, part 1 a comparison deeming a - healthtechs3 · 2018-04-09 · recruitment • affiliation...
TRANSCRIPT
© HTS3 2018
SURVEY READINESS, PART 1 – A
COMPARISON OF DEEMING
AUTHORITIES
April 6, 2018
BUILDING LEADERS – TRANSFORMING HOSPITALS – IMPROVING CARE
© HTS3 2018
1 45 YEARS OF DELIVERING RESULTS
HealthTechS3 is a 45 year old, award-winning healthcare
consulting and strategic hospital services firm based in
Brentwood, Tennessee with clients across the United
States.
We are dedicated to the goal of improving
performance, achieving compliance, reducing costs,
and ultimately improving patient care. Leveraging
consultants with deep healthcare industry experience,
HealthTechS3 provides actionable insights and guidance
that supports informed decision making and drives
efficiency in operational performance.
Our consultants are former hospital leaders and
executives. HealthTechS3 has the right mix of
experienced professionals that service hospital clients
across the nation. HealthTechS3 offers flexible and
affordable services, consulting, and technology as we
focus on delivering solutions that can be implemented
and provide a positive, measurable impact.
1
© HTS3 2018
2 STRATEGY – SOLUTIONS – SUPPORT
GOVERNANCE & STRATEGY FINANCE CLINICAL CARE
& OPERATIONS RECRUITMENT
• Affiliation Consulting
• Executive & Management
Leadership Development
• Strategic Planning & Market
share Analysis
• Community Health Needs
Assessment
• Compliance Consulting
Services
• Performance Optimization /
Margin Improvement
• Revenue Cycle & Business
Office Operations
• Productivity & Staffing
Consulting
• Continuous Survey Readiness
• Quality Assurance
Performance Improvement
• Lean Culture
• Customer Experience
• Clinical Resource
Management
• Care Coordination – Primary
Care Practice
• Physician Practice & Clinic
Assessment
• Long Term Care Consulting
• Swing Bed Consulting
• Perioperative Services
Consulting
• Executive Recruitment
• Manager and Clinical
Positions
• Physician / Provider
Recruitment
• Information Technology
Professionals
• Interim Placement
OPTIMUM PRODUCTIVITY TOOLKIT
© HTS3 2018
3 2ND QUARTER 2018 WEBINARS Survey Readiness, Part 1 – A Comparison of Deeming Authorities
Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief
Clinical Officer
Email: [email protected]
Date: April 6th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2oG2So2
What do you get with an Interim Executive?
Host: Mike Lieb, FACHE, Vice President, HealthTechS3
Email: [email protected]
Date: April 11th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2t9hn9m
Survey Readiness Part 3 -Human Resource and Competency Regulatory
Standards – Strategies for Success
Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical Officer
Email: [email protected]
Date: May 4th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2oHKuLK
Creating a Lean Culture in Healthcare
Hosts: Faith M Jones, MSN, RN, NEA-BC, HealthTechS3 Director of
Care Coordination
Email: [email protected]
Date: May 8th, 2018
Time: 12:00pm CT
Register Here: http://bil.ly/2FI17il
Survey Readiness, Part 4 – A Focus on Governance and Leadership
Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA,
Regional Chief Clinical Officer
Email: [email protected]
Date: May 18th, 2018
Time: 12:00pm CT Register Here: http://bit.ly/2ozq3RQ
Swing Bed – Just the Questions Please!
Host: Carolyn St.Charles, RN, BSN, MBA, Regional Chief Clinical
Officer
Email: [email protected]
Date: June 1st, 2018
Time: 12:00pm CT
Register Here: http://bit.ly.2oxfyyr
© HTS3 2018
4 2ND QUARTER 2018 WEBINARS CON’T Aligning the Social Determinants of Health to the CHNA
Host: Diane Bradley, PhD, RN, NEA-BC, CPHQ, FACHE, FACHCA, Regional Chief
Clinical Officer
Email: [email protected]
Date: June 15th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2F6U05O
Care Coordination: Adding Behavioral Health to your Chronic Care Management
Program
Host: Faith M Jones, MSN, RN, NEA-BC HealthTechS3 Director of Care Coordination
and Lean Consulting
Email: [email protected]
Date: June 28th, 2018
Time: 12:00pm CT
Register Here: http://bit.ly/2FbZFad
© HTS3 2018
5 SPEAKER
Diane Bradley
Regional Chief
Clinical Officer
Diane began her healthcare career as a staff nurse in the
Emergency Department of a major medical center. She has
worked in a variety of staff, administrative and consulting roles and
has been in her current position as Regional Chief Clinical Officer
with HealthTechS3 for the last eight years.
