The “Accreditation Options” series from Compass Clinical Consulting has so far evaluated the strengths and limitations of the four primary accrediting organizations with deemed status from CMS (Centers for Medicare and Medicaid Services) below:
1. Understanding the Healthcare Facilities Accreditation Program
2. Accreditation Options: Understanding the Joint Commission
3. Understanding DNV GL - Healthcare’s National Integrated Accreditation for Healthcare Organizations program
4. Understanding the Center for Improvement in Healthcare Quality
One additional but rarely used option is to eschew any external accrediting body and instead select state-based review for Medicare/Medicaid approval of the Conditions of Participation.
There are advantages and costs associated with all options. But few organizations understand, much less consider, the state option.
State Designated Agencies
Each state has a designated agency, usually the state department of health, contracted with CMS for supervision and evaluation of all participating hospitals. Most hospitals encounter a state survey following a complaint, but CMS also requires that states conduct a validation (follow-up to accrediting agency survey to assure comprehensiveness) of 5% of accreditation surveys. Less well known is the option of obtaining the state department of health certification for initial and continuing approval for Medicare and Medicaid participation, rather than an accreditation organization. There is no requirement that any facility obtain accreditation, so the state agency’s approval for Medicare and Medicaid participation is sufficient for CMS participation.
Choosing the state option has advantages and possible disadvantages that leadership should consider in the decision-making process.
Advantages
Advantages of the state option include the following:
Cost reduction. Direct costs of accreditation are easy to calculate, including the annual expense paid to the external agency for membership, survey, education, access to standards, support consultation, and workshops. Less quantifiable but probably much larger costs include: staff devoted to accreditation functions; leadership and manager time spent in pursuit of standards compliance; additional resources external to the accrediting agency such as software, mock survey consultants, accreditation agency consultations, monitoring systems, and communication and enforcement of standards to hospital staff and physicians; and general support for staying up-to-date with the complexities of ever-changing standards and interpretation of these standards. The total annual direct and indirect costs of accreditation probably equal $500,000 and greater in a freestanding community hospital.
Less administrative burden. Successfully meeting accreditation standards requires significant time and attention devoted to compliance—time and attention that might be better deployed on strategic issues and concerns of the hospital.
Competitive impact. Few consumers or physicians pay any attention to an organization’s accreditation status. In fact, it is frequently perceived as an irritant by medical staff—in their perspective, it is a
nother burden on their workload with little visible payoff.
Licensure. In some states, an annual or biennial licensure inspection from the state is inevitable, so using the state survey to determine compliance with the CMS Conditions of Participation simply streamlines external intrusion.
Disadvantages
Of course, there are also disadvantages associated with using the state option to consider, including the following:
Payers. A requirement for accreditation may be included in insurance contracts. Choosing the state option will require review of all payer mandates and contractual obligations related to accreditation status and organization.
Competitive pressure. Other hospitals in the market may highlight their accreditation status as an indicator of quality and assurance to potential consumers of safety. Consider your competitive market.
Altered perception. Staff and physicians may perceive that the hospital is switching to a less stringent form of accreditation because hospital leadership believes they cannot pass the standards set by the accrediting organization and can only meet the minimum standards in the CoPs.
State enforcement vagaries. The rigidity and capriciousness of state enforcement varies by state department of health. Hospitals in some states might find that accreditation processes better prepare the institution for state scrutiny.
The decision to select an accreditation source is critical. But too often, organizations forget the state option, as external accrediting agencies such as TJC, HFAP, DNV GL, and CIHQ are not the only route to Medicare participation.
In the final installment of the “Accreditation Options” series, we will summarize the options available to hospital leaders as they consider the strategic choice of selecting an accrediting body – or deciding to forgo an accrediting agency and elect the state option.
End part 6 of the Accreditation Options series.
This is an 8-part series on Accreditation Options for Hospitals and Health Systems. The series is compiled in a PDF if you’d like to read all 8 parts at Compass Clinical Consulting.
About the author
Kate Fenner, PhD, RN understands hospital leadership. First as a nurse, and later as an education leader and consultant, Kate has immersed herself in the regulatory and operational issues that face today’s healthcare organization for more than 35 years. Throughout her career, she has worked with and presented to hospitals on a variety of regulatory topics including performance improvement, leadership standards, human resources management, root cause analysis, and board involvement in quality. In addition, she has led and participated in dozens of mock surveys to help healthcare organizations meet the standards and expectations of regulatory bodies such as The Joint Commission, CMS, and state departments of health.
Website: www.Compass-Clinical.com
Tel. 800-241-0142
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