Facility Ah-kred-i-ta’-shun 101


Accreditation is a process that a healthcare institution, provider, or program undergoes to demonstrate compliance with standards developed by an official agency.  Accreditation for institutions and agencies in the United States and Canada is voluntary.1

Most of us are aware of the Eligibility Requirement from the Commission on Cancer (ER1) that requires a facility to be accredited by a recognized federal, state, or local authority appropriate to the facility type.  Accreditation ensures that care is provided in a safe environment.

There are three major facility accreditation agencies; The Joint Commission (TJC), Det Norske Veritas Healthcare, Inc. (DNV) and Healthcare Facilities Accreditation Program (HFAP) approved by the Centers for Medicaid and Medicare Services (CMS).

All of the above agencies have many facets to Quality and Performance Improvement departments within a hospital.  Did you know that Registry Partners has consultants that work specifically with clients to identify solutions based on facility needs, deadlines, and existing staff to support their defined initiatives to ensure a successful facility accreditation?

In addition to the work of the Oncology Division that supports Commission on Cancer (CoC) and National Accreditation Program for Breast Centers (NAPBC), our Quality Division can provide the following expertise for facility accreditation:

  • Data analysis to identify opportunities for improvement
  • Developing key performance indicators (KPI’s)
  • Developing performance dashboards and balances scoreboards
  • Team training on PDSA (Plan, Do Study, Act) performance model for process redesign
  • Failure Mode and Effect Analysis (FMEA) projects to meet The Joint Commission requirements
  • Improve outcomes to assure maximum reimbursement under pay-for-performances/value-based purchasing programs
  • Tracking, analyzing, and implementing improvement strategies for core measures, Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators, and Hospital Acquired Conditions

Stay tuned to this blog for more information about accreditation, quality, PDSA and FMEA models.

For more information on Quality Improvement and accreditations please contact Registry Partners at 1-866-287-2968 or visit our website at www.registrypartners.com

1Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing and Allied Health