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to provide quality health care services.

What is the goal of hospitals and other healthcare facilities


Accreditation agencies, peer review organizations, and other government agencies all present standards based on their particular objectives
true or false


provided by governmental agencies. The licensure review evaluates whether a health care facility is capable of providing minimum standards of quality care


The government will also_____ programs that are licensed to accept Medicare/Medicaid patients. This program is administered through the Department of Health and Human Services.


a voluntary form of review sought by a health care facility

non-governmental peer group

Who grants accreditation?

Standards of accreditation

broad statements specifying expected outcomes and not necessarily processes

Interpretations of the standards

serve to guide facilities in complying with the standards, allow different sizes and types of facilities to use different methods to achieve the desired outcomes.

commitment to quality healthcare

Accreditation provides evidence of a health care facility's?

joint commission

The best example of an accrediting agency is the?

The American Osteopathic Association

also accredits many facilities

external agencies that set standards for health care facilities

American Academy of Pediatrics, American College of Obstetricians/Gynecologists, American College of Surgeons, and the AMA.

American National Standards Institute (ANSI)

The US representative to ISO is the organization called the?


works to promote the development of standards, testing and certification to encourage quality products

The ISO 9000 Quality Systems Standard

a series of standards that provide guidance in the development and implementation of an effective quality management system


The ISO uses the term______ in referring to the process of meeting the ISO 9000 standards


In recent years, some hospitals have chosen not to seek accreditation from the Joint Commission or other accrediting agencies but instead seek registration from the International Organization for Standardization, an international agency consisting of 100 member countries
true or false?

mission of the joint commission

To improve the safety and quality of care provided to the public through the provision of accreditation and related services that support performance improvement in health care organizations


the American College of Surgeons (ACS) develops the Minimum Standards for Hospitals


The ACS officially transfers its Hospital Standardization Program to JCAH - Joint Commission on Accreditation of Hospitals


- Congress passes the Social Security Amendments of with a provision that hospitals accredited by JCAH are "deemed" to be in compliance with most of the Medicare Conditions of Participation and thus can participate in the Medicare and Medicaid programs

accreditation standards

There are printed standards unique to each of the various types of organizations that seek Joint Commission approval
These standards address the organization's level of performance in specific areas - not simply what the organization can do but what it is actually doing
The standards set maximum achievable performance expectations for activities that affect the quality of patient care

facilities the joint commission accredits

Ambulatory care
Behavioral health care
Critical access hospital
Home care
Laboratory Services
Long Term Care
Office-Based Surgery


The standards also address the eligibility of facilities to seek accreditation
true or false


For example, one of the standards for hospitals is that the organization be in the U.S. or one of its territories


Each manual is divided into chapters
true or false

some chapters in hospital manual

Information Management(IM)
Rights and Responsibilities (RI)
Medication Management (MM)
Medical Staff (MS)
Record of Care, Treatment and Services (RC


Each chapter is comprised of standards followed by rationale followed by elements of performance or EPs
true or false


Documentation icons are used to indicate when written documentation is needed to demonstrate performance


is a statement that defines the performance expectations for a facility to provide safe, high-quality care, treatment, and services


is either "compliant" or "not compliant" with a standard


Accreditation decisions are based on counts of standards scored as "not compliant
true or false


explains why it's important to achieve the standard
It is a statement that provides background, justification, or additional information about a standard


The standard's rationale is not scored
true or false

elements of performance

specific performance expectations and/or structures or processes that must be in place in order for a facility to provide safe, high-quality care, treatment or services

EP compliance

The scoring of _____ determines a hospital's overall compliance with a standard


Before a facility can determine its compliance with a standard, each EP must be scored
true or false

The EPs

"scored" to show compliance with the standards

Score 1

indicates partial compliance

Score 2

indicates satisfactory compliance

Score 0

indicates insufficient compliance


Each EP falls into one of two categories and is scored (0,1, or 2) based upon that category
true or false

Category A

the EP is based on track record and performance requirement
An example is the abbreviation list - either it is there or not

