Question

Hospital Administration and Management

in health care, there are several accrediting agencies that supervise and regulate a variety of healthcare settings. Do some research on the type of accrediting agency that you believe governs the type of facility you see yourself working in, either now or in the future. Next,

write a short summary of the accrediting agency, and identify one to two accrediting regulations the agency enforces. How can you prepare your facility to comply with these regulations?

What barriers do you anticipate having to overcome to achieve and maintain compliance? How can a healthcare administrator affect the accreditation process?

Hospital Administration and Management

Reference Your textbook may be used as a reference.

The APA format for your text is as follows:

Langabeer, J. R., & Helton, J. (2016). Health care operations management: A systems perspective (2nd ed.). Burlington, MA: Jones & Bartlett Learning.

Answer 1

Accreditation is a sign that an institution ascribes to, believes in, and has met an external set of basic criteria for its programs. An accredited school will have passed a thorough inspection of its educational and administrative policies and practices, gauged by peers actually in the profession. An accredited school is credentialed as being an institution that graduates students who are fully prepared to succeed in their area of specialty.

The Importance of Choosing an Accredited Program

Accreditation should be one of your top qualifying criteria when researching programs. You want the very best education and when a program can boast accreditation from either the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or the Accrediting Bureau of Health Education Schools (ABHES), you can be assured your school can deliver the most current curriculum.

Beyond the assurance that your school offers the high quality medical assistant education that you’ll need to prepare for a career in this field, you’ll also find that accreditation carries additional benefits:

• Not only will these accrediting agencies assure that the how’s and what’s of learning are in place, but that you will form an educational bedrock for future growth.
• If you receive a medical assistant certificate from school accredited by either the CAAHEP or ABHES, you will be able to later build on that certificate to complete an associate’s or bachelor’s degree and be assured your credits will transfer.
• With an accredited school credential on your resume, you can sit for the national certification exam and become a Certified Medical Assistant.

One critical key benefit to attending an accredited program is that they offer access to federal financial aid to help you pay for school and supplies. It is important to have a supplemental means with which to pay for your education. Keep in mind that there are also plenty of scholarships available from a wide range of foundations and organizations in your local area and nationally.

Programs that have regional accreditation may also be satisfactory for many students, and there are six locations that govern specific areas of the United States. When a program has regional accreditation, you can still build on the completed schooling, in that you can transfer your credits to other educational institutions and earn a higher degree. Make sure to do a comparison of the programs to ensure that you will learn what you need in order to succeed in your medical assisting career.

Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable.

Accreditation is a sign that an institution ascribes to, believes in, and has met an external set of basic criteria for its programs. An accredited school will have passed a thorough inspection of its educational and administrative policies and practices, gauged by peers actually in the profession. An accredited school is credentialed as being an institution that graduates students who are fully prepared to succeed in their area of specialty.

The Importance of Choosing an Accredited Program

Accreditation should be one of your top qualifying criteria when researching programs. You want the very best education and when a program can boast accreditation from either the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or the Accrediting Bureau of Health Education Schools (ABHES), you can be assured your school can deliver the most current curriculum.

Beyond the assurance that your school offers the high quality medical assistant education that you’ll need to prepare for a career in this field, you’ll also find that accreditation carries additional benefits:

• Not only will these accrediting agencies assure that the how’s and what’s of learning are in place, but that you will form an educational bedrock for future growth.
• If you receive a medical assistant certificate from school accredited by either the CAAHEP or ABHES, you will be able to later build on that certificate to complete an associate’s or bachelor’s degree and be assured your credits will transfer.
• With an accredited school credential on your resume, you can sit for the national certification exam and become a Certified Medical Assistant.

One critical key benefit to attending an accredited program is that they offer access to federal financial aid to help you pay for school and supplies. It is important to have a supplemental means with which to pay for your education. Keep in mind that there are also plenty of scholarships available from a wide range of foundations and organizations in your local area and nationally.

