Healthcare accreditation has many benefits for an organization but choosing the right agency can be challenging. Accreditation to a healthcare organization stimulates continuous improvement. It enables the organization to demonstrate a commitment to quality care. It raises community confidence in the services provided by the healthcare organization and provides an opportunity for healthcare organizations to benchmark with the best. The goal of healthcare accreditation is to ensure that organizations meet acceptable levels of quality. Accreditation in the United States involves non-governmental entities (accrediting organizations) as well as federal and state government agencies. Healthcare facilities have the opportunity to choose between a variety of options. The Joint Commission (TJC)(www.jointcommission.org), Det Norske Veritas (DNV) (www.dnv.com), Center for Improvement in Healthcare Quality (CIHQ) (www.cihq.org), and Centers for Medicare and Medicaid (CMS) (https://www.cms.gov) are the primary options for hospitals accreditation needs, as well as other healthcare organizations. Other options include, but are not limited to, American Association for Accreditation of Ambulatory Surgery Facilities (www.quada.org), Accreditation Association for Ambulatory Health Care (https://www.aaahc.org), Accreditation Commission for Health Care (www.achc.org), etc.
Let’s discuss two accrediting organizations that you may not be familiar with…
Who is DNV?
DNV (Det Norske Veritas) was established in 1864 in Oslo, Norway, and has been operating in the United States since 1898. DNV’s purpose is to safeguard life, property, and the environment. DNV has a worldwide reputation for quality and integrity in certification, standards development, and risk management over a wide range of industries, including extensive international healthcare experience. On September 26, 2008, the US Centers for Medicare and Medicaid (CMS) approved DNV Healthcare (DNVHC) by granting it deeming authority for hospitals. Any hospital accredited by DNVHC after that date is deemed to be in compliance with the Medicare Conditions of Participation (CoP).
DNV’s vision is to be a trusted voice to tackle global transformations. Its values are beliefs that shape our performance; these ideals are the behaviors expected of all employees in DNV:
- To care for each other, our customers, our planet, and that we take care of ourselves.
- To dare to explore, to experiment, to be different, and to be courageous, curious, and creative.
- To share our experience and knowledge. We collaborate with each other and our customers, and we continue to grow and develop as a result.
What is DNV’s Role in Healthcare Accreditation?
DNV surveys and accredits organizations in the ISO 9001 (International Organization for Standardization) and NIAHO Standards (National Integrated Accreditation for Healthcare Organizations). The ISO 9001 Standards provide the framework for a sustainable regulatory compliance, allowing organizations to use its combined knowledge, wisdom, and innovation to improve quality and safety, and it is the framework within which methodologies such as LEAN and Six Sigma are better understood and utilized. All these together drive quality transformation into the organization’s core processes. The NIAHO Standards are based on the CMS Conditions of Participation.
ISO 9001’s quality management system is able to improve overall performance and sustainability. By doing so you will be able to consistently deliver patient care and services that meet the regulatory requirements therefore enhancing customer satisfaction. ISO 9001 allows you to address risks and opportunities for improvement. DNV uses a process approach, incorporating Plan-Do-Check-ACT (PDCA) and risk-based thinking. This approach allows an organization to plan its processes and its interactions. It allows an organization to ensure that it's processes are resourced and managed, and that opportunities for improvement are determined and acted on.
Consistent and predictable results are achieved more effectively when activities are understood and managed as interrelated processes that function as a coherent system.
Risk-based thinking assists organizations to determine the factors that could cause its processes and its quality management system to deviate from the planned results, to put in place preventative controls to minimize negative effects, and to make maximum use of opportunities that arise. The objectives of risk-based thinking in a hospital setting are as follows: to provide confidence in the organizations ability to consistently provide patients with the best possible care by addressing potential risks, enhance patient satisfaction, and exceed expectations. IOS 9001 brings risk-based thinking front and center and helps to identify opportunities which can be considered the positive side of risk.
How is Healthcare Accreditation Achieved?
To achieve healthcare accreditation with DNV you will go through a process different from other accrediting agencies.
- During the initial visit you will gain accreditation to NIAHO (meet the requirement for CMS) and be provided with an ISO 9001 introduction and education: compliance, or certification within three years.
- During visit two (one year after accreditation) you will continue accreditation by undergoing a survey to NIAHO and a survey for progress in implementing ISO 9001.
- During the third visit (two years after accreditation) you will again continue accreditation by undergoing a survey to NIAHO and continue to work toward ISO 9001 implementation.
- During the fourth visit (three years after accreditation) you will have a NIAHO survey, and it is the last year to achieve ISO 9001 compliance/certification. If you are in compliance with ISO 9001 a statement will be included on your Certificate of Accreditation.
