Public Health Foundation - ACCREDITATION: A Study of Issues and Characteristics Applicable to Public Health

ACCREDITATION:

A Study of Issues and Characteristics
Applicable to Public Health

Prepared by the Public Health Foundation
with support from the
CDC Public Health Practice Program Office

May 1998

I. Background and Overview

The Public Health Foundation (PHF) designed this study to contribute information to the ongoing national, state, and local discussions regarding performance measures and the feasibility of implementing a national system of voluntary accreditation for public health departments. This was accomplished by examining the benefits, drawbacks, and policy implications of accreditation within other health-related disciplines as a framework for analysis. The specific objectives were to:

Develop a broad understanding of the issues involved in accreditation;

Identify existing accreditation systems in health-related disciplines that have conducted some analysis of the accreditation process;

Extract lessons learned and key issues of developing and maintaining an accreditation process from other disciplines;

Determine and describe the relevant aspects of other voluntary accreditation programs to public health; and

Disseminate the results to the public health community.

This study is part of a multi-year effort supported by the Centers for Disease Control and Prevention (CDC) to develop a National Performance Standards Program in public health. The methodology is detailed below.

II. Methodology

Information was initially collected through background research to build firsthand knowledge of the relevant issues of accreditation and performance measures and to identify other projects already in progress. The preliminary research allowed discovery of findings from previous accreditation studies as well as studies using performance measures in general.

The main components of the background research included: informal interviews with experts in the field and staff from other organizations involved in accreditation work; a limited literature review of articles published in peer-reviewed journals; Internet searches for web sites of accrediting organizations, information about systems in place, and other electronically-published information; and electronically posting a brief description of the project plan with questions on the Public Health Network (PHN) to solicit feedback, discussion, and other information available from the public health community.

Following the background research, the scope and focus of this study were refined in conjunction with the National Association of County and City Health Officials (NACCHO) and CDC. Progress and information were also shared with the Association of State and Territorial Health Officials (ASTHO), the National Association Local Boards of Health (NALBOH), the American Public Health Association (APHA), and other public health partners through regular updates.

Information collected during the preliminary research and fact finding stages of this project was used to develop an Interview Guide, which served as a framework for the formal interview portion of the study. The Interview Guide was designed for systematic, yet flexible, collection of information from each organization selected for inclusion in the study. The research involved examining the structure and system of four major accrediting bodies by interviewing individuals from both the accrediting bodies and applicable membership organizations.

Research questions for the accrediting bodies focused on exploring and examining the following topics:

overarching and relevant issues of accreditation;

reasons to begin a voluntary accreditation system;

process of accreditation;

development of accreditation criteria and performance measures;

necessary steps for maintaining an up-to-date accreditation system; and

advantages and disadvantages of accreditation.

Research questions for the membership bodies focused on exploring and examining the following topics:

overarching and relevant issues of accreditation;

reasons to begin a voluntary accreditation system;

financial and personnel investments;

requirements and strategies for maintaining accreditation status;

analysis of accreditation in general; and

advantages and disadvantages of accreditation.

The accrediting bodies were selected because of their applicability to developing a national voluntary accreditation system for public health agencies. The specific applicable characteristics included that the systems:

were health-related;

voluntarily accredited organizations;

utilized a nationwide system;

accredited different sizes of organizations; and

allowed different levels of accreditation.

Information was collected via a review of organization-produced documents and formal phone interviews with key staff from the following organizations:

Accrediting Bodies

American Accreditation Healthcare Commission/URAC (Commission/URAC)

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

National Committee for Quality Assurance (NCQA)

Community Health Accreditation Program (CHAP)

Membership Organizations

American Hospital Association (AHA)

American Association of Health Plans (AAHP)

III. Matrix: Summary of Findings

The information collected was organized into a matrix around common aspects and issues of the systems examined — including the structure, incentives, disincentives, and overall implications of implementing an accreditation system. The organizational structures of the accrediting bodies are included to provide a contextual overview of the information collected and to facilitate a better understanding of the applicable contributions of each accrediting organization to the field of public health. The matrix reflects that the four accrediting bodies served as the units of analysis. The first portion of the matrix includes descriptive, factual information provided by both the accrediting bodies and membership organizations. The second portion includes qualitative information and is divided according to the source of the comment.