Programs that have regional accreditation may also be satisfactory for many students, and there are six locations that govern specific areas of the United States. When a program has regional accreditation, you can still build on the completed schooling, in that you can transfer your credits to other educational institutions and earn a higher degree. Make sure to do a comparison of the programs to ensure that you will learn what you need in order to succeed in your medical assisting career.

Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable.

Standards development process

Joint Commission standards are developed with input from health care professionals, providers, subject matter experts, consumers, and government agencies (including the Centers for Medicare & Medicaid Services). They are informed by scientific literature and expert consensus and reviewed by the Board of Commissioners. New standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured.

The standards development process includes the following steps:

• Emerging quality and safety issues suggesting the need for additional or modified requirements are identified through the scientific literature or discussions with The Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, consumer groups or others.
• The Joint Commission prepares draft standards using input from technical advisory panels, focus groups, experts and other stakeholders.
• The draft standards are distributed nationally for review and made available for comment on the Standards Field Review page of The Joint Commission website.
• After any necessary revisions, standards are reviewed and approved by executive leadership.
• The survey process is enhanced, as needed, to address the new standards requirements, and pilot testing of the survey process is conducted.
• Surveyors are educated about how to assess compliance with the new standards.
• The approved standards are published for use by the field.
• Once a standard is in effect, ongoing feedback is sought for the purpose of continuous improvement.

A collection of agencies regulate and govern the technological side of healthcare in the U.S. The Department of Health and Human Services Office for Civil Rights (OCR) is in charge of HIPAA enforcement, by auditing healthcare providers and their business associates and handing out fines for noncompliance. The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) both play roles as healthcare compliance resources and regulators of the meaningful use program.

CMS is in a position to reduce the Medicare reimbursement payments of meaningful use participants that fail to meet the criteria and OCR has started to audit covered entities and business associates for HIPAA compliance.

The Food and Drug Administration (FDA) also has a place in managing health IT. The FDA evaluates medical devices and classifies them by the level of risk they could present to users.

Healthcare compliance resources and agencies

• Centers for Medicare & Medicaid Services (CMS)
• HIPAA (Health Insurance Portability and Accountability Act)
• ONC (Office of the National Coordinator for Health Information Technology)
• US Department of Health and Human Services (HHS)
• Office for Civil Rights (OCR)
• Centers for Disease Control and Prevention (CDC)
• health information exchange (HIE)
• ICD-10 (International Classification of Diseases, Tenth Revision)

OCR and HIPAA compliance
Office for Civil Rights

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is responsible for enforcing HIPAA Privacy and Security Rules. To this end, the OCR investigates privacy violations and enforces penalties for noncompliance.

Prior to the HITECH Act, the OCR only audited a HIPAA covered entity when a patient filed a complaint with the agency. However, the HITECH Act now requires the OCR to conduct periodic audits of providers and HIPAA business associates to ensure they are HIPAA compliant.

In addition to holding covered entities accountable, the OCR publishes HIPAA Privacy Rule guidance materials, which are intended to help organizations meet requirements for compliance. The OCR also provides a variety of healthcare compliance resources in the form of training materials and guidance materials for covered entities.

Meaningful use attestation
Centers for Medicare & Medicaid Services

The Centers for Medicare and Medicaid Services (CMS), also a division of HHS, is responsible for the administration of Medicare, Medicaid and the Children's Health Insurance Program.

The HITECH Act also adds several key tasks to CMS' list of responsibilities that are intended to advance health IT. Under the HITECH Act, hospitals and eligible professionals who failed to demonstrate the meaningful use of electronic health record (EHR) technology by 2015 will be penalized in the form of reduced Medicare and Medicaid reimbursements. However, those who demonstrate meaningful use before the deadline are eligible for financial incentives.

To this end, CMS is charged with the following:

• Implementing the federal government's EHR Incentive Programs
• Defining criteria for meaningful use of certified EHR technology
• Drafting standards for the certification of EHR technology
• Updating HIPAA health information privacy and security regulations

Health data Interoperability
Office of the National Coordinator for Health IT

The Office of the National Coordinator for Health Information Technology (ONC) is the principal entity responsible for coordinating nationwide efforts to implement and use advanced health information technology and health information exchange. To this end, the ONC is spearheading the effort to move America's healthcare system from paper to electronic health records. This includes programs to encourage EHR adoption, as well as the use of other technologies, by holding competitions and offering prizes.

