in Healthcare Quality (CIHQ): The newest CMS-approved accrediting agency (since 2011).
Accreditation Commission for Health Care (ACHC): An organization that accredits multiple types of healthcare organizations, from ambulatory care to hospitals and beyond.
Why is Accreditation Necessary? Understanding CMS Conditions of Participation (CoPs)
The Centers for Medicare & Medicaid Services (CMS) Conditions of Participation (CoPs) form the backbone of all accreditation programs. Hospitals must meet these standards to participate in Medicare and Medicaid programs. When a hospital receives accreditation from an approved organization like TJC or DNV, they are granted "deemed status," meaning they are considered to meet or exceed the Medicare CoP standards.
The CoPs cover various aspects of healthcare delivery, including:
Patient care
Medication management
Infection control
Physical environment
Emergency preparedness
Quality assurance and performance improvement
This means that a hospital’s accreditation preparation team must have representation from a variety of stakeholders in the organization. AND that means that survey preparation is not the SOLE responsibility of the hospital quality director.
Step 1: Build Your Accreditation Leadership Team
Assembling the Right Team
The foundation of successful accreditation preparation starts with building a dedicated team:
Designate an Accreditation Coordinator: This person will serve as the central point of contact and will manage the overall preparation process.
Identify Department Leaders: For each major accreditation standard or chapter, assign a team leader who understands that specific area. For example, a senior pharmacist might lead medication management standards, while an infection preventionist leads infection control.
Include Leadership Representation: Ensure C-suite engagement with at least one executive sponsor who can provide necessary resources and authority.
Consider Multidisciplinary Representation: Include clinical and non-clinical staff who can provide diverse perspectives on hospital operations.
Team Responsibilities
Your accreditation team should:
Study relevant standards for their assigned areas
Conduct gap analyses
Develop action plans to address identified gaps
Monitor progress toward compliance, including review of past accreditation survey findings, action plans, and ongoing monitoring to assure compliance
Educate staff in their departments
Participate in mock surveys
Serve as liaisons during the actual survey
Step 2: Master the Standards and Requirements
Obtain and Review Relevant Materials
Acquire Current Standards Manuals: Purchase or download the current standards from your accrediting body. For example, The Joint Commission Accreditation Manual or DNV's NIAHO Standards.
Review Interpretive Guidelines: These provide insight into how surveyors interpret and apply standards. Also - be sure to review the CMS Conditions of Participation State Operations Manual for your hospital type. These provide detailed information about the practices, policies, and documentation that CMS expects each organization to have in place in order to achieve deemed status. State Operations Manual for Acute Care Hospitals, State Operations Manual for Critical Access Hospitals
Stay Updated on Changes: Regularly check for updates to standards through newsletters, websites, and announcements from your accrediting organization.
Understand Survey Methodology: Familiarize yourself with your accreditor's survey approach. For instance, The Joint Commission uses the Tracer Methodology, while DNV emphasizes a risk-based approach.
Focus on Historically Problematic Standards
Review data on the most commonly cited standards. For example, The Joint Commission publishes an annual report on top cited standards, which often include:
Medication management
Infection control
Environment of care
Life safety
Medical record documentation
Stay tuned for Part 2 where we will dig into the specific activities your team will need to complete in order to prepare for your next survey!