The matrix is designed to serve as basis for further work by PHF and its public health partners, including CDC, NACCHO—particularly its Voluntary Accreditation Committee, and the Association of State and Territorial Health Officials (ASTHO) in exploring the development and implementation of a National Performance Standards Program. PHF plans to apply the information contained in this study to further work in identifying, exploring, and developing recommendations for planning and operationalizing a national performance measurement surveillance system for public health organizations.

* A representative of JCAHO was not available for interview. Statements about JCAHO reflect information garnered from printed materials and responses provided from interviews with staff from the membership organizations included in the study.

Summary of Findings

		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Mission		To improve the quality of care provided to the public by setting standards and evaluating the performance of healthcare organizations against those standards.	To provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, thereby allowing them to make more informed health care purchasing decisions. Efforts are organized around accreditation and performance measurement.	To improve the quality and efficiency of managed care.	To provide leadership for enhancing the health and well being of diverse communities. This is achieved by: - developing standards of excellence that assure the management of ethical, humane, and competent care in home, community, and public health settings - developing and disseminating innovative products, services, and models of care - creating partnerships - utilizing resources efficiently
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Types of Organizations Accredited		hospitals (general, psychiatric, children’s and rehabilitation) home care providers mental health facilities nursing homes and long-term care facilities ambulatory care facilities clinical and pathology laboratories health care networks (including health plans, integrated delivery networks, preferred provider organizations, and other networks)	managed care organizations physicians organizations managed behavioral health care organizations credentials verification organizations	preferred provider organizations point-of-service plans provider sponsored organizations individual practice associations health maintenance organizations, and other network-based health plans utilization management organizations workers’ compensation managed care programs	home health care organizations hospice care organizations private duty agencies home medical equipment agencies in-home pharmacy services home infusion therapy organization supplemental staffing agencies community nursing centers services of public health departments
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
History of System		JCAHO formed in 1951 to accredit hospitals expanded to include other types of healthcare organizations, beginning in 1988 in 1989 began accreditation of managed care organizations but initiative was shortly dropped until 1994 when new managed care standards were implemented	NCQA began accrediting managed care organizations in 1991 expanded to include other programs since 1991 accreditation levels to be revamped for 1999	Utilization Review Accreditation Commission (URAC) chartered in 1990 to establish accreditation standards and programs for managed health care change in name to Commission/URAC/URAC in 1996 represented expansion to cover accreditation of range of managed care activities modules for accreditation of additional aspects of managed care currently under development	CHAP formed in 1965 to accredit home health agencies CHAP originally formed in a collaboration between APHA and the National League for Nursing (NLN) CHAP became an independent subsidiary of the NLN in 1987
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Governance and Funding Mechanism		Board of Directors includes representatives of the American College of Physicians (ACP), American College of Surgeons (ACS), American Hospital Association (AHA), American Medical Association (AMA), American Dental Association, public members, and an at-large nursing representative funded by accreditation fees Quality Healthcare Resources exists as non-profit consulting subsidiary of the Commission	Board of Directors includes employers, consumer and labor representatives, health plans, quality experts, regulators, and representatives from organized medicine funded by accreditation fees, educational conference fees, publications, and state and federal grants	16-member Board of Directors that includes representation from all constituencies affected by managed care: employers, consumers, regulators, health care providers, and the workers’ compensation and managed care industries funded by accreditation fees, educational conference fees, publications, and grants	Board of Directors includes: experts in the field of quality improvement, representatives of business and insurance, home health and community health providers, and individual consumers funded by accreditation fees
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
