Accreditation and Regulatory Support Services

Every hospital’s commitment to providing safe, high quality patient care must be matched by a commitment to perpetual readiness for regulatory and accreditation surveys. Seemingly well run hospitals throughout the United States have fallen under increasing scrutiny from The Joint Commission, the Centers for Medicare and Medicaid (CMS), the American Osteopathic Association’s (AOA) Healthcare Facilities Accreditation Program (HFAP) and state health departments.

The Joint Commission’s 2008 Annual Report notes that improvement is still required on most quality and safety measures and that hospital compliance has decreased in some of the National Patient Safety Goals. This finding is alarming as many of these measures were introduced in 2002 and hospitals are still not performing consistently in 2007. This data should represent a concern to all hospitals as these findings indicate there are more stringent surveyors in an environment where a coalition of organizations are requiring compliance with constantly changing standards.

“Hospitals must do more than simply perform specified tasks to achieve compliance with Joint Commission NPSGs. To assure safe health care environments, hospitals must continually analyze fundamental workflow systems and redesign those systems as needed. Hospitals must go beyond the tasks of removing a dangerous medication from a patient care unit or requiring a specific safety feature on a medical device. They must achieve goals such as "improve the accuracy of patient identification" by changing how individuals caring for patients do their jobs. Achieving this kind of behavioral change among providers takes time, motivation, reinforcement, reward, patience, and support."
– The Joint Commission 2008 Annual Report

Just as the Joint Commission points out in their 2008 Annual Report, The Sibery Group has embraced this approach and built its foundation on the belief that improvement and change require:

an accurate assessment of the current state,

defining the ideal state,

recommending solutions that take into account how systems work, and

implementing sustainable solutions by focusing on people, processes, facilities and structures.

Fall-out from poor performance in the regulatory and accreditation environment has resulted in loss of accreditation, interim accreditation status, media crisis, loss of payers, downgrading of bond ratings, loss of clinical training programs, market share loss, physician exit and senior management turnover. The shift toward unannounced survey visits of increasing intensity has made regulatory and accreditation compliance and continuous readiness more crucial than ever.

 

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