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Hospital Accreditation Options

Voluntary accreditation is one way that hospitals demonstrate adherence to the Medicare conditions of participation (CoPs), the minimum standards that hospitals must meet in order to be a Medicare or Medicaid provider. The three approved voluntary accreditation options for hospitals are: Det Norske Veritas Healthcare, Inc. (DNV), the American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP), and The Joint Commission (TJC).

Hospital Accreditation Options

GNYHA Briefing on Hospital Accreditation Options (October 6, 2010)
- Agenda
- Presentations
  - American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP) 5.1 MB (George A. Reuther, M.B.A., Chief Operating Officer, HFAP)
  - Det Norske Veritas Healthcare, Inc. (DNV): Introduction to DNV Healthcare and NIAHO, A New Choice for Hospital Accreditation 7.8 MB (Rebecca Wise, M.H.A., Chief Operating Officer, DNV)
  - The Joint Commission (TJC): Working with Health Care Organizations to Improve Quality and Safety 1.9 MB (Ann Scott Blouin, R.N., Ph.D., Executive Vice President, Accreditation and Certification Operations, TJC)
- Articles and Related Materials
  - Overview of Hospital Accreditation Options 54.2 KB (LRU-6, July 1, 2010)

American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP)

Overview
- American Osteopathic Association’s Healthcare Facilities Accreditation Program (HFAP) 5.1 MB (George A. Reuther, M.B.A., Chief Operating Officer, HFAP, October 6, 2010)
Accreditation Contract
- NYS DOH Collaborative Agreement with the AOA’s Healthcare Facilities Accreditation Program 251 KB (LRU-7, June 19, 2009)

Det Norske Veritas Healthcare, Inc. (DNV)

Overview
- Det Norske Veritas Healthcare, Inc. (DNV): Introduction to DNV Healthcare and NIAHO, A New Choice for Hospital Accreditation 7.8 MB (Rebecca Wise, M.H.A., Chief Operating Officer, DNV, October 6, 2010)

The Joint Commission

Overview
- The Joint Commission (TJC): Working with Health Care Organizations to Improve Quality and Safety 1.9 MB (Ann Scott Blouin, R.N., Ph.D., Executive Vice President, Accreditation and Certification Operations, TJC, October 6, 2010)
Accreditation Contract
- New York State-JCAHO Collaborative Survey Agreement 210 KB (2005-2010)
- NYS DOH and JCAHO Renew Collaborative Survey Agreement 7.3 MB (ML-194, August 9, 2006)
- JCAHO Extends Deadline for Executing Amended 2006 Accreditation Contract and Develops Electronic Process for Requesting Amendments to the Contract 98.3 KB (ML-190, October 19, 2005)
- 2006 JCAHO Accreditation Contract 82.6 KB(ML-139, August 3, 2005)
Accreditation Standards
- 2007 JCAHO Medical Staff Standards 373 KB
- GNYHA Comments on JCAHO Proposed Revisions to Medical Staff Standard MS.1.20 54.7 KB (ML-86, March 24, 2006)
Survey Process
- Accreditation Process Changes for 2004—Shared Visions - New Pathways 1.6 MB
Unannounced Survey Process
- JCAHO Unannounced Survey Process - GNYHA Lessons Learned 65.8 KB (ML-141, May 15, 2006)
- JCAHO Unannounced Survey Process Update 121 KB (ML-75, March 2006)
National Patient Safety Goals
Strategic Surveillance System
- GNYHA Briefing on the Joint Commission’s Strategic Surveillance System 40.6 KB (EN-36, November 19, 2007)
- Strategic Surveillance System (S3): Understanding and Using Reports 699 KB (December 3, 2007)
Universal Protocol For Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™
Quality Report
- ML-137 (2004) JCAHO Plans to Release Hospital-Specific Quality Report on July 15, 2004 111 KB
- Performance Measurement Information in 2004 Quality Reports 485 KB
- Frequently Asked Questions 98.3 KB
ORYX Core Measures
- Webinar on The Joint Commission Performance Measurement Activities (February 14, 2012)
  - Promoting Quality Improvement in Healthcare: The Joint Commission and Accountability Measures 1.2 MB (Jerod M. Loeb, PhD and Sharon L Sprenger, MPA, RHIA, CPHQ, Division of Healthcare Quality Evaluation (DHQE), Frank S. Zibrat, Accreditation Systems Integration & ORYX, Division of Accreditation and Certification Operations)
  - Click here to view webinar
- CMS’s Outpatient Quality Measures Will Be Acceptable for Joint Commission Accreditation in 2008 49.9 KB (ML-163, December 3, 2007)
- ORYX Update: Marking a Data Transmission Milestone for Hospital Core Measures 106 KB
- A Comprehensive Review of Development and Testing for National Implementation of Hospital Core Measures
Certification Programs
Other
- Emerging and Challenging Issues for the Joint Commission and Accredited Organizations in 2009 84.9 KB(EN-38, December 15, 2008)
  - Agenda 94.3 KB
  - Joint Commission Briefing: 2009-Emerging and Challenging Issues 3.1 MB (Ann Scott Blouin, RN, PhD, Executive Vice President, Accreditation and Certification Operations, Patricia Adamski, RN, MS, MBA, Director, Standards Interpretation Group and the Office of Quality Monitoring, December 15, 2008)
  - 2009 Standards FAQs (The Joint Commission) 277 KB
  - Sentinel Event Alert #42 - Safely Implementing Health Information and Converging Technologies (December 11, 2008)
  - Conflict Management Toolkit 748 KB (American Health Lawyers Association)
  - Disruptive MD Policy (York Hospital) 1.1 MB
  - Evaluating "The Gold Seal of Approval"^TMand an Alternative Accreditor 465 KB(The Joint Commission)
  - Health Care at the Crossroads: Strategies for Improving the Medical Liability System and Preventing Patient Injury 662 KB
Updates
- The Joint Commission Update 53.9 KB (March 8, 2012)
- The Joint Commission Update 53.2 KB (December 21, 2011)
- Joint Commission Update: Joint Commission Report, Improving America's Hospitals: A Report on Quality and Safety 46.8 KB (JCU-1, March 22, 2007)