This final installment in our series on "Accreditation Options" helps hospital executives determine which accreditation source is the best match for their organization. Previously in the series, we analyzed the four main sources for external accreditation with deeming status CMS: The Joint Commission, Healthcare Facilities Accreditation Program, Det Norske Veritas Healthcare and the Center for Healthcare Improvement.
Regardless of choice — including the option of not seeking accreditation and instead gaining approval through survey by the state agency responsible for 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 DNVHC process more appropriate, but a complex academic medical center would probably find the various specialty accreditation services of TJC more aligned 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 AMCs, are almost exclusively tied to TJC accreditation with the exception of 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 the TJC 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.
DNVHC: Pioneer
Those pioneers seeking DNVHC accreditation have embarked on a new approach. A commitment to DNVHC requires yearly surveys, with the ultimate goal of achieving ISO9001 certification. Standards, interpretive guidelines and other accreditation process information are provided at no cost. Most interesting is the change in corporate culture implicit in DNVHC accreditation. When an organization chooses DNVHC accreditation, it moves away from a mentality of meeting standards and toward a focus on operating quality management systems as a core business function.
CIHQ: Pragmatic/Practical
CIHQ's approach to accreditation is very straightforward. Of all of 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 so new (attaining deemed status last year), 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 in order 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.
Victoria Fennel 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, she manages the quality of accreditation and compliance engagements and directs client education and advisement.