In her role as Regional Chief Clinical Officer, Diane conducts mock
surveys for Critical Access Hospitals, Acute Care Hospitals, Long
Term Care, and provides guidance and assistance to senior leaders
and middle management with expertise in a variety of areas and
especially quality, patient safety, and a holistic approach to the
patient experience focusing on relationships.
One of Diane’s special areas of interest is developing innovative
approaches to operations that promotes cost-effectiveness,
improves efficiencies, encourages continual performance
improvement and accountability at all levels of the organization.
585-671-2212
© HTS3 2018
OUR AGENDA
I. Overview of Structure
II. Compare and contrast the CMS deeming authorities.
III. Understand the importance of meeting standards relative to quality
and patient safety.
IV. Develop a plan for continual readiness versus emergent readiness.
6
© HTS3 2018
7 HEALTH CARE ACCREDITATION – DEEMING AUTHORITIES
The Joint Commission (TJC)
jointcommission.org
Healthcare Facilities Accreditation Program (HFAP) – acquired by AAAHC in
October 2015 from American Osteopathic Association
hfap.org
Center for Improvement in Healthcare Quality
cihq.org
Det Norske Veritas (DNV) NIAHO
dnvglhealthcare.com
© HTS3 2018
8 STRUCTURE
HHS
TJC DNV HFAP CIHQ
CMS
© HTS3 2018
9 CENTERS FOR MEDICARE AND MEDICAID SERVICES
A department of Health & Human Services
Responsible for issuing the Medicare Conditions of Participation
(CoPs) as a standard of care
Hospitals are responsible for meeting the CoPs to obtain
reimbursement for care rendered to Medicare beneficiaries
© HTS3 2018
10 COMPARISON
Side by Side Comparison Matrix
TJC HFAP DNV CIHQ Overview Founded 1951 as a result of
efforts by the American College of Surgeons to create standardization in hospital. Voluntary process with focus at quality and patient safety. 20,000+ organizations accredited by TJC. Deeming status from CMS.
Founded 1945 by American Osteopathic Association and acquired by AAHHS in 2015. Focus on assessing osteopathic hospitals. Voluntary collaborative process with focus on quality and patient safety. Accredits 1,000+ organizations. Deeming status from CMS.
DNV has had presence in manufacturing industry for many years. 2008 received deeming status from CMS. Focus is continuous readiness, assessing risks using ISO criteria and methodology.
CIHQ is a privately-held company established in 1999 and headquartered in Round Rock, TX. Historically, CIHQ had been a consulting organization providing accreditation and regulatory support services to almost 240 hospitals across the United States. In 2011, they began a transformation to being an accrediting organization and attained deeming authority in 2013.
Standards Standards are developed around functional chapters, for example Leadership, Provision of Care. The Standards are linked to CMS Conditions of Participation (CoPs). JC has led the way in pushing National Patient Safety Goals out to healthcare organizations which has led the way to consistency for specific high-risk healthcare practices
Standards are evidenced-based and linked to CoPs. HFAP also has select patient safety initiatives.
Standards are directly linked to CoPs. Less prescriptive with more focus on measurement and improvement in outcomes over time.
Standards are based – almost solely – on the Medicare Conditions of Participation (COP) for Acute Care Hospitals. The specific requirements under each standard are based on the interpretive guidelines of the COP published by CMS in their State Operations Manual (SOM).
On-site Survey Tracer methodology – tracing path of the patient and high-risk systems and processes.
Review of patient-centered processes; educational in focus.
National Integrated Accreditation for Healthcare Organizations (NIAHO) and ISO surveys done collaboratively
© HTS3 2018
11 COMPARISON CON’T
Survey Schedule
Every 3 years Every 3 years Annually Every 3 years
Surveyors Nurses, physicians, pharmacists, engineers, healthcare administrators certified by TJC.
Healthcare clinicians and administrators; paid volunteers, usually working in healthcare.
