7 Steps to Align a Health System's Accreditation Programs

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About two years ago, Dayton, Ohio-based Kettering Health Network began reevaluating its practice of having separate accreditation programs for each of its eight hospitals. Originally, six hospitals were accredited by The Joint Commission and two hospitals were accredited by The Healthcare Facilities Accreditation Program. However, the health system wanted to standardize its accreditation approach to streamline the accreditation process.

KHN eventually decided to bring all its hospitals under HFAP's accreditation program to increase the health system's efficiency and help ensure all its hospitals were compliant with CMS' conditions of participation. "Having a single accreditor helps [a health system] integrate a single strategy and culture throughout the enterprise," says Joe Cappiello, COO of HFAP.

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Here are seven steps to align a health system's hospitals under one accreditation program.

1. Evaluate accreditors. The first step in choosing one accreditation organization is to evaluate and compare different accreditors. KHN brought representatives from each of its eight hospitals together to compare The Joint Commission, HFAP and Det
Norske Veritas. The group looked at how often the organizations surveyed hospitals, the costs involved and its alignment with the CoPs, according to Christina Turner, chief quality officer of KHN.

One of the reasons KHN chose HFAP is that its requirements closely match the CoPs — HFAP was the first deemed accreditor for Medicare in 1965, and thus has 47 years of experience with the CoPs. "The most important thing an organization should be concerned about is what the accreditor brings and how it supports the strategic vision of that organization," Mr. Cappiello says. One of KHN's goals was to ensure compliance with CoPs; HFAP's alignment with the CoPs made it a natural choice for KHN.

2. Consolidate resources. Establishing one accreditor for all hospitals in a system can enable the system to consolidate resources, particularly manpower. Originally, each of KHN's hospitals had its own accrediting committee. When aligning under HFAP, KHN established a single steering committee that would oversee accreditation at all hospitals. In addition, the health system assigned two people as network managers for accreditation at all hospitals instead of having one network manager at each hospital.

3. Study the accreditation manual. The next step in standardizing accreditation programs across a health system is understanding all the requirements of the chosen accreditor. At KHN, each hospital assigned different chapters of the HFAP manual to various staff leaders. Since two KHN hospitals were already accredited by HFAP, representatives from those hospitals became mentors to the staff leaders at the other hospitals.

4. Self-assess compliance. Next, health systems should implement any changes needed to meet the requirements of the accreditor. Then, they should assess their compliance by doing mock surveys.  KHN's steering committee conducted mock surveys using the HFAP manual. The committee performed a gap analysis to identify strengths and weaknesses and shared this data with the accreditation leaders at the hospitals to guide further efforts.

5. Address deficiencies. After identifying areas of weakness, hospitals need to develop strategies to improve performance. At KHN, hospitals focused on acclimating hospital clinicians to being observed on quality measures. While many of the hospitals had complete documentation of quality processes, they needed to ensure they could reflect documentation in real practice while under direct observation.

"We spent time getting them comfortable talking about what they were doing while they were doing it and having people watch what they're doing," Ms. Turner says. For example, mock surveyors would observe clinicians and ask questions such as, "Tell me what you're doing," and "Why did you do that?"

6. Share knowledge. When all hospitals have the same accreditor, it is easier to share best practices about how to meet requirements. When all KHN's eight hospitals came under HFAP, the hospitals were able to share mistakes and achievements to help each other comply with the regulations.

Each hospital underwent its survey separately and sequentially. After each hospital's survey, the steering committee would create standards for meeting areas of weakness and share them with the next hospital, such that each successive survey had better results. "We were able to apply [what we learned] to rapid process improvement," Ms. Turner says.

7. Educate and communicate with staff. One of the biggest challenges of aligning all hospitals under one program at KHN was gaining buy-in to the change, according to Ms. Turner. KHN put a lot of effort in educating staff on what HFAP is, why it was chosen and what the change meant for each hospital.

KHN educated the hospitals through the mock surveys, education sessions on CoPs, pamphlets, poster board sessions and one-on-one meetings. Involving key staff leaders in preparing for accreditation also helped KHN communicate the reason for and requirements of the change to all levels of the organization.

"We wanted to make people understand why we felt it was important. We don't want people to see this as one more thing we have to do; we want to connect it to the validation of the care we give, ensuring that the care we're giving is the safest it can be," Ms. Turner says.

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