Category C

the EP is based on the number of times an organization does not meet the particular EP
Example is measuring the medical record delinquency at regular frequency and the organization does not meet minimum standards "x" amount of times

track record

is the amount of time that a hospital has been in compliance with a standard, element of performance or other requirement
This time limit differs for an initial survey and a full survey


The Joint Commission assesses compliance using several processes - one of which is the on-site survey
Since January, 2006, all the Joint Commission surveys have been unannounced
Initial Surveys are announced
true or false


on-site evaluation piece of a continuous process
The focus will be on encouraging the health care organization to continuously use the standards to achieve and maintain excellent operational systems

medium to large facilites

the survey team is comprised of a nurse, a physician and an administrator

smaller organizations

surveyor team will have a nurse and a physician

2-5 days depending on several factors including the size of the hospital and the services provided

what is the length of the survey

at daily briefings and during a medical staff conference luncheon

Surveyors communicate their observations when?

on the last day of the survey

The leadership exit conference is held when?

their preliminary accreditation decision

The surveyors confer the report of findings along with what?

the commission on accreditation

The final decision is made by who?


is awarded to a facility that is in compliance with all standards at the time of the on-site survey or has successfully addressed all requirements for improvement (RFI) in an Evidence of Standards Compliance (ESC) submission

provisional accreditation

is awarded to a facility that fails to demonstrate resolution of all RFIs in an ESC or Measures of Success (MOS) submission or meet all requirements for timely submission of data and information to The Joint Commission.

Medicare Condition

-Level Deficiency Follow-Up Survey results when an organization has one or more Conditions of Participation (CoPs) scored as a Condition-level deficiency. This rule does not apply to organizations that are not currently Medicare certified

conditional accreditation

results when a health care organization fails to resolve the requirements of a Provisional Accreditation status or was in substantial noncompliance with applicable Joint Commission standards. The organization must remedy identified problem areas through the submission of an ESC and undergo an on-site follow-up survey.

Preliminary Denial of Accreditation

results when there is justification to deny accreditation to the organization at the time of survey. The organization can appeal the denial.

Denial of Accreditation

results when the health care facility has been denied accreditation. All review and appeal opportunities have been exhausted

Preliminary Accreditation

results when the health care facility demonstrates compliance with selected standards in the first survey conducted under the Early Survey Policy

Periodic Performance Review (PPR)

A process in which a facility evaluates its own compliance with the standards and identifies areas for improvement. This is conducted and submitted to the Joint Commission prior to the survey


The organization updates the PPR tool annually - there are 4 options for this
true or false


The health care organization will submit a plan of action to the Joint Commission for standards that are assessed as "not compliant
true or false

organization's corrective plan action

should describe the planned action for each element of performance that is noncompliant

measure of success

The organization then develops a _______ for each of these elements

measure of success

a numerical or other quantitative measure validating that an action was effective and sustained

The Joint Commission's Standards Interpretation Group (SIG) staff

will review plan of actions with the facility over the phone and indicate whether the corrective actions and the time frames are acceptable
At the on-site visit, surveyors will evaluate whether plans of action were completed as planned

Priority Focus Process (PFP)

uses information about an individual organization to more clearly focus the on-site survey on priority areas of safety and quality of care


gathers data about an organization from multiple sources and analyzes the data using a set of defined, automated rules which turns the data into information that surveyors can use to tailor the survey to the needs of the organization


groups of patients in distinct populations for which data are collected


processes, systems, or structures in a health care organization that significantly impact the quality and safety of care

examples for clinical service groups for hospitals

General medicine and general surgery

Tracer Methodology

- an evaluation method that is designed to uncover systems issues


The tracer methodology is the cornerstone of the Joint Commission survey
true or false

tracer methodology

traces the experience of care for a number of individuals (identified by CSGs) through the organization's entire health care process
It allows the surveyors to identify performance issues in one or more steps of the process

The goal of program-

specific tracer activity is to identify safety concerns within different levels and types of care

individual tracer activity

the type of evaluation that traces the care experiences of a patient while in the hospital

Patient flow system tracers

address potential treatment delays, medical errors and unsafe practices that may occur during periods of patient congestion

60% of the survey process

The Tracer Methodology process comprises about?