NIAHO surveyors trained annually – clinicians and healthcare administrators.
Standards/ Scoring
Elements of Performance (EPs) are scored based on compliance. Findings must be resolved within 45 or 60 days after survey, depending on the criticality of the findings.
Discrepancies are identified; organization has 30 to 60 days to resolve and respond.
Scores are aggregated. As issues are identified, corrective actions must be implemented and monitored.
Standard and Condition Level Deficiencies, Immediate Threat to Health and Safety Deficiency
Cost Associated
with Standards Material
Yes Yes No No
Survey Outcomes
Accredited
Accredited with Follow-up Survey
Contingent Accreditation
Preliminary Denial
Denial
Full Accreditation
Interim Accreditation
Denial of Accreditation
Accredited
.Jeopardy Status
Not Accredited
Accreditation
Accreditation at Risk
Denial/Withdrawal of Accreditation
Cost Cost is based on size and complexity of the organization.
Cost is based on size and complexity of the organization.
Cost is based on size and complexity of the organization.
Cost is based on size and complexity of the organization.
Contact
www.jointcommission.com
www.hfap.org
www.dnv.com
www.cihq.org
Source: Meldi, Rhodes & Gippi. SYNERGY. “The Big Three: A Side by Side Matrix Comparing Hospital Accrediting Agencies”.
© HTS3 2018
12 HISTORY -- TJC
• Oldest of the accrediting bodies; began in 1951
• Has had hospital deeming authority since 1965
• Standard development dates back to the early 1900s when the American College
of Surgeons created its Hospital Standardization Program
• Formerly called the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – Name changed in 2007 to The Joint Commission (TJC)
• 11/09 – CMS approval
• 4,546 Hospital and CAH in 2011
• 4,429 Hospital and CAH in 2013 (90% of accredited hospitals)
• 4,032 Hospital and CAH in 2016 (88% of accredited hospitals)
© HTS3 2018
13 TJC GOAL
To help hospitals become “high reliability” organizations for delivering safe,
effective care. The Joint Commission helps hospitals help patients to achieve
continual progress toward quality healthcare.
© HTS3 2018
14 TJC’S CAMH CHAPTERS
• Accreditation Participation
• Environment of Care
• Human Resources
• Infection Prevention
• Information Management
• Medication Management
• Medical Staff
• Nursing
• Provision of Care
– Performance Improvement
– Patient Rights
– Emergency Management
– Life Safety
– National Patient Safety Goals
– Record of Care
– Transplant Safety
– Waived Testing
© HTS3 2018
15 CONSIDERATIONS
• Cost (around $35,000)
• Poorly aligned with the CoPs
• Proprietary Standards, e.g. NPSG
• Prescriptive standards
• Complex scoring methodology
© HTS3 2018
16 HISTORY – DNV [TRUE NORTH] NIAHO
• Developed by Norwegian DNV which began in 1864 as a global entity
• Approved by CMS as a deeming authority in 2008
• DNV Healthcare is an international accrediting body
• Surveys done annually
• Headquarters near Katy, TX
• 12/19/07 Application to CMS started
• 424 Hospital and 84 CAH on 3/28/2018
© HTS3 2018
17 DNV GOALS
DNV has two major goals:
1. To access compliance and educate hospitals in best practices. Hospitals can use
innovation to develop new methods for producing positive results.
2. DNV holds hospitals accountable to ensure that processes are planned,
managed, measured, documented, and continually improved.
© HTS3 2018
DNV’S NIAHO CHAPTERS
18
© HTS3 2018
19 CONSIDERATIONS
• Cost (around $32,000)
• Closely aligned with the CoPs
• Recently added a few proprietary standards
• Survey is completed annually; continual readiness
• Use ISO 9001 in Years 3 & 4 – similar to Baldrige with a focus on quality outcomes
• Scoring methodology simple – Non-conformity 1 (NC-1) and Non-conformity 2 (NC-2)
© HTS3 2018
20 HISTORY -- HFAP
• Focus on assessing osteopathic hospitals.
• Voluntary collaborative process with focus on quality and patient
safety.
• About 85% of the HFAP standards are directly tied to the CMS
Conditions of Participation (CoPs).
• Accredits around 214 organizations as of 2012.