Is CIHQ right for you?
CIHQ (The Center for Improvement in Healthcare Quality) is the nation’s newest accreditation provider approved by CMS to deem Acute Care, Critical Access, and Acute Psychiatric Hospitals as meeting Medicare Conditions of Participation. CIHQ also provides accreditation for Substance Use Disorder Treatment Centers, Free-Standing Emergency Centers, and Congregate Living Health Facilities, as well as Center of Excellence Designations and Disease-Specific Certifications. CIHQ is a privately held company established in 1999 and headquartered in Mexia, TX. They provide accreditation services to hundreds of hospitals and other healthcare entities across the United States, Puerto Rico, and Guam. As a deemed-status provider, CIHQ provides hospitals with the tools and support they need to successfully achieve accreditation. CIHQ's philosophy and approach to accreditation is to engage with hospitals in a collegial, respectful, and educational manner.
CIHQ’s purpose is to:
- ADVOCATE on behalf of our members in shaping the accreditation and regulatory environment by working with CMS in the development of standards and regulations.
- EDUCATE members on standards, regulations, and the survey process and encourage the professional growth of individuals in the field of healthcare accreditation through national certification.
- ADVISE members on changes to standards and regulations and the impact on their organization.
- ASSIST members in determining their compliance with accreditation standards and CMS certification requirements.
- IMPROVE the ability of members to successfully meet the challenges of today’s regulatory environment.
CIHQ states its Mission, Vision, and Values as follows:
Mission
- To create a regulatory environment that enables healthcare organizations to effectively deliver safe, quality patient care.
Vision
- To be viewed by its members as an indispensable ally in their accreditation and regulatory compliance efforts.
Values
- CIHQ seeks to fulfill its Mission and Vision through living the following values:
- Partnership
- Integrity
- Accountability
- Collegiality and Openness
- Stewardship
What About the CIHQ Standards?
The standards are based on the Medicare Conditions of Participation (COP) for Hospitals. The specific requirements under each standard are based on the interpretive guidelines of the COP published by CMS in the State Operations Manual (SOM). Since the fundamental responsibility of a deeming authority is to ensure that a hospital meets the Medicare COPs, it makes sense to ensure that the standards are consistent with those regulations. Also, the CIHQ requirements are based on the interpretive guidelines by CMS to ensure that your compliance with the standards will translate into your compliance with CMS requirements. So yes, hospitals can use the CIHQ accreditation to meet applicable requirements for participation in the Medicare program. Also, a hospital can be accredited without needing to participate in Medicare. Many hospitals choose this option to satisfy State licensure requirements and/or insurance company contracting requirements.
CIHQ has developed a reasonable and modest set of additional standards to address gaps in the COPs in the areas of patient safety and quality care. However, remember that the primary purpose is to deem hospitals as being in compliance with the Medicare COPs so they can participate in the Medicare reimbursement program – not add additional burdens on them.
Achieving Accreditation from CIHQ
CIHQ will survey and accredit all services and sites of care listed on the hospital’s license and billed under the hospital’s Medicare certification number (CCN). The length of a full survey will depend on the size and complexity of your hospital. An average size hospital will have a 2-4 day survey with a team of 2-4 surveyors – including a facilities specialist. Surveys are conducted by full-time clinicians with years of experience in the hospital setting. Surveyors undergo a rigorous training program and are nationally certified in this field. Full accreditation surveys are conducted every three years.
CIHQ’s Resources Available per their Website
CIHQ provides the following resources at no additional charge to accredited organizations:
- Free, unlimited site-wide access to the standards and survey procedures in both electronic and PDF format.
- Monthly webinars on how the standards are surveyed with an opportunity for accredited hospitals to get their questions answered.
- Template policies, forms, staff training aides, and other documentation tools to assist in your compliance efforts.
- Discounted rates on attendance at their annual Accreditation and Regulatory Summit.
- Unlimited access to web-based reference and staff training libraries.
- Alerts to changes in standards and CMS regulations as well as unlimited access for standards interpretation.
In summary, choosing an accrediting agency for your organization is challenging. You need to review all the websites and decide what works best for your organization. The agencies mentioned are all based on the CMS standards with an addition of standards specific to the accrediting agency. DNV is unique in that they have their ISO 9001 standards separated out from the NIAHO (CMS CoPs) and visit more frequently than the others. However, CIHQ has other advantages that might work for your organization.
For more information on how the C&A team can assist you with healthcare accreditation and regulatory compliance visit us at https://www.courtemanche-assocs.com/services/survey-readiness/ Better Compliance, Better Care.
