In our series on "Accreditation Options," we have analyzed the four main sources for external accreditation with deeming status CMS: the Healthcare Facilities Accreditation Program (HFAP), The Joint Commission (TJC), DNV GL - Healthcare (DNV GL), and the Center for Improvement in Healthcare Quality (CIHQ). This article helps healthcare executives determine which accreditation source is the best match for their organization.
This is part 7 of an 8-part feature on accreditation options for Hospitals and Health Systems. Read. Read previous articles below:
1. Accreditation options update: Going bare —The state option as an alternative to accreditation
2. Understanding the center for improvement in healthcare quality (CIHQ)
3. Accreditation options: Understanding DNV GL - healthcare’s national integrated accreditation for healthcare organizations program
4. Accreditation options update: Understanding the Joint Commission (TJC)
5. Accreditation options update: Understanding the Healthcare Facilities Accreditation Program (HFAP)
6. Accreditation: A hospital CEO’s strategic choice
Regardless of choice—including the option of not seeking accreditation and instead gaining approval through survey by the state agency responsible for Centers for Medicare and Medicaid Services (CMS) oversight—selecting an accreditation source is a strategic decision meriting leadership consideration for an appropriate organizational fit.
Because these are choices with real differences, executives should select an accreditation vendor based on criteria. But what criteria make one organization a better fit than the others?
A good fit
An accreditation source should be selected to fit an organization's mission, vision, and culture. Simply put, the accrediting source must match the organization's complexity, clinical focus, and values. For example, hospitals deeply involved in Six Sigma or Lean process redesign might find the DNV GL process more appropriate, but a complex academic medical center would probably find the various specialty accreditation services of TJC to align more with its organizational mission.
Accreditation by an accrediting organization is a voluntary process, and hospitals are still subject to compliance and validation surveys from CMS and/or relevant state health agencies that use CMS investigation methodologies, which emphasize results more than management systems.
Summary of options
Here is a summary of the options and some considerations for hospital executives as they determine strategy for their organization.
HFAP: Predictable
Community hospitals seem to be more open to seeking alternatives to TJC accreditation. Many community hospitals have converted to HFAP, finding the process more predictable and more closely aligned with the CMS Conditions of Participation. Some believe that HFAP surveyors are more oriented to real-world clinical operations because they are drawn from a pool of working volunteers instead of working as full-time surveyors as with TJC. Costs for HFAP are more predictable because most organizations do not seek outside consultation as they prepare for survey.
TJC: Market leader
Many hospital systems, including academic medical centers, are almost exclusively tied to TJC accreditation except for those sponsoring osteopathic education, which typically prefer HFAP approval for deemed status. TJC considers itself a performance improvement organization above and beyond its deeming status role. Standards and accountability measures are developed to support this role, and information is provided to organizations to assist them in attaining compliance.
Because TJC’s accreditation program includes requirements that exceed the CoPs, organizations choosing TJC should expect to invest time and resources in order to maintain currency with TJC’s new and changing standards, as well as in the potential need for external consultation in preparation for survey. Beyond periodic accreditation surveys, TJC can conduct supplemental surveys or require that the hospital work with TJC when sentinel events are reported. These additional encounters may result in additional charges to the hospital. Additionally, it is noteworthy that because TJC accredits a variety of entities, leaders should consider this factor when seeking one-stop accreditation.
DNV GL: Pioneer
Those pioneers seeking DNV GL accreditation have embarked on a new approach. A commitment to DNV GL requires yearly surveys, with the ultimate goal of complying with ISO9001:2015 Standards, while actual certification as an ISO9001 organization is optional. Interpretive guidelines and other accreditation process information are provided at no cost. Most interesting is the change in corporate culture implicit in DNV GL accreditation. When an organization chooses DNV GL accreditation, it moves away from a mentality of meeting standards toward a focus on operating quality management systems as a core business function.
CIHQ: Pragmatic/Practical
CIHQ's approach to accreditation is straightforward; of all the accrediting organizations, its standards most closely align with the CoPs. Novice to expert accreditation coordinators will appreciate the links in the standards to frequently asked questions, as well as access to other regulations. The triennial survey window is tighter than other accrediting organizations (between the 34th to 36th months). However, organizations will undergo a mid-cycle survey around the 18th month. Because this option is newer, hospital accreditation is the only survey program provided at this time. So, a complex organizational system would need to seek accreditation for programs that are not under the hospital's Medicare certification number – such as critical access hospitals, ambulatory surgery centers, or home health – from another accreditation provider.
Selection and communication
One significant determinant of the appropriate accreditation source for an organization should be community standards and how those standards are reflected in managed-care contracting. If all regional competitors are TJC accredited, breaking away from this norm and seeking accreditation from a new source requires an organization to communicate the rationale and advantages of the change. Third-party payers, regulators, and community leaders will need to understand the motivation for such a change for it to be approved. However, in some communities, hospital leaders may find that payers and purchasers are indifferent to accreditation agencies, as long as their hospital "qualifies for Medicare."
However a hospital chooses, accreditation means compliance with the Conditions of Participation, which means continuous compliance and ongoing attention to monitoring compliance. Beyond that, other factors influence the choice of accreditation agencies. The key change from the past is that now, there is a choice, and the differences among agencies are real. Hospitals should select a vendor that meets its needs, and not feel compelled to accept the agencies' rules.
This article was previously published in Becker’s Hospital Review. Compass Clinical Consulting has updated the content to reflect changes in the Accreditation Options since previous publication.
Victoria Fennel, PhD, RN-BC, CPHQ has more than 20 years of healthcare leadership experience. She has spent the majority of her career in nursing leadership roles and brings expertise in evidence-based practice, nursing education, quality management, performance improvement, accreditation, risk management, patient safety, and patient-centered care. As Director of Accreditation and Clinical Compliance for Compass Clinical Consulting, Victoria manages accreditation and compliance engagements, directs client education and advisement, and has led Compass’ efforts to help healthcare organizations prepare for scrutiny from accrediting bodies such as the Centers for Medicare and Medicaid Services (CMS), the Joint Commission (TJC), and Healthcare Facilities Accreditation Program (HFAP).
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.