External Relationships		Joint Commission established by ACP, ACS, AHA, AMA, and Canadian Medical Association hospitals accredited deemed to be in compliance with most federal conditions for participation in Medicare and most Medicaid plans maintains cooperative accreditation agreements with CHAP for home care and the Commission on Office Laboratory Accreditation to reduce redundancy in the accreditation of health care organizations representatives of AAHP, AHA and other organizations from the Board of Directors sit on network standards committee and other technical and policy development work groups	jointly established in 1979 by Group Health Association of America and American Managed Care Review Association to establish standards works with other accrediting bodies on general issues affecting the health care field AAHP member sits on Committee on Performance Measures (HEDIS development) In 1998, NCQA purchased one of its "competitors," the Medical Quality Commission—which closed operations in March 1998. does not maintain any formal relationship with membership organizations, but relies on expertise for consultation and input proactively solicits public comment on standards and value of accreditation process approves other sources of data such as the National Practitioner Data Bank in accreditation process	URAC purchased American Accreditation Program, Inc. the only accrediting body for preferred provider organizations, in 1995 19 states and DC accept Commission/URAC accreditation in lieu of licensure many states have adopted regulations that closely parallel Commission/URAC standards Commission/URAC maintains regular contact with state officials collaboration with overlapping programs maintained Commission/URAC maintains a list of member organizations including AAHP, that sit on its Board of Directors collaboration with major health-related organizations established through member and board organizations standards development process involves major constituencies affected by accreditation and involves a public comment and testing phase to ensure external validation of the standards	CHAP formed by collaboration between APHA and the National League for Nursing (NLN) CHAP became an independent subsidiary of the NLN in 1987 as an independent body, CHAP currently maintains a collaborative arrangement with NLN—as a subsidiary CHAP can draw upon NLN’s resource base to improve community and home health care service delivery mutual recognition between JCAHO and CHAP for home health organizations accreditation CHAP accreditation maintains deemed status for Medicare home care application for deemed status for hospice under review by HCFA
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Accreditation Options Available		Accreditation with Commendation: granted for 3 years to organizations demonstrating exemplary performance Accreditation: granted for 3 years to organizations in overall compliance with applicable standards Accreditation with Recommendations: granted to organizations with a list of recommendations that must be resolved within a specified period of time or the organization risks losing accreditation Provisional Accreditation: accreditation decision that results when an organization has demonstrated substantial compliance in the first of two surveys; second survey conducted approximately six months later to allow the organization time to demonstrate a track record of performance Conditional Accreditation: indicates that multiple, substantial standards-compliance deficiencies exist in an organization; correction of deficiencies must be demonstrated through a follow-up survey	Full Accreditation: granted for 3 years to organizations that have excellent continuous quality improvement programs and meet NCQA’s standards (40% of reviewed organizations) One-Year Accreditation: granted to organizations that have well-established quality improvement programs and meet most NCQA standards; provided with a specific list of recommendations and reviewed again after one year (37% of reviewed organizations) Provisional Accreditation: granted for one year to organizations that have adequate quality improvement programs and meet some NCQA standards; must demonstrate progress before they can qualify for higher levels of accreditation (11% of reviewed organizations) Under Review: those organizations for which an initial accreditation determination has been made but is under review Certification: only components of an organization, such as credentialing and utilization management, examined in order to streamline oversight of delegated services and promote continued accountability and CQI for the services offered by delegated organizations	Full Accreditation: granted for two years to organizations/services meeting set of standards for particular module Conditional Accreditation: granted to startup organizations/services or organizations/services that have only recently implemented a policy/procedure such that on-site verification of compliance is not possible Options of system: seven modules allow accreditation for separate sets of services or in combination to reflect array of services offered by different types of organizations seeking accreditation by the Commission/ URAC. For example: network credentialing offered for preferred provider organizations and other similar networks that do not offer the full array of health care services; also used as a first step for full service network accreditation; health network accreditation offered for managed care networks that are not responsible for utilization management.	JumpStart: streamlined and expedited process offered for new services or programs (initially 6 months, then annual reviews for first 3 years) Accreditation: (4 years) with or without required actions, progress report, or focus visit Deferred Accreditation: pending additional information or a focused site visit (initial accreditation only) Deemed Accreditation: determination of compliance with CHAP standards and Medicare Conditions of Participation Types of CHAP citations: commendations (organization exceeds the standard), recommendation (action to be taken to improve the quality of services and products and/or operational aspects of the organization), and required actions (immediate response is indicated, compliance with standard necessary in order to maintain accreditation) accreditation customized to particular services examined