ONC's mission also includes coordinating health IT policy, providing leadership in the development, recognition and implementation of standards, and the certification of health IT products. In addressing these myriad tasks, the ONC uses the HealthIT.gov site to share healthcare compliance resources and other helpful information.

The FDA and medical devices
Food and Drug Administration

In addition to regulating drugs, the Food and Drug Administration (FDA) also regulates the safety and effectiveness of X-ray equipment and medical devices. This includes approving new devices before they go to market, defining manufacturing and performance standards and tracking reports of device malfunction and serious adverse reactions.

The FDA assigns medical devices, software and other equipment to categories of regulatory control. The categories, or classes, define the regulatory requirements for those items. On a scale of Class III (high risk) to Class I (low risk) the FDA classifies medical device data systems (MDDS) as Class I devices. Class I devices are subject to general regulatory control and exempt from premarket notification requirements, which eases certain requirements. The FDA determined that MDDS that receive or store data from medical devices do not need to be subject to stringent regulations.

The FDA has taken a similar approach with mobile health applications. The administration has looked into regulating mHealth and wellness apps and devices, and determined that most don't pose a significant threat to patient safety.

Accreditation agency rundown
Hospital accreditation agencies

CMS has approved a limited number of hospital accreditation agencies, including: The Joint Commission, the Healthcare Facilities Accreditation Program and DNV Healthcare Inc., the Accreditation Association for Ambulatory Health Care, the Accreditation Commission for Health Care, Inc., the American Association for Accreditation of Ambulatory Surgery Facilities, the Center for Improvement in Healthcare Quality, the Community Health Accreditation Program and The Compliance Team.

The Joint Commission, founded in 1951, is an independent organization that accredits and certifies healthcare organizations and programs in the U.S. Its healthcare accreditation program involves an on-site survey conducted by a commission team at least once every three years. Most states require accreditation by The Joint Commission as a prerequisite for licensing and Medicaid reimbursement.

The Joint Commission also issues advice regarding the protection of personal health information. For example, TJC warned healthcare organizations that "it is not acceptable" for physicians and other practitioners to send patient orders via text messages due to security and privacy issues.

DNV Healthcare Inc. integrates ISO 9001:2008 with Medicare Conditions of Participation. DNV's hospital accreditation is the National Integrated Accreditation for Healthcare Organizations (NIAHC). Hospitals do not have to comply with ISO 9001 to be accredited by DNV -- they have up to three years from their effective Medicare participation date (determined by CMS) to become ISO 9001 compliant.

DNV also offers primary stroke center certification and critical access hospital accreditation.

The Chicago-based Healthcare Facilities Accreditation Program incorporates National Quality Forum (NQF) standards for patient safety and care quality into its accreditation programs for acute care and critical access hospitals, ambulatory surgical centers, clinical laboratories, behavioral and mental health facilities, ambulatory care and office-based surgery centers and primary stroke centers. Healthcare compliance resources available from this organization include a description of NQF's 34 safe practices and a series of webinars that explain the certification process. The program is run by the American Osteopathic Association.

The Accreditation Association for Ambulatory Health Care, founded in 1979, accredits more than 5,000 healthcare organizations including community health centers and other medical and dental facilities. It is based in Skokie, Ill.

The Accreditation Commission for Health Care, Inc. was established by The Association for Home & Hospice Care of North Carolina in 1986 and focuses on accreditation of in-home and alternate-site care providers. It is based in Cary, N.C.

The American Association for Accreditation of Ambulatory Surgery Facilities, headquartered in Gurnee, Ill., originated in 1980 and maintains a mission of standardizing quality care in ambulatory surgery facilities. More than 2,000 healthcare facilities are accredited by the association.

The Center for Improvement in Healthcare Quality was established in 1999 and is based in Round Rock, Texas. Acute care and critical access hospitals make up most of the group's membership, which cooperates with CMS on the development of healthcare standards and regulations.

