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Chapter 15 - PI in HealthCare

STUDY
PLAY
Accreditation
The act of granting approval to a healthcare organization based on whether the organization has met a set of voluntary standards developed by an accreditation agency
Certification
The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries
Compliance
The process of meeting a prescribed set of standards or regulations to maintain active accreditation, licensure, or certification status
Compulsory Reviews
The examination of a healthcare facility and its processes and infrastructures as required by state laws and regulations
Conditions of Participation
A set of regulations published by the CMS to outline requirements of approved programs providing healthcare services to beneficiaries of Medicare/Medicaid programs
Deemed Status
The term used for the assumption by CMS that an organization meets the Medicare/Medicaid Conditions of Participation as a result of prior accreditation by AAAHC, AOA, CARF, or the Joint Commission
Document Review
An in-depth study performed by accreditation surveyors of an organization's policies and procedures, administrative records, human resources records, and other similiar documents
Exit Conference
A meeting that closes a site visit during which the surveyors representing an accrediting organization summarize their findings and explain any deficiencies
Licensure
The process of granting a healthcare organization or an individual healthcare practitioner a license to practice
Opening Conference
A meeting conducted at the beginning of the accreditation site visit during which the surveyors outline the schedule of activities and list any individuals whom they would like to interview
Quality Improvement Organizations (QIO)
Private or public agencies contracted by the CMS to undertake examination and evaluation of the quality of healthcare rendered to beneficiaries of federal healthcare programs
Site Visit
An in-person review conducted by an accreditation survey team; the visit involves document reviews, staff interviews and other activities
Survey Team
A group of individuals sent by an accrediting agency to review a healthcare organization for accreditation purposes
Tracer Methodology
A process Join Commission surveyors use during the on-site survey to analyze an organization's systems; by following individual patients through the organization's healthcare process as experienced by patients
Voluntary Reviews
An examination of an organization's structures and processes conducted at the request of a healthcare facility seeking accreditation from a reviewing agency
CARF
Commission on Accreditation of Rehabilitation Facilities; 1966
AOA
American Osteopathic Association; 1945
NCQA
National Committee for Quality Assurance; 1991
AAAHC
Accreditation Association for Ambulatory Health Care
RFIs
Requirements for Improvement