Study Set Content:
Confirmation by an entity that an organization complies with their
predetermined standards
Certification
Adhering to the requirements of a standard, law, rule or regulation
Compliance
Voluntary guidance and direction to practitioners and other audiences based
on consensus of professional judgement, expert opinion and documented evidence.
Guideline
The American Osteopathic
Association’s (AOA) accrediting organization for the operation of hospitals
Healthcare Facilities Accreditation Program (HFAP)
Principal accrediting organization for the operation of hospitals
and other health care organizations.
The Joint Commision
Legally binding requirement imposed by a legislative body
Law
Accrediting
organization for the operation of hospitals
National Integrated Accreditation for Healthcare Organizations (NIAHO)
The continuous measurement, analysis and improvement of
the performance of systems and processes to achieve desired outcomes
Performance Improvement
Formal approach to the analysis of performance and the
systematic approach to improve it.
Quality Improvement
Governmental order having the force of law
Regulation
Authoritative recommendation meant to guide behaviors associated with
specific, limited situations.
Rule
Statement that defines the performance expectations, structures ,or
processes that must be in place for an organization to provide safe and high-quality
care ,treatment and services
Standard
a. Key component in the accreditation process, whereby a surveyor/s
conducts anon-site evaluation
Survey
Federal agency that administers
health-related programs
(Medicare program, Children’s
Health Insurance Program (CHIP)
and Health Insurance Portability
and Accountability Act (HIPAA).
Maintain oversight of the survey and
certification of “acute and
continuing care providers
facilities.
Centers for Medicare and
Medicaid Services (CMS)
Founded in 1951, principal accrediting
body for the operation of hospitals
and other health care organizations.
an independent, not for profit
organization dedicated to improving
the safety and quality of health care
Engages in issues and activities
concerning the advancement of
healthcare safety and quality
The Joint Commission
The Joint Commission
1951
JCI PERFORMANCE IMPROVEMENT STANDARDS:
1. Monitor performance and collect data
2. Aggregate and analyze data
3. Analyze undesirable patterns and trends in performance
4. Identify and manage sentinel events
5. Use information from data analysis, identify and prioritize opportunities for
improvement
6. Improve performance by taking action on improvement opportunities
7. Evaluate those actions for effectiveness and taking further action when
improvement is not achieved or sustained.
Principal accreditation agency for
osteopathic medical colleges and
health care facilities.
Not limited to osteopathic hospitals
and some health care
organizations are accredited by
both HFAP and the Joint
Commission
American Osteopathic
Association (AOA)
Healthcare facilities
Accreditation Program
(HFAP)
Accreditation is for
3 years
Standards integrate requirements based on
CMS Conditions of Participation with
International Organization for
Standardization (ISO) 9001 Standards.
Designed to facilitate the development and
implementations of a Quality
Management System for health care
organizations.
National Integrated
Accreditation for Health
Care Organizations
(NIAHO)
