The newest hospital accreditation option is the Center for Improvement in Healthcare Quality (CIHQ). Originally formed in 1999, CIHQ is a membership organization with more than 360 hospitals and other healthcare entities throughout the United States.
This is part 5 of an 8-part series on Accreditation Options for Hospitals and Health Systems.
Read Part 1: Accreditation: A CEO’s Strategic Choice
Read Part 2: Understanding the Healthcare Facilities Accreditation Program
Read Part 3: Accreditation Options: Understanding the Joint Commission
Read Part 4: Understanding DNV GL - healthcare’s National Integrated Accreditation for Healthcare Organizations program
The mission of CIHQ is to "create a regulatory environment that evaluates healthcare organizations to effectively deliver safe, quality patient care. Its purpose is to:
• Advocate on behalf of [its] members in shaping the accreditation and regulatory environment by working with CMS in the development of standards and regulations.
• Educate members on standards, regulations, and the survey process and encourage the professional growth of individuals in the field of healthcare accreditation through national certification.
• Advise members on changes to standards and regulations and the impact on their organization.
• Assist members in determining their compliance to accreditation standards and CMS certification requirements.
• Improve the ability of [its] members to successfully meet the challenges of today’s regulatory environment.”
CIHQ was originally composed of two divisions (consultation and professional certification). The accreditation division was created in 2013. As the Centers for Medicaid and Medicare Services (CMS) began to re-emerge as a dominant force in the hospital accreditation environment, CIHQ saw a need for an accreditation organization to help hospitals be successful in the CMS certification process and provide an effective voice for their members in helping to shape the regulatory environment in which they work. The accreditation division received deeming authority from CMS in July 2013.
At the time of publication, 47 hospitals have attained CIHQ accreditation. CIHQ also offers certification in the disease management programs for acute stroke ready hospitals, primary stroke centers, comprehensive stroke centers, heart failure, and hip and knee replacement surgery, as well as certification for centers of excellence for rehabilitation care and long-term acute care.
Standards
CIHQ standards are primarily (about 95%) based on CMS' Conditions of Participations (CoPs). There are some additional requirements related to key patient safety and quality of care concerns. The 28 chapters in its manual closely resemble the names of the chapters in the CoPs.
Survey process
CIHQ surveys all services and sites that are listed on the hospital's cost report and fall under the hospital's provider number. Unlike some of the other accrediting organizations, CIHQ does not require a hospital to undergo a survey for any component that does not fall under the hospital's provider number.
CIHQ performs two types of surveys: full and focused. Full surveys include the initial survey and the triennial survey. Both surveys are unannounced. The initial survey is conducted within four months of receipt of the hospital's application. The triennial survey is conducted between months 34 and 36. Usually, a full survey consists of two or three surveyors, including at least one registered nurse and one facilities specialist. The length of the survey varies from two to four days, depending on the size and complexity of the organization.
A typical survey includes a combination of CMS survey procedures with tracer methodology; review of documents; visits to patient care and support service areas—all sites where anesthesia and sedation are administered will be surveyed and a sample of outpatient services will be visited; a building tour; and review of credentials and personnel files. CIHQ does not hold interview sessions with large groups of people or committees.
Focused surveys consist of mid-cycle, complaint, and follow-up surveys. All surveys are unannounced. The mid-cycle survey occurs around the 18th month. Generally, it is a one-day survey conducted by one surveyor to assess the hospital's compliance with any new regulations that have been published since the hospital's initial or triennial survey. Larger hospitals may have two surveyors for a one-day visit.
CIHQ will investigate any complaints submitted to them. While most complaints can be handled via correspondence, an on-site survey may be conducted if the complaint is serious. If the hospital sustained a Condition-level finding or if there was an immediate threat to health and safety deficiency, a follow-up survey will be conducted. Note that a full re-survey will occur if these findings were present during the initial survey. The only expense to the organization is travel costs, as CIHQ does not charge survey fees for focused surveys.
Standards are scored as pass/fail using CMS' three levels of deficiencies:
1. Standard-level (noncompliance with one or more standards)
2. Condition-level (noncompliance with one or more standards that would substantially limit an organization's capacity to furnish adequate care or would jeopardize or adversely affect the health or safety of patient if the deficiency recurred)
3. Immediate threat to health and safety (a situation where noncompliance with one or more standards/CMS requirements has caused or is likely to cause serious injury, harm, impairment, or death to a patient)
Accreditation status is awarded as "accredited," "accreditation at risk" (violation of key CIHQ policies or survey requirements), or "accreditation withdrawn or denied" (failure to address the accreditation at risk issue, failure to pay accreditation fees, or refusal to permit CIHQ to conduct a survey or provide necessary information).
CIHQ follows the "10 and 10 methodology" for sending the final report to the organization within 10 business days and requiring an acceptable corrective action plan (CAP) for all deficiencies within 10 calendar days of posting of the final report. Note that an acceptable CAP for an immediate threat to health and safety deficiency requires submission within 72 hours. CIHQ has specific electronic forms to guide the organization in writing the CAP. Generally, the maximum timeframe for completion of the CAP is 45 calendar days from the last day of the survey for standard-level deficiencies, 30 calendar days for Condition-level deficiencies, and 10 calendar days for immediate threat to health and safety deficiencies.
Senior CIHQ staff review the CAP and notify the organization in writing if the plan is acceptable (no further action required) or unacceptable. If the plan is unacceptable, CIHQ staff will explain why and indicate what modifications need to be made. The organization will then submit a second CAP within seven calendar days. If the second CAP is unacceptable, the organization will have a third and final opportunity to submit an acceptable CAP within five calendar days. If the third plan is unacceptable, the accreditation status will be changed to "accreditation at risk." Either a full or focused follow-up survey will be conducted to validate implementation of the CAP for any Condition-level deficiencies.
Below are the most frequent findings that cause Condition-level deficiencies in CIHQ accreditation surveys:
1. Noncompliance to fire safety system maintenance and testing requirements
2. Violations of the NFPA 2012 Life Safety Code
3. Noncompliance to standards addressing sterilization and high-level disinfection
4. Noncompliance to standards requiring monitoring to patients in restraint/seclusion
5. Noncompliance to standards addressing compounding of sterile IV products
Benefits
The following resources are available at no additional charge to CIHQ accredited organizations:
• Access to standards and survey procedures (survey activities guide)
• Monthly audio conferences regarding survey procedures with time for Q&A
• Template policies, forms, staff training aides, and other documentation tools to assist in compliance efforts
• Attendance for two at the CIHQ Annual Accreditation & Quality Summit; organization pays only travel expenses
• Access to a web-based reference library with links to healthcare regulations
• Notification of changes in standards and CMS regulations
• Access to in-house panel of consultant experts for CIHQ or CMS standards interpretation
• Discounts from CIHQ partner companies and organizations that provide various services
Costs
Full surveys are paid in three installments based on an annual fee schedule, which includes surveyor travel expenses. Pricing is based on the number of licensed beds, the length of the survey, the number of surveyors, and the number of sites providing anesthesia services. CIHQ asserts that their prices are competitive with other accrediting organizations. There are no survey fees for focused surveys — only travel expenses are billed to the organization.
For hospitals seeking deemed status by an accrediting organization that closely follows the CoPs, CIHQ offers a convincing option. More information can be found at www.cihq.org.
###
Next in the Accreditation Options series, we explore state-based review for Medicare/Medicaid approval of the Conditions of Participation as an alternative to accreditation.
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).
Website: www.Compass-Clinical.com
Tel. 800-241-0142
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.