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Standards Utilized		initially utilized one uniform set of standards current standards include specific sets for ambulatory care, mental health care, clinical laboratories, health care networks, home care, hospitals, and long term care health care networks further divided into four separate accreditation tracks: health plans, integrated delivery networks, preferred provider organizations, and other networks	50 core standards cover six main areas: quality improvement, physician credentialing, members’ rights and responsibilities, preventive health services, utilization management, and medical records service-specific standards incorporate unique qualities of program under evaluation standards for new health plans: subset of existing MCO standards, without the requirement that a plan already has a demonstrated record of improvement over time (plan must exist for at least 18 months before being eligible for regular accreditation) separate subsets of standards for certification processes	individual sets of standards developed to reflect the services and needs accredited within each of the seven modules: Full Health Network, Network Credentialing, Health Network, Workers Compensation Network, Health Utilization Management, Workers’ Compensation Utilization Management, and Credentials Verification Organizations under development: accreditation modules and standards for 24-hour telephone demand management and case management organizations	core standards form the basis of the program-specific standards addressing: structure and function of the organization; quality of services and products provided; adequacy of resources; and long-term viability of the organization program-specific standards: combined with the core standards and tailored to the program mix of applicant organization self-study: a comprehensive internal self-assessment completed by the applicant organization prior to the CHAP site visit
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Focus of Standards		general standards categories: rights, responsibilities, and ethics; continuum of care; education and communication; health promotion and disease prevention; leadership management of human resources; management of information; and improving network performance in addition to general standards, accreditation focuses on the unique, applicable characteristics of specific services and organizations	Quality Improvement (40% of organization’s score): focuses on how well the organization examines the quality of care given to its members, how well the organization coordinates all parts of its delivery system; and what improvement in care and service the organization demonstrates Physician Credentialing (20%): focuses on how the organization meets specific requirements for investigating the training and experience of physicians in its network Members’ Rights and Responsibilities (10%): focuses on how clearly the organization informs members about how to access health services, choose a physician, and make a complaint Preventive Health Services (15%): focuses on how well the organization encourages preventive tests and immunizations Utilization Management (10%): focuses on how reasonable and consistent the organization’s process is for deciding what health services are appropriate Medical Records (5%): records are examined for how consistently they meet NCQA standards specific standards sets focus on particular aspects of program being evaluated; for example Managed Behavioral Health Accreditation also focuses on coordination of behavioral health with medical care; implementation of population-based CQI management systems; and emphasis on preventive behavioral health	Each accreditation module has its own set of standards and focus: Full Health Network: network management, utilization management, quality management, credentialing, and member participation/ protection Network Credentialing: development and implementation of a credentialing program; oversight of a credentialing committee; requirements for informa-tion included in the credentialing application; initial credentialing verification requirements; recredential-ing verification and timeframe for processing request; maintenance and confidentiality requirements that apply to each credentialing file; and protocols for delegating credentialing functions to third parties Health Network: provider participation and network management standards; quality management standards; provider credentialing standards; and member participation and protection standards Workers Compensation Network: provider selection and contracting; access and availability; grievance procedures; marketing; development and implementation of a quality manage-ment program; primary-source and secondary-source verification of practi-tioner credentials; recredentialing processes; time frames for credentialing and recredentialing; and requirements and protocols for delegating network functions to third parties Health Utilization Management: confidentiality; staff qualifications and credentials; program qualifications; quality improvement programs; access-ibility and on-site review procedures; information requirements; utilization review procedures; and appeals Workers’ Compensation Utilization Management: based on the Commission/URAC Health Utilization Management Standards and adapted for workers’ compensation issues Credentials Verifications Organizations: basic functions of credentialing and verifications	Core standards: educational qualifications/ creden-tials of all levels of management staffing patterns/workload distribution and human resource management policies and procedures for public disclosure and client rights environmental controls, use of space, and corporate climate quality improvement processes, including consumer satisfaction, benchmarking program evaluation, and planning contracts and agreements financial controls, resources, and information systems, and management information systems strategic planning, monitoring, and evaluation risk assessment and management marketing strategies and initiatives use of collected data innovative programs/networking Program-specific standards: overall program management qualification/credentials, orientation, supervision and training of staff quality improvement/utilization review activities client satisfaction (from interviews and surveys) staff interviews inter- and intra-organizational coordination client outcomes benchmarking program planning and evaluation program viability infection control and safety program innovations/collaboration/ networking
