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Accreditation & Oversight

Every hospital and health system is responsible for developing and implementing a comprehensive and systematic quality management system.  Such a system is directed at continually improving care provided to patients and preventing harm or injury to patients and all who work within the hospital environment.

Many hospitals and health care systems will utilize external standards, often developed by peers within the health care professions, to either develop and/or assess the comprehensiveness of the organization's quality management structure and its ability to ensure the safety and quality of care provided to patients.

One form of use of external standards is 'accreditation'.  As defined in a recent book: Protecting American Health Care Consumers by Eleanor DeArman Kinney, accreditation is defined:

'Accreditation is a voluntary process by which an organization demonstrates that it meets the standards established by its professional peers.  Accreditation serves two important functions. First, it establishes standards against which to measure the quality of an organization.  Second, it determines whether institutions have complied with established standards and have therefore earned the imprimatur of accreditation'.

In addition to accrediting organizations, hospitals and health care systems can choose from a variety of other standards programs whose standards are directed at helping organizations build a continual improving quality management system.  Programs, such as ISO 9000 and Six Sigma, while originally developed for use in the manufacturing sector, have found increasing usefulness and application within the health care sector.

A third source for external standards are those developed and enforced by regulatory authorities at both the state and Federal level.

Accreditation has also been used by state and regulatory agencies to confer 'deemed' status.  Deemed Status' relative to health care organizations originated with the creation of the Medicare program in 1965.  Under the authority of Section 1865 of the Social Security Act, hospitals accredited by the Joint Commission on Accreditation of Heathcare Organizations or the American Osteopathic Association are automatically 'deemed' to meet all the health and safety requirements, except the utilization review requirement, the psychiatric hospital special conditions, and the special requirements for hospital providers of long-term-care services.

The 'deeming' concept is also utilized by a wide number of states as meeting state health and safety requirements.  Organizations that have 'deeming' status vary from state to state.

The American Hospital Association (AHA) recommends and supports the process of voluntary, private accreditation.  The choice of an accrediting organization should be determined by the hospital and health systems in regard to the needs of its patients and its business needs.

The American Hospital Association (AHA) recommends and supports the process of voluntary, private accreditation.  The choice of an accrediting organization should be determined by the hospital and health systems in regard to the needs of its patients and its business needs.

 

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