© HTS3 2018
21 HFAP GOAL
The HFAP goal is to continue to help healthcare facilities deliver high quality
patient care through the application of its consistent standards while continuing
to streamline and improve its survey processes.
© HTS3 2018
22
© HTS3 2018
23 CONSIDERATIONS
• Strictly adhere to CoPs
• The standards for each program are cross-walked to the CoPs. This cross-
walk approach means anyone reading the HFAP standards manual can
clearly see how each standard ties directly to the Medicare requirements.
• Standard changes are infrequent
• When changes occur, the updates are provided for free to HFAP clients
• Moderately complex scoring system
• HFAP does not have the brand recognition due to the original focus on
osteopathic hospitalsDefined methodology
• Fee is all-inclusive (around $27,000)
© HTS3 2018
24 HISTORY – CIHQ
• Privately-held company established in 1999 and headquartered in
Round Rock, TX.
• Initially accredited ambulatory facilities.
• CIHQ had been a consulting organization providing accreditation and
regulatory support services – can accredit acute and critical access
hospitals.
• Provides services to about 240 hospitals.
• Interested in becoming a deeming authority in 2011.
• Attained deeming authority in 2013
© HTS3 2018
25 CIHQ GOALS
Our mission is to create a regulatory environment that enables healthcare
organizations to effectively deliver safe, quality patient care.
CIHQ seek to fulfill its Mission and Vision through living the following
values:
Integrity
Accountability
Collegiality and Openness
Stewardship
© HTS3 2018
26 CIHQ CHAPTERS
Governance & Leadership Management of the Medical Record
QAPI Use of Restraint & Seclusion
Medical Staff Targeted Patient Quality & Safety Practices
Human Resources Anesthesia Services
Managing the Care Environment Dietary (Nutrition) Services
Infection Prevention & Control Discharge Planning Services
Emergency Preparedness Emergency Services
Utilization Review Laboratory Services
Patient Rights Organ, Tissue & Eye Procurement
Medication Management Nursing Services
Nuclear Medicine Services Outpatient Services
Operative & Invasive Services Rehabilitative Services
Radiology Services Respiratory Services
Swing Bed
© HTS3 2018
27 CONSIDERATIONS
• Standards are based on the Medicare Conditions of Participation (COP) for
Acute Care Hospitals.
• Cost is dependent on organization bed size – range is from $5000-22,000
(400 beds)
• There is a “reasonable and modest set of additional standards to address
gaps in the COP’s in the areas of patient safety and quality care”.
• Full accreditation surveys are conducted every three years.
• There is a focused mid-cycle survey that will be conducted approximately 18
months into a hospital’s survey cycle.
© HTS3 2018
28 VALIDATION SURVEYS
There are two types of validation surveys:
1. Surveys conducted on a representative sample basis, which may be
either comprehensive surveys of all Medicare conditions or focused
surveys on a specific condition or conditions;
or
2. Surveys in response to a "substantial allegation" – generally a
complaint. These surveys focus on those Medicare conditions related
to the allegations.
© HTS3 2018
29 PROS AND CONS
PROs CONs
• Accreditation indicates the organization • Are minimal standards sufficient
has met the minimal standards today?
• TJC often viewed as the “Gold Standard” • Cost – dollars and resources
• Competition between deeming authorities associated with preparing for
• Continual readiness survey
• Continual improvement • Sometimes confusing if there are
proprietary standards and CoPs
• Lack of frequency for State agencies to
conduct survey
• Surveyed too frequently
© HTS3 2018
30 DECISION-MAKING
• Discuss – what is the consensus within your organization?
• Remember, compliance with the CoPs is the only requirement.
• Is the financial investment an option for your organization?
• What does private accreditation mean to your constituents?
• Do your constituents know who TJC, DNV, HFAP or CIHQ are and what does accreditation mean to them?
© HTS3 2018
31 THANK YOU FOR YOUR TIME
© HTS3 2018
Dallas Office 2745 North Dallas Parkway,
Suite 100, Plano, TX 75093
Brentwood Office 5110 Maryland Way, Suite 200
Brentwood, TN 37027
Our Phone Main Office: 615.309.6053
Executive Placement: 972.265.4549
Email / Website Diane Bradley
585-671-2212
Thank you!
32
32