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Quality Focus of Accreditation Body		standards set forth performance expectations for activities that affect the quality of patient care; if an organization does the right things and does them well, there is a strong likelihood that its patients will experience good outcomes modifying approach to include more information on clinical quality in 1997, incorporated the use of outcomes and other performance measures into the accreditation process	40% of accreditation score based on quality improvement quality improvement enhances the accreditation status of any organization reviewed by NCQA modifying approach to include more information on clinical quality development of 1999 standards will incorporate performance-based accreditation including evaluation of health organizations based on their results, attention on areas of public concern, and encouragement of upgrading existing information systems to track accountability meets public desire for accountability for the quality of care provided to plan members	quality measures included in all sets of standards private accrediting body, supported by coalition of providers, vendors, purchasers, and contractors, helps ensure quality in managed care operations and provide foundation across states by maintaining accreditation, organizations have established ongoing activities to improve quality and maintain CQI programs improve quality by identifying areas for enhancement through the accreditation process and implementing recommended changes	standards focus on quality of component evaluated outcomes data directly related to quality improvement initiatives–more focused and results-oriented accreditation system reviewed periodically to ensure that it accurately reflects any developments in the field and appropriately targets key elements of services accredited commitment of time required to undergo review process intimates certain level of quality self-evaluation process improves systems and services accreditation system based on meeting consumer needs
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Accreditation Process		application process that includes submission of mission statement; policies regarding applicable standards; minutes and reports of committee meetings; management plans; sample education materials; network-wide planning documents; and description of performance improvement activities on-site review process includes: review of documents, tour of facilities, and staff interviews survey review team composed of at least one MD and one RN, additional surveyors as needed with applicable background to organization being evaluated accreditation awarded based on scoring system that is organized around performance areas; not necessarily compliance with each standard but overall compliance average 4-6 months between application and accreditation decision formal grievance mechanism allows organizations to voice concerns about review process	set of standards published for review by applicant educational conferences offered to assist organizations in preparing for process initial step of application process involves self assessment practice review encouraged prior to review for an accreditation decision after submission of application, on-site review completed by team of senior-level managed care experts and physicians: examine records, staff, and the training and experience of plan physicians review team composed of MD, administrative surveyor, and additional surveyors as needed report of review team reviewed by Review Oversight Committee who makes the accreditation decision average 7-8 months between application and accreditation decision if denied accreditation, review team focuses on education and identifying objectives to help improve organization; summary of review results publicly posted formal appeals process in place	application describes compliance to standards that measure quality and performance; standards include both "shalls" and "shoulds" "desk top" (paper application review) and on-site reviews performed by staff educational approach promotes interactive dialogue committee review system to grant or deny accreditation; accreditation is granted to those organizations scoring 100% of the "shall" standards and 60% of the "should" standards 3-4 month process if denied accreditation, formal grievance procedure available to investigate any complaints if complaint filed against accredited body, Commission/URAC conducts re-evaluation and may assess sanctions depending on the nature of the violation	first step of application process involves review of standards and extensive self-assessment process (initial and year 1 of each 3-year cycle) unscheduled site visit by review team, who reviews core and program-specific standards to determine compliance review team composed of two experts in the field trained to evaluate organization’s capacity and relevance to community determination of compliance with standards based on clarification of information, verification of findings and quantification of data collected site visit team makes recommendation to Board of Review who ultimately determines accreditation status timeframe for review dependent on complexity of organization and level of preparedness up to 6 months from receipt of initial application to final review and accreditation decision if denied accreditation, list of improvements needed and suggestions are reported to applicant organization
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Costs		application fee ($1,000) plus site visit/survey review team cost ($10,175 base fee, plus cost of extra surveyor days) preparation materials also available for purchase by potential applicants	costs vary based on