The Community Health Accreditation Program was jointly created by the National League for Nursing and the American Public Health Association in 1965. It is headquartered in Washington D.C. and accredits community and home-based healthcare organizations.

The Compliance Team was founded in 1994 and provides accreditation to healthcare providers in Puerto Rico, the U.S. Virgin Islands and all fifty states.

Barrier to the implementation of accreditation

Data that allowed for creating this category indicate that, from quality managers' point of view, difficulties related to accreditation, more specifically to their implementation and maintenance, have to do with organizational culture and staff turnover. Therefore, two subcategories were also created within this category. Culture is an element that is part of the informal structure of organizations, and unlike the elements that are part of the formal structure, such as organization charts, regulations, and technique and procedure manuals, they are not explained or viewed in a
concrete or documentary form18. In view of the above, maybe as a result of the subjectivity of the presented issue, managers interviewed, who have the responsibility of putting into practice a complex quality management system that is based, among others, on the rationalization of work, on the standardization of processes and on the assessment of concrete results, mentioned the organizational culture as a barrier to the implementation of accreditation.

The biggest difficulty is to break paradigms. There is the cultural issue. Like it or not, you will have to break paradigms, to implement the culture. And it is also [difficult] for senior management. It was very difficult at the beginning, but we did it (QMH4).

There is a great challenge of patient quality and safety is to implement the culture of quality within the organization [...]. The implementation of culture, I think that's the big challenge.

The main difficulty is culture. Indeed, it's culture. It was a moment of great union. It was exhausting because it is very difficult to break paradigms, to introduce concepts and make things happen, because it's cultural.

Changing is not easy. It's a health institution, in which the implementation of quality management programs is very different from in a factory. But it tends to change. People can see the difference over time. Perception by managers is not instant.

Great difficulties keeping the workforce and the process of accreditation. You train professionals today and tomorrow they leave, you no longer have them to provide services with safety and quality

Standards development process

Joint Commission standards are developed with input from health care professionals, providers, subject matter experts, consumers, and government agencies (including the Centers for Medicare & Medicaid Services). They are informed by scientific literature and expert consensus and reviewed by the Board of Commissioners. New standards are added only if they relate to patient safety or quality of care, have a positive impact on health outcomes, meet or surpass law and regulation, and can be accurately and readily measured.

The standards development process includes the following steps:

    Emerging quality and safety issues suggesting the need for additional or modified requirements are identified through the scientific literature or discussions with The Joint Commission’s standing committees and advisory groups, accredited organizations, professional associations, consumer groups or others.
    The Joint Commission prepares draft standards using input from technical advisory panels, focus groups, experts and other stakeholders.
    The draft standards are distributed nationally for review and made available for comment on the Standards Field Review page of The Joint Commission website.
    After any necessary revisions, standards are reviewed and approved by executive leadership.
    The survey process is enhanced, as needed, to address the new standards requirements, and pilot testing of the survey process is conducted.
    Surveyors are educated about how to assess compliance with the new standards.
    The approved standards are published for use by the field.
    Once a standard is in effect, ongoing feedback is sought for the purpose of continuous improvement.

A collection of agencies regulate and govern the technological side of healthcare in the U.S. The Department of Health and Human Services Office for Civil Rights (OCR) is in charge of HIPAA enforcement, by auditing healthcare providers and their business associates and handing out fines for noncompliance. The Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator for Health IT (ONC) both play roles as healthcare compliance resources and regulators of the meaningful use program.

CMS is in a position to reduce the Medicare reimbursement payments of meaningful use participants that fail to meet the criteria and OCR has started to audit covered entities and business associates for HIPAA compliance.

The Food and Drug Administration (FDA) also has a place in managing health IT. The FDA evaluates medical devices and classifies them by the level of risk they could present to users.

