Preparedness and Response Blog

Hospital Accreditation and it's Impact on Emergency Management

Written by Mary Lou Weden | May 30, 2016 4:39:00 PM
In order for a health care organization to participate in and receive payment from the Medicare or Medicaid programs, it must meet the eligibility requirements for program participation, including a certification of compliance with the Conditions of Participation or Conditions for Coverage, for health care suppliers, which are set forth in federal regulations.
The certification is based on a survey conducted by a state agency on behalf of the Centers for Medicare & Medicaid Services (CMS) or a national accrediting organization, such as The Joint Commission, that has been approved by CMS as having standards and survey processes that meets or exceeds Medicare’s requirements. Health care organizations that achieve accreditation through a Joint Commission are deemed as meeting Medicare and Medicaid requirements.

What is Accreditation?

Per the CMS, section 1865(a)(1) of the Social Security Act permits providers and suppliers who are accredited by an approved national accreditation organization (AO) to be exempt from routine surveys by State agencies to determine compliance with Medicare conditions. Accreditation by an AO is voluntary and not required for Medicare certification or participation in the Medicare Program. A provider’s or supplier’s ability to bill Medicare for covered services is not impacted if it chooses to discontinue accreditation from a CMS-approved AO or change to another AO. The Act indicates that, if the Secretary finds that accreditation of a provider entity by a national accreditation body demonstrates that all applicable conditions are met or exceeded, the Secretary may deem those requirements to be met by the provider or supplier. Before permitting deemed status for an AO's accredited provider entities, the AO must submit an application for CMS review and approval.

Who is Approved by CMS to Accredit Health Care Organizations?

Agencies approved by CMS include The Joint Commission (TJC), Det Norske Veritas Healthcare, Inc. (DNV GL) and American Osteopathic Healthcare Facilities Accreditation Program (HFAP).  The Joint Commission is arguably the largest and most noted survey organization in the U.S. today.  According to The Joint Commission, it has "accredited hospitals for more than 60 years and today accredits approximately 4,055 general, pediatric, long term acute, psychiatric, rehabilitation and specialty hospitals, and 358 critical access hospitals, through a separate accreditation program." More than 70 percent of the nation's hospitals are accredited by TJC, and almost 90 percent of hospitals in the U.S. have obtained their accreditation through The Joint Commission.

What Comprises the Survey Process?

The Joint Commission survey process is data-driven, patient-centered and focused on evaluating actual care processes. The Joint Commission concentrates not only on the evaluation of processes but also on educating organizations on best practices.  Surveys are unannounced and generally occur within a window between 18 to 36 months since the last full survey visit.  The onsite visit generally follows a tracer methodology in which the surveyor(s) will follow the patient care experience throughout the continuum of care processes in an organization.  Additionally, there is an Environment of Care, or EOC, session in which survey experts in their field conduct a building tour.  It is within the EOC chapter where emergency management standards and elements of performance are evaluated. 

What is the Emergency Management Chapter All About?

The EM chapter of TJC is divided up into standards and elements of performance to achieve the overall standard.  The standards are grouped into three major themes: emergency operations plan, response and recovery plan and evaluation.  There are 12 standards and 111 elements of performance within these primary themes.  The scoring methodology varies depending upon the standard and element of performance.  In general, The Joint Commission utilizes a 3 point scale:  0- for an element of performance that has insufficient compliance; 1 - for partial compliance; 2 - satisfactory compliance.  The Joint Commission has a rich set of tools and documents that further define the standards, rationale and elements of performance to assist a hospital in its journey towards accreditation.  The emergency manager should seek the advice of their hospital's staff assigned to the area of readiness for The Joint Commission accreditation and adherence to quality and care standards. 

Is There Technology That Can Help Me Prepare for TJC Survey on Emergency Management?

The largest challenge for an emergency manager or a leader tasked with the chapter on Emergency Management for The Joint Commission is documenting and showing evidence of your procedures and processes at your health care facility/system.  The volume of paper can easily fill many binders.  The challenge is to keep it all straight and up to date with appropriate review signatures so that your documentation follows your practice and your practice follows what you state in your emergency operations plan and the standards by your accrediting body.  Best practice is to keep all pertinent documents demonstrating compliance in an easy to find, central location for all to view.  An electronic document library and management system, whereby the emergency manager can not only control the content, but make it available to all who need access is a huge time saver.  Instead of multiple copies in various locations, stakeholders in the EM program at your facility can log into the electronic library and gain access. 
Because TJC utilizes a tracer methodology for its reviews, the emergency manger can expect the reviewer to begin with either your EOP or hazard vulnerability assessment (HVA).  Both the EOP and HVA provide cornerstones for your EM program.  After reviewing your HVA, the reviewer may ask to see your last several drills.  Keep in mind that it may be as long as 36 months since your last on-site review and because of the timing, you may have up to 6 or more documented exercises, drills and/or actual events that have occurred.  Your after action report, lessons learned and tracking log of improvements is open for review and must show a logical progression  and linkage to your HVA, updates in your policies and procedures, and revision of your EOP. 
The usage of an electronic, web-based incident command tool that keeps historical information readily available, including a description of your exercise, who participated, and a tracking log of improvements - including date, assignments, progress, etc., will facilitate your review and ease your burden of assembling information at time of your unannounced survey.  The bottom line is to leverage technology to assist you in advancing your hospital's EM program.  Today's emergency manager is busy planning, coordinating, communicating and evaluating their EM program.  Let technology be your partner in your EM program by looking for tools that will help you plan, respond and recover from day-day to emergencies and disasters.