Role Of Regulation And Accreditation In Quality

Role Of Regulation And Accreditation In Quality

Accreditation is the process of measuring an organization’s performance against established standards and identifying areas for improvement that includes both self-assessment and external peer assessment [EJa]. Many accrediting programs have been established for the purpose of healthcare delivery. Standards, laws, and regulations that help to ensure safety, quality, privacy, and an accessibility guide the healthcare industry. The most important role of quality improvement or accreditation-related programs is to enforce compliance and regulation in healthcare by collecting and analyzing data on a daily basis.

The Joint Commission is a government agency.

The Joint Commission is a non-profit organization that is the country’s oldest and largest standard-setting and accrediting body in healthcare [Ope17]. After a doctor named Ernest Codman proposed a result for hospital standardization, the Joint Commission was formed to continue the study and improve medical outcomes. Every three years, the healthcare organization must submit to an onsite survey conducted by the Joint Commission survey team in order to maintain compliance with the Joint Commission. A proper Health Information Technology system must be in place to facilitate the collection of data that aids in the improvement of care quality. Because of some criticism leveled at the Joint Commission, such as being too lenient or approving the entire board of corporate members from the healthcare industry, management has decided to shift its focus to other quality improvement or accreditation programs to be considered in the upcoming revenue cycle.

The National Quality Assurance Committee

The National Committee for Quality Assurance is a non-profit organization founded in 1990 with the goal of improving healthcare quality through standards, measures, programs, and accreditation. The program oversees physician, health plan, and medical group accreditation. According to the NCQA website, it is the only accreditation program in the country that uses a comprehensive evaluation of health plans, and its accreditation scores are based on actual results obtained on a set of clinical measures as well as consumer experience.

The NCQA requires insurance companies to meet five requirements: quality management and improvement, utilization management, credentialing, and credentialing members’ rights and responsibilities, and member connections. The NCQA is recognized by 42 states in the United States and operates under all federal laws and regulations. It meets the requirements for Medicaid commercial plans, and Medicaid is mandated in more than a dozen states. Because it is critical to align with market requirements, NCQA accepts results that adhere to CMS reporting requirements.

Healthcare protocols have been redefined as a result of NCQA’s contribution to the healthcare system, doctors are constantly learning new ways to practice, and patients have learned to become more engaged in their care. As a result, lives are saved, illnesses are avoided, and healthcare costs continue to fall. The cost of program recognition varies depending on whether it is a single site, a multi-site, or a partner in the quality discount program. Single-site pricing is for organizations with three or fewer practice sites and includes an initial fee of $50-$500 and an annual fee of $12-$120. Along with that fee, there is an annual reporting fee of up to $6200.00. The initial fee for a multi-site is the same as for a single site, and the annual reporting fee has a maximum of $7650.00.

The Accreditation Program for American Medical Schools

Individual physicians can be accredited by the American Medical Accreditation Program based on core standards in education, licensure, ethics, and practice operations [AHC97]. The American Medical Association, based in Chicago, created the program. According to a Managed Care Mag article, AMAP compares physicians to national standards and peer performance in credentialing, personal qualifications, the environment of care, clinical performance, and patient care outcomes [Joa97]. Prior to AMAP, there were duplicate processes in place for physician credentialing, resulting in conflicting criteria. The program is in charge of gathering, verifying, and consolidating the portfolios of physicians into a single file. Plans and hospitals charged lower fees as a result of such credentialing decisions.

Physicians are credentialed under the AMAP in many managed care plans, as well as Medicare and Medicaid. The American Medical Accreditation Program costs $50 to $150 per year, depending on membership status. Most healthcare organizations pay the AMA membership fee and provide continuing education for that physician. What is the significance of the AMA program to a physician? A physician, for example, performs services on a patient who has Medicare or Medicaid insurance. Services will not be reimbursed if the physician is not credentialed with Medicare or Medicaid. The provider will incur a loss for the entire service/claim, and Medicare or Medicaid has every right to refuse payment for services because the provider is not credentialed with the plan.

Program for Accreditation of Healthcare Facilities

Healthcare Facilities Accreditation is a nationally recognized accreditation organization with CMS authority. The program’s goal is to promote high-quality patient care and safety through recognized standards. The program is a non-profit that assists healthcare organizations in maintaining the highest level of patient care while also complying with government regulations. When the program first began in 1943, it only accredited osteopathic hospitals, ensuring that residents received the necessary training. Because of its expansion beyond osteopathic hospitals, the Healthcare Facilities accreditation program now includes over 200 hospitals and more than 200 healthcare facilities, including labs. Since the program’s inception by the Centers for Medicare and Medicaid Services, HPAP has accredited healthcare facilities and authorized laboratories to obtain CLIA clearance for over 60 years.

According to research, the average cost for a healthcare facility to participate in the HFA program for three years is $25,000 [Dia09]. However, the cost is determined by the organization’s size and volume. There is a registration fee, and the cost of the program and survey varies according to the number of surveyors assigned to that healthcare facility. To help advance patient quality and safety, the program participates in numerous federal, state, and local support programs. The HFAP benefits include a copy of the manual, which includes the surveyor’s grading procedure. Furthermore, the program gives healthcare facilities 10 days to correct survey deficiencies before being granted full or interim accreditation or denied. Another advantage of HFAP is that hospitals do not need to be accredited by HFAP to be certified by HFAP, which is advantageous for hospitals seeking state designations [Bec14].

Conclusion

According to the data collected from each accreditation program, all play significant and important roles in terms of quality and safety standards, as well as the revenue cycle of healthcare facilities. Based on the data collected, the hospital should select the HFAP with a ranking of 1 because it is accredited by CMS and is nationally recognized. Following that is the NCQA, which is known as one of the top healthcare organizations due to its statistics. Finally, because of its significance in physician profiles, the AMA. According to NCBI, patients treated at accredited hospitals were more likely to receive higher quality care, based on a Centers for Medicare and Medicaid Services analysis. All healthcare facilities strive for quality care and patient safety, and evidence shows that accreditation programs improve the care process.

References

AHC Media. (1997, September). Retrieved from AHC Media: https://www.ahcmedia.com/articles/36953-amap-accreditation-standards-at-a-glance

Beckers Hospital. (2014, June 03). Retrieved from Clinical Leadership and Infection Control: https://www.beckershospitalreview.com/quality/accreditation-options-understanding-the- healthcare-facilities-accreditation-program.html

Jaafaripooyan, E. (n.d.). Healthcare Accreditation Systems; Further perspective on Performance Measures. International Journal for Quality in Healthcare, 645-656.

Meldi, D. (2009). Industry and Government Relations Committee. The Big Three, 14. Open Learning Initiative. (2017). Retrieved from Open Learning Initiative: https://oli.cmu.edu/jcourse/workbook/activity/page? context=e6f7b4e380020ca6011e26015f3c61df

Szabo, J. (1997, November 1). Managed Care MAG. Retrieved from Managed Care Mag: https://www.managedcaremag.com/archives/1997/11/tough-road-ahead-amas-physician- accreditation-program

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Post a total of 3 substantive responses over 2 separate days for full participation. This includes your initial post and 2 replies to classmates or your faculty member.

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Respond to the following in a minimum of 175 words:

How do regulations and accreditation help enforce quality healthcare? Discuss ways in which they help to improve the healthcare system.

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Post 2 replies to classmates or your faculty member. Be constructive and professional.