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The act of granting approval to a healthcare organization


The act of granting a healthcare organization or an individual healthcare provider permission to provide services of a defined scope in a limited geographical area


Grants approval for a healthcare organization to provide services to a specific group of beneficiaries

Compulsory reviews

Performed to fulfill legal or licensure requirements

Voluntary reviews

Conducted at the request of the healthcare facility seeking accreditation


the process of meetinga prescribed set ofstandards orregulation to maintain active accreditation, license, or certification status

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

This organization has been responsible for accrediting healthcare organizations since the middle 1950s and determines whether the organization is continually monitoring and improving the quality of care they provide.

Commission on Accreditation of Rehabilitation Facilities (CARF)

This private, not-for-profit organization is committed to developing and maintaining practical, customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.

National Committee for Quality Assurance (NCQA)

managed care organizations, managed behavioral health organizations, and credentials verification for physician organizations.

Conditions of Participation

Every organization that provides services to Medicare and Medicaid beneficiaries must demonstrate its compliance with this set of standard

Data repository

A large database that stores every data element collected within a healthcare organization and is used for PI activities is called:

Information warehouse

This technology allows organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizations activities

Comparative performance data

When healthcare organizations evaluate their Joint Commission core measure data with similar organization, they are using this

American Osteopathic Association (AOA)

"The professional association of osteopathic physicians, surgeons, and graduates of approved colleges of osteopathic medicine that inspects and accredits osteopathic colleges and hospitals"

Accreditation Association for Ambulatory Health Care (AAAHC)

"A professional organization that offers accreditation programs for ambulatory and outpatient organizations such as single-specialty and multispecialty group practices, ambulatory surgery centers, college/university health services, and community health centers"

State Licensure

Gives the agency legal permission to operate only within that state

Quality improvement orgainizations (QIO)

retrospectively reveiw patient records to ensure that the care provided by practioners meet the federal standards for medical necessity, level of care, and quality of care

deemed status

approval granted to healthcare organizations that have undergone accrediation through a national accrediting organization that complies with the conditions of participation for the Medicare and Medicaid programs.

document review

"An in-depth study performed by accreditation surveyors of an organization's policies and procedures, administrative records, human resources records, performance improvement documentation, and other similar documents, as well as a review of closed patient records"

exit conference

"A meeting that closes a site visit during which the surveyors representing an accrediting organization summarize their findings and explain any deficiencies that have been identified; at this time, the leadership of the organization also is allowed an opportunity to discuss the surveyors' perspectives or to provide additional information related to any deficiencies the surveyors intend to cite in their final reports"

opening conference

A meeting conducted at the beginning of The Joint Commission accreditation site visit during which the surveyors outline the schedule of activities and list any individuals whom they would like to interview

site visit

a visit in an official capacity to examine a site to determine its suitability for some enterprise

survey team

group that conducts the site survey

tracer methodology

assessment of opertainal systems and processes in relation to the actual experiences of selected patients who are currently under the organiztion's care

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