Accreditation and Regulatory Compliance

1. Accreditation and Regulatory Compliance Linda R.Greene,RN,MPS,CIC,FAPIC linda_greene@urmc.rochester.edu Manager, Infection Prevention UR Highland Hospital Rochester, NY linda_greene@urmc.rochester.edu

2. What do all the letters mean? • JC- Joint Commission ( accrediting body) • DNV -Det Norske Veritas (accrediting body) • CMS - The Centers for Medicare & Medicaid Services- Regulatory body • FDA- Food and Drug Administration • EPA – Protecting environmental health

3. Role of Accrediting Organization Federal deemed statusIn order for a health care organization to participate in and receive federal payment from Medicare or Medicaid programs, one of the requirements is that a health care organization meet the government requirements for program participation, including a certification of compliance with the health and safety requirements called Conditions of Participation (CoPs) or Conditions for Coverage (CfCs), which are set forth in federal regulations. The certification is achieved based on either a survey conducted by a state agency on behalf of the federal government, such as the Centers for Medicare & Medicaid Services (CMS), or by a national accrediting organization that has been approved by CMS as having standards and a survey process that meets or exceeds Medicare’s requirements. https://www.jointcommission.org/facts_about_federal_deemed_status_and_state_recognition/

5. The Joint Commission Standards cited most often: Infection Prevention Environment of care

6. Tips JC Major focus on Instructions for Use (IFU’s) Need to reference Policies High level disinfection and sterilization ( hot issues) Use a risk assessment for difficult areas.

7. Risk Assessment

8. Tracers

9. Resources • http://cqrcengage.com/apic/home- APIC Public Policy

10. CMS Conditions of Participation CMS develops Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health care organizations must meet in order to begin and continue participating in the Medicare and Medicaid programs. These health and safety standards are the foundation for improving quality and protecting the health and safety of beneficiaries. CMS also ensures that the standards of accrediting organizations recognized by CMS (through a process called "deeming") meet or exceed the Medicare standards set forth in the CoPs / CfCs.

11. CMS COP Important publication and effective dates: • Original publication date - June 17, 1986 (51 FR 22010); effective September 15, 1986 • Hospital Conditions of Participation: Quality Assessment & Performance Improvement Final Rule (68 FR 3435); published January 24, 2003; effective March 25, 2003

12. Where are we now? Although infection control was elevated to a Medicare Condition of Participation (CoP)  in 1986, it has essentially been unchanged for more than 30 years. Because of this lack of action, current requirements no longer fully conform to current standards for infection prevention and control, creating a burden on hospitals that are currently operating under regulations that are outdated, inefficient, and inconsistent with infection prevention control requirements in other healthcare settings.

13. CMS 3 Important programs: • The Hospital Readmissions Reduction Program is designed to improve quality of care and care transitions by incentivizing the reduction of hospital readmissions. • The Hospital VBP ( Value Based Purchasing) Program, established by the Affordable Care Act, implements a pay-for- performance approach to the payment system that accounts for the largest share of Medicare spending • Hospital – acquired Condition( HAC) Reduces payment to worst performing hospitals

14. How do I Compare? https://www.medicare.gov/hospitalcompare/search.html

15. Infection Measures

16. Generating CMS Infection Reports

17. CMS Resources https://www.cdc.gov/nhsn/cms/index.html

18. Questions