Accreditation for Healthcare Facilities (Changed in 2000)

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While the Joint Commission remains the dominant accrediting body in health care, the Balanced Budget Act (BBA)and subsequent budget Refinement Act (BBRA) of 1999 gave CMS (Center's for Medicare/Medicaid Services) the authority to establish and oversee a programs that allows private, national accreditation organizations to "deem" that a Medicare Advantage organization is compliant with certain Medicare requirements.

Those six are:

  • Quality Assurance
  • Anti-Discrimination
  • Access To Services
  • Confidentiality and Accuracy of Enrollee Records
  • Information on Advance Directives
  • Provider Participation Rules

To be approved for deeming authority, an accrediting organization must demonstrate thta their program meets or exceeds the Medicare requirements for which they are seeking the authority to deem compliance.

Three organization have been authorized at this time for (hospitals/nursing homes/clinics)

  • Joint Commission, which follows below
  • HFAP American Osteopathic Association's Healthcare Facilities Accreditation Program)
  • DNV Healthcare, Inc known as NIAHO National Integrated Accrediation for Healthcare Organizations (September 26, 2008)

The Joint Commission

The JCAHO is the nation’s predominant standard setting and accrediting body in health care. They evaluate and accredit about 19,000 health care organizations and programs within the United States. They are also extensively involved internationally. Established in 1951, the organization has developed state of the art, professionally based standards and evaluated the compliance of healthcare organizations against constantly changing benchmarks.

JCAHO’s mission is to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in health care organizations.

Accreditation by the JCAHO is recognized nationally and internationally as a symbol of quality and that accreditation certifies that a specific organization meets or exceeds JCAHO standards. To earn and maintain accreditation, an organization must stand the rigors by a JCAHO survey team on a random selective basis.

JCAHO has many accreditation services including:
· General, psychiatric, children’s and rehabilitation hospitals,
· Healthcare Networks and Preferred Provider networks
· Home Care organizations and durable medical equipment services
· Nursing Homes and other Long Term facilities
· Assisted Living services
· Behavioral Health Care Organizations
· Ambulatory Care Providers
· Clinical Labs

JCAHO standards address an organizational level of performance in key areas, such as patient rights, and the standards focus not only on what the organization has, but what the organization accomplishes. The JCAHO develops their standards in consultation with health care experts, providers and consumers. These standards set forth performance requirements andexpectations for most activities that affect patient care.

According to the JCAHO, organizations seek accreditation because the JCAHO
· Assist organizations in improving their quality of care
· May be used to meet certain Medicare certification requirements
· Enhances public confidence
· Provides a staff educational tool
· Enhances Medical Staff recruitment
· Expedites third party payments
· Fulfills many state license requirements
· Enhances access to managed care contracts
· May favorably influence bond ratings and access to financial markets

In 1996 JCAHO introduced a primary performance management system for the accreditation process called ORYX – a reporting mechanism for accreditation which is also used to monitor the results of that accreditation yearly. The system became active in 1997 for hospitals, long term care, networks, home care, behavioral care and labs.

In addition to offering accreditation the JCAHO sponsors a variety of educational programs and provides an extensive list ofpublications for health care managers. The national conference for JCAHO this year will focus on Patient Safety and Quality of Care. There are numerous other seminars and conferences that address every standard component.

Based in Chicago, the JCAHO is governed by a 28 member Board of Commissioners which includes nurses, physicians,consumers, medical directors, administrators, providers, employers, labor representatives, planners, quality experts, health insurance administrators and educators. Its board of commissioners brings countless years of experience and expertise in the health care, business sector. JCAHO corporate members include the American College of Physicians, American Society of Internal Medicine, the American College of Surgeons, the American Dental Association, the American Hospital Association and the American Medical Association.

HFAP Healthcare Facilities Accreditation Program (American Osteopathic Association)

HFAP is also recognized by:

  • National Committee for Quality Assurance (NCQA)
  • Accreditation Council for Graduate Medical Education (ACGME)
  • State departments of public health
  • Managed care organizations
  • Insurance companies

Clear and Direct Survey Standards

HFAP standards have been “cross-walked” to the Medicare Conditions of Participation (CoPs) for each type of facility. This cross-walk approach means anyone reading the HFAP standards m anual can clearly see how each standard ties directly to a Medicare CoPs.