Types of patients used in tracer methodology

Patient in the intensive care units
Patient entering hospital thru ED
Patient in labor and delivery
Patient who receives sedation and anesthesia
Patient on a SNF unit
Patient who is a 23-hour admit
Patient receiving dialysis
Psychiatric patient
Pediatric patient
Rehab patient
Deceased patient or terminal patient
Patient who is a possible organ donor or transplant recipient


More time will be spent on tracer activity and there will be less time for interviews and document review
true or false


The surveyor will talk to a patient during the tracer activity if it is appropriate and the patient is willing
true or false


Permission must be granted by the patient before the surveyor speaks to him or her
true or false

surveyors will also trace specific systems related to care

In addition to tracing care recipients throughout the organization?

system tracer for medication management

could involve following the path of a particular medication through selection, procurement, storage, prescribing or ordering, preparing, dispensing, administration, and monitoring of effects


Topics of system tracers may change from year to year as the health care environment changes but generally include
high-risk system processes
true or false

examples of program specific tracers

Suicide prevention
Laboratory integration
Patient flow
Resident centered care
Fall reduction
Hospital readmission

decision process and quality report

when an organization receives recommendations at survey, they are required to submit an Evidence of Standards Compliance (ESC) report which is basically a progress report

within 45-60 days following survey

This ESC must be submitted when?

retaining the "Accredited" decision

submission of the ESC is essential in ?

effective January 1, 2004

the Joint Commission released a list of nine unacceptable drug abbreviations, acronyms and symbols when?

banned abbreviations by the joint commission

U - for unit
IU - for international unit
Q.D., QD, q.d., qd, QOD, q.o.d and Q.O.D -
Trailing zero - X.0 mg
Lack of leading zero .X mg

Hospital medical record statistics form

One of the documents reviewed is the Hospital Medical Record Statistics Form

(ORR) ongoing record review

is required but the specifics of how it is done is up to the hospital


A survey by Medical Records Briefing indicates _____of ORR is done on a monthly basis

six National Patient Safety Goals (NPSGs)

In July 2002, the Joint Commission approved its first set of _______with 11 related specific requirements for improving the safety of patient care in health care organizations.


All the Joint Commission accredited health care organizations are surveyed for implementation of the goals and requirements—or acceptable alternatives—as appropriate to the services the organization provides
true or false


In 2004, the Joint Commission began developing program-specific NPSGs for each of its accreditation and certification programs in order to make the goals and requirements more relevant to the non-hospital accreditation programs
true or false

A sentinel event

an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof

because they signal the need for immediate investigation and response

Such events are called "sentinel" why?


Each organization must establish mechanisms for identifying, reporting and managing these events
true or false

Examples of reviewable sentinel events

Suicides in a staffed setting or within 72 hours of discharge
Unanticipated death of a full-term infant
Abduction of an individual
Discharge of an infant to the wrong family
Surgery on the wrong individual or body part
Hemolytic transfusion reaction involving blood or blood products due to incompatibilities
Unintended retention of a foreign object in an individual after surgery
Severe neonatal hyperbilirubinemia
Prolonged fluoroscopy or delivery of radiotherapy to the wrong body region or 25% above the planned radiotherapy dose


A health care organization is encouraged but not required to report to the the Joint Commission any sentinel event
true or false


A facility must conduct a root cause analysis which is a process for identifying the basic or causal factors that underlie variation in performance
true or false

root cause analysis

focuses primarily on systems and processes and not on individuals

Subsequent to the root cause analysis

the facility should adopt an action plan that identifies the changes to be made and how it is to be done when?

joint comission

maintains a database from the review of sentinel events and root cause analyses and publishes this info on the Joint Commission web site


Since the database was implemented in January 1995, the Joint Commission has received______ reports of sentinel events


Approximately _____ of sentinel events result in patient death


Approximately _____ of sentinel events occurred in a general hospital

Joint Commission or the Healthcare Facility Accreditation Program (HFAP)
true or

Of the 5,810 hospitals in the U.S., the vast majority are accredited by?


