Facts about Critical Access Accreditation

The has accredited for more than 50 years. In 2001, The Joint Commission introduced a new program to accredit critical access hospitals. CAHs are hospitals identified by the Centers for & Services as having met, or eligible to meet, the conditions for becoming a CAH, that is, the hospital:

. Maintains no more than 25 total beds, including both acute care and/or swing beds. . Keeps hospitalized 96 hours or less. . Has received authorization to become a CAH from the state office of rural health.

As of October 2009, there were 1,310 CAHs in the United States. In 2002, The Joint Commission obtained deemed status recognition for its CAH accreditation program from CMS allowing The Joint Commission to conduct both conversion surveys (the initial survey to become a CAH) and recertification surveys.

Benefits of accreditation Critical access hospitals seek Joint Commission accreditation because it: . Strengthens community confidence in the quality and safety of care, treatment, and services. . Improves risk management and risk reduction. . Helps organize and strengthen safety efforts. . Provides education on good practices to improve business operations. . Provides professional advice and counsel, enhancing staff education. . Provides a customized, intensive process of review grounded in the unique mission and values of the organization. . Enhances staff recruitment and development. . Provides deeming authority for Medicare certification. . Recognized by insurers and other third parties. . May reduce liability insurance costs. . Provides a framework for organizational structure and management. . May fulfill regulatory requirements in select states.

Standards The CAH program was developed with careful consideration of the Medicare Conditions of Participation (COPs) requirements for CAHs. As required to maintain deeming authority, all Medicare COPs for CAHs are encompassed by Joint Commission standards published in the Accreditation Manual for Critical Access Hospitals. Certain standards link directly to specific Medicare COPs. While some of the standards are different than those in the Joint Commission’s hospital accreditation manual, the functional performance areas are identical. The accreditation policies, including the Sentinel Event Policy and the Accreditation Participation Requirements (except for ORYX performance measurement requirements) are also identical to the hospital program. In 2010, the standards chapters focus on:

▪ Environment of Care ▪ Medical Staff ▪ Emergency Management ▪ National Goals ▪ Human Resources ▪ Nursing ▪ Infection Prevention and Control ▪ Provision of Care, Treatment, and Services ▪ Information Management ▪ Performance Improvement ▪ Leadership ▪ Record of Care, Treatment, and Services ▪ Life Safety ▪ Rights and Responsibilities of the Individual ▪ Medication Management ▪ Transplant Safety

Survey process To earn and maintain accreditation, a CAH must undergo an on-site survey by a Joint Commission survey team. Joint Commission surveys are unannounced and occur 18 to 39 months after the previous full survey. The Joint Commission survey process examines the hospital’s acute, swing bed and outpatient services in one integrated on-site review. The objective of the survey is to evaluate the quality and safety of care, treatment, and services provided by the CAH, and to provide education and guidance that will help staff continue to improve the hospital's performance. Joint Commission surveyors are experienced professionals who are extensively trained and receive continuing education to keep up-to-date on advances in quality-related performance evaluation. Surveyors are also required to successfully complete a certification examination. During the survey, surveyors observe activities, interview patients and staff, and review documents. They may spend a significant amount of time on patient units, observing care as it is carried out, and tracking a patient(s) through his or her hospital stay—in person and through medical records—to find out how the hospital's systems and processes work in supporting patient care. The survey process for CAHs is based on the model created for small and rural hospitals. After receiving accreditation, the CAH is required to remain in compliance with all standards during its three-year accreditation cycle.

Performance measurement requirements CAHs are exempt from the requirement to transmit data via a performance measurement system to The Joint Commission, but they are required to select and use six performance measures relevant to the services they provide and the patients they serve. If they wish, CAHs may voluntarily collect data on core (i.e. nationally standardized) measure sets that might be appropriate to their patient population. During the on-site survey, CAHs will share their measurement data—whether core or non-core—results and conclusions with surveyors. For more information, contact Frank Zibrat, associate director, ORYX Implementation, at [email protected] or (630) 792-5992.

Cost of CAH accreditation For 2010, the annual fee for CAHs is $1,090 and the on-site survey fees are:

$1,700 Per surveyor, first day $1,310 Per surveyor, second and subsequent days

$4,705 For Early Survey Option 1 (per survey) $4,705 Early Survey Option 1 follow-up survey

$2,100 Life Safety Code Specialist

The on-site survey fee is paid at the beginning of the year in which the on-site survey will be conducted, along with the annual fee, and covers survey-related direct costs. For more information about pricing, contact The Joint Commission’s Pricing Unit at (630) 792-5115.

For more information Contact Mark Pelletier, executive director, Hospital Programs and Accreditation and Certification Services, at [email protected] or (630) 792-5755, or visit www.jointcommission.org. 3/10