Healthcare compliance resources and agencies

    Centers for Medicare & Medicaid Services (CMS)
    HIPAA (Health Insurance Portability and Accountability Act)
    ONC (Office of the National Coordinator for Health Information Technology)
    US Department of Health and Human Services (HHS)
    Office for Civil Rights (OCR)

    Centers for Disease Control and Prevention (CDC)
    meaningful use
    health information exchange (HIE)
    ICD-10 (International Classification of Diseases, Tenth Revision)

OCR and HIPAA compliance
Office for Civil Rights

The Office for Civil Rights (OCR) within the U.S. Department of Health and Human Services (HHS) is responsible for enforcing HIPAA Privacy and Security Rules. To this end, the OCR investigates privacy violations and enforces penalties for noncompliance.

Prior to the HITECH Act, the OCR only audited a HIPAA covered entity when a patient filed a complaint with the agency. However, the HITECH Act now requires the OCR to conduct periodic audits of providers and HIPAA business associates to ensure they are HIPAA compliant.

In addition to holding covered entities accountable, the OCR publishes HIPAA Privacy Rule guidance materials, which are intended to help organizations meet requirements for compliance. The OCR also provides a variety of healthcare compliance resources in the form of training materials and guidance materials for covered entities.

Meaningful use attestation
Centers for Medicare & Medicaid Services

The Centers for Medicare and Medicaid Services (CMS), also a division of HHS, is responsible for the administration of Medicare, Medicaid and the Children's Health Insurance Program.

The HITECH Act also adds several key tasks to CMS' list of responsibilities that are intended to advance health IT. Under the HITECH Act, hospitals and eligible professionals who failed to demonstrate the meaningful use of electronic health record (EHR) technology by 2015 will be penalized in the form of reduced Medicare and Medicaid reimbursements. However, those who demonstrate meaningful use before the deadline are eligible for financial incentives.

To this end, CMS is charged with the following:

-- Implementing the federal government's EHR Incentive Programs

-- Defining criteria for meaningful use of certified EHR technology

-- Drafting standards for the certification of EHR technology

-- Updating HIPAA health information privacy and security regulations

Health data Interoperability
Office of the National Coordinator for Health IT

The Office of the National Coordinator for Health Information Technology (ONC) is the principal entity responsible for coordinating nationwide efforts to implement and use advanced health information technology and health information exchange. To this end, the ONC is spearheading the effort to move America's healthcare system from paper to electronic health records. This includes programs to encourage EHR adoption, as well as the use of other technologies, by holding competitions and offering prizes.

ONC's mission also includes coordinating health IT policy, providing leadership in the development, recognition and implementation of standards, and the certification of health IT products. In addressing these myriad tasks, the ONC uses the HealthIT.gov site to share healthcare compliance resources and other helpful information.

The FDA and medical devices
Food and Drug Administration

In addition to regulating drugs, the Food and Drug Administration (FDA) also regulates the safety and effectiveness of X-ray equipment and medical devices. This includes approving new devices before they go to market, defining manufacturing and performance standards and tracking reports of device malfunction and serious adverse reactions.

The FDA assigns medical devices, software and other equipment to categories of regulatory control. The categories, or classes, define the regulatory requirements for those items. On a scale of Class III (high risk) to Class I (low risk) the FDA classifies medical device data systems (MDDS) as Class I devices. Class I devices are subject to general regulatory control and exempt from premarket notification requirements, which eases certain requirements. The FDA determined that MDDS that receive or store data from medical devices do not need to be subject to stringent regulations.

The FDA has taken a similar approach with mobile health applications. The administration has looked into regulating mHealth and wellness apps and devices, and determined that most don't pose a significant threat to patient safety.

Accreditation agency rundown
Hospital accreditation agencies

CMS has approved a limited number of hospital accreditation agencies, including: The Joint Commission, the Healthcare Facilities Accreditation Program and DNV Healthcare Inc., the Accreditation Association for Ambulatory Health Care, the Accreditation Commission for Health Care, Inc., the American Association for Accreditation of Ambulatory Surgery Facilities, the Center for Improvement in Healthcare Quality, the Community Health Accreditation Program and The Compliance Team.