About 1,000 are not accredited by either of these private accrediting agencies but continue to participate in federal reimbursement programs by undergoing CMS surveys
true or false


Hospitals can save from $50,000 to $450,000 by not seeking the Joint Commission accreditation
The benefits should be weighed against the cost
One benefit is that some hospitals must be accredited to maintain postgraduate education and training programs
true or false

benefits of joint commission accreditation

Strengthens community confidence in the quality and safety of care, treatment and services
Provides a competitive advantage in the marketplace
Improves risk management and risk reduction
Helps organize and strengthen patient safety efforts
Provides education on good practices to improve business operations
Provides professional advice and counsel thereby enhancing staff education
Enhances recruitment and enhances development

Hugh Greeley, founder of The Greeley Company,

According to _____"Don't underestimate the benefits of accreditation, but don't be surprised when more and more facilities begin to question its cost

(AOA)American Osteopathic Association

represents more than 47,000 osteopathic physicians (D.O.s), promotes public health, encourages scientific research, serves as the primary certifying body for D.O.s, and is the accrediting agency for all osteopathic medical schools and healthcare facilities


The American Osteopathic Association's Healthcare Facilities Accreditation Program (HFAP) has been accrediting medical facilities since ?

the federal government
state governments
insurance carriers
managed care organizations

The AOA is recognized nationally by? the federal government, state governments, insurance carriers and managed care organizations


has been granted "deemed status" by the CMS
This means that an accredited hospital can participate in Medicare and Medicaid

In order to be eligible for AOA accreditation, a hospital must:

Be designated as an Osteopathic institution

2. Have a minimum of twenty-five (25) adult and pediatric beds

3. Have been in operation for not less than twelve (12) months immediately preceding the date of application for accreditation

4. Provide professional care and hospital service on a 24-hour basis.

medical department record guidelines

Medical records shall be maintained on all patients admitted for hospital care

Separate records shall be maintained on all newborn infants.

Records shall be retained by the hospital for a period of time established by the statutes of limitation in its state.

The confidentiality of medical records shall be maintained

medical department record guidelines

Written consent of patients, former patients or persons authorized to act in behalf of patients or former patients shall be obtained before copies of medical records are released
Final diagnoses, secondary diagnoses, procedures and complications must be coded and indexed
There should be an area for the medical staff to complete records
All original medical records, including x-ray films, electrocardiogram tracings, laboratory reports, etc., are the property of the hospital and shall be kept on file in conformity with the law
These files should be secure and fireproof and may be microfilmed in accordance with state and local permits.


The Health Information Management Department director should be qualified to perform the required duties. This may be an RHIA, RHIT or parttime RHIT with consultation provided by an RHIA.
true or false

"deemed status"

Hospitals with ISO registration do not have?


was formed in 1946 in Geneva, Switzerland with the intention to promote the development of international standards to increase the trade of products and services between countries


The core of the ISO 9000 Quality Systems Standard is a series of five international standards that provide guidance in the development and implementation of an effective quality management system
ISO 9001
ISO 9002
ISO 9003
ISO 9000-1
ISO 9004-1
true or false


While ISO9001 is the most comprehensive quality system, ISO 9002 is used by hospitals, banks, hotels, restaurants, etc.
true or false

Four Steps to ISO 9000 Registration

Phase I-
Phase II-
Phase III-
Phase IV-

Phase I

Organizing for registration

Phase II

Preparing for registration

Phase III

The registration audit

Phase IV

Continuing registration through surveillance audits


An organization is not actually "ISO certified" because ISO has not directly verified compliance with the standards
Certification comes from the selected registrar independently of ISO
The ISO standards only show the elements required to achieve quality system objectives
Individual organizations and companies are responsible for achieving the objectives they have set in their own standards
true or false


Minimize repetitive auditing
Improve an organization's quality system
Improve documentation
Yield cost savings and improve profitability
Improve awareness among physicians, managers, and staff
Because it is process based rather than compliance based it is much easier to implement
Minimal preparation time in comparison to the six to nine months needed for a Joint Commission survey
If a facility is ISO 9000 qualified or registered, any other survey processes will be much simpler and less costly
true or false

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