HFAP standards reflect Medicare standards (40%), patient safety (27%), quality improvement (29%), environmental safety (26%) and patient treatment (47%).

Compliance with HFAP requirements assures compliance with Medicare standards.

Basis of HFAP accreditation survey standards:

  • Medicare Conditions of Participation (CoPs)
  • NFPA Life Safety Code
  • Institute for Healthcare Improvement
  • Agency for Healthcare Research & Quality (AHRQ)
  • National Quality Forum
  • Medicare Foundation
  • Additional non-Medicare quality standards
  • Suggestions and input from our customers

High-Quality, Helpful Surveyors

Our surveyors are practicing medical professionals, with practical field experience and a helpful attitude—when a problem is discovered, they are ready to discuss options in real time.

HFAP accreditation survey teams have an average of three surveyors: A physician serves as team captain, along with a registered nurse and hospital administrator.

To ensure surveyors maintain a high level of professional quality, HFAP requires:

  • All surveyors attend mandatory training workshops to augment the real-world experience they bring with them
  • HFAP surveyor teams are not "fixed", so surveyors work with a variety of other surveyors
  • During each survey, each team member scores the other team members in a variety of categories

Comprehensive, Straight-Forward Survey Process

The HFAP facility accreditation process can take from six to nine months to complete, from application to accreditation.

The basic steps in the accreditation surveying process include:

  • Application
  • Survey
  • Deficiency report
  • Plan of corrections
  • Accreditation action

When switching your accreditation to HFAP our staff can work with you to ensure that there is no interruption in reimbursement. Ideally, we would like to begin the application process at least six months prior to the expiration date of your current accreditation.

Cost-Effective Quality Survey

Our customers tell us we provide the most cost effective approach.

Determining the HFAP facility accreditation survey fee is straight-forward, varying only by the size and volume of your organization. And because our standards are so clearly written, additional consultations and workshops are available, but not required.

There are three main elements to the HFAP fee for accrediting a facility:

  1. Triennial Registration Fee ($3,900 X 3 = $11,700) plus adjustment for volume tied to Medicare Cost Report
  2. Purchase of Accreditation Standards Manual ($375)
  3. Reimbursement for direct costs of conducting the survey, depending on the number of surveyors assigned to your facility and their travel costs. (Avg. $10,600)

Currently, a three-year accreditation averages $8,600 annually.

DNV NIAHO National Integrated Accreditation for Healthcare Organizations

NIAHO is designed from the ground up to drive quality transformation into the core processes of running a hospital. NIAHO helps healthcare organizations meet their national accreditation obligations and achieve ISO 9001 compliance in the same seamless program. Our surveys are conducted annually. The results are transformative.

NIAHOSM compresses the survey cycle from every three years to annually, thereby ensuring continual quality improvement.


As a global leader in standards and industry certifications, we know that infrequent surveys create a fire-drill effect that drains valuable resources and provides little lasting value to the organisation being audited.

Our goal is to offer healthcare organizations and companies a new alternative to hospital accreditation. The NIAHOSM program is the first new hospital accreditation program in the United States in 40 years.

DNV has already accredited 27 hospitals in 22 states participating in the NIAHOSM program.

DNV (Det Norske Veritas) was established in 1864 and is an independent foundation with a purpose to safeguard life, property and the environment. Increasing patient safety and reducing errors in healthcare is an important part of that purpose.

On 27 July, 2007, DNV acquired TUV Healthcare Specialists which was actively developing NIAHOSM. DNV’s experience in hospital evaluations and rating spans the globe. DNV has been awarded by UK’s NHSLA (National Health services Litigation Authority) a five year programme to evaluate and rate the hundreds of hospitals it controls in England.

Furthermore, DNV has issued 1,200 ISO certificates to healthcare facilities worldwide, including hospitals, outpatient clinics, diagnostic centres, laboratories, nursing homes and homecare centres.

Headquarters for DNV Healthcare Inc. is Houston, Texas, with offices in Cincinnati, Ohio and we maintain survey staff throughout the United States.


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