The Joint Commission, founded in 1951, is an independent organization that accredits and certifies healthcare organizations and programs in the U.S. Its healthcare accreditation program involves an on-site survey conducted by a commission team at least once every three years. Most states require accreditation by The Joint Commission as a prerequisite for licensing and Medicaid reimbursement.

The Joint Commission also issues advice regarding the protection of personal health information. For example, TJC warned healthcare organizations that "it is not acceptable" for physicians and other practitioners to send patient orders via text messages due to security and privacy issues.

DNV Healthcare Inc. integrates ISO 9001:2008 with Medicare Conditions of Participation. DNV's hospital accreditation is the National Integrated Accreditation for Healthcare Organizations (NIAHC). Hospitals do not have to comply with ISO 9001 to be accredited by DNV -- they have up to three years from their effective Medicare participation date (determined by CMS) to become ISO 9001 compliant.

DNV also offers primary stroke center certification and critical access hospital accreditation.

The Chicago-based Healthcare Facilities Accreditation Program incorporates National Quality Forum (NQF) standards for patient safety and care quality into its accreditation programs for acute care and critical access hospitals, ambulatory surgical centers, clinical laboratories, behavioral and mental health facilities, ambulatory care and office-based surgery centers and primary stroke centers. Healthcare compliance resources available from this organization include a description of NQF's 34 safe practices and a series of webinars that explain the certification process. The program is run by the American Osteopathic Association.

The Accreditation Association for Ambulatory Health Care, founded in 1979, accredits more than 5,000 healthcare organizations including community health centers and other medical and dental facilities. It is based in Skokie, Ill.

The Accreditation Commission for Health Care, Inc. was established by The Association for Home & Hospice Care of North Carolina in 1986 and focuses on accreditation of in-home and alternate-site care providers. It is based in Cary, N.C.

The American Association for Accreditation of Ambulatory Surgery Facilities, headquartered in Gurnee, Ill., originated in 1980 and maintains a mission of standardizing quality care in ambulatory surgery facilities. More than 2,000 healthcare facilities are accredited by the association.

The Center for Improvement in Healthcare Quality was established in 1999 and is based in Round Rock, Texas. Acute care and critical access hospitals make up most of the group's membership, which cooperates with CMS on the development of healthcare standards and regulations.

The Community Health Accreditation Program was jointly created by the National League for Nursing and the American Public Health Association in 1965. It is headquartered in Washington D.C. and accredits community and home-based healthcare organizations.

The Compliance Team was founded in 1994 and provides accreditation to healthcare providers in Puerto Rico, the U.S. Virgin Islands and all fifty states.

Barrier to the implementation of accreditation

Data that allowed for creating this category indicate that, from quality managers' point of view, difficulties related to accreditation, more specifically to their implementation and maintenance, have to do with organizational culture and staff turnover. Therefore, two subcategories were also created within this category. Culture is an element that is part of the informal structure of organizations, and unlike the elements that are part of the formal structure, such as organization charts, regulations, and technique and procedure manuals, they are not explained or viewed in a concrete or documentary form18. In view of the above, maybe as a result of the subjectivity of the presented issue, managers interviewed, who have the responsibility of putting into practice a complex quality management system that is based, among others, on the rationalization of work, on the standardization of processes and on the assessment of concrete results, mentioned the organizational culture as a barrier to the implementation of accreditation.

The biggest difficulty is to break paradigms. There is the cultural issue. Like it or not, you will have to break paradigms, to implement the culture. And it is also [difficult] for senior management. It was very difficult at the beginning, but we did it (QMH4).

There is a great challenge of patient quality and safety is to implement the culture of quality within the organization. The implementation of culture, I think that's the big challenge.

The main difficulty is culture. Indeed, it's culture. It was a moment of great union. It was exhausting because it is very difficult to break paradigms, to introduce concepts and make things happen, because it's cultural.

Changing is not easy. It's a health institution, in which the implementation of quality management programs is very different from in a factory. But it tends to change. People can see the difference over time. Perception by managers is not instant.

Great difficulties keeping the workforce and the process of accreditation. You train professionals today and tomorrow they leave, you no longer have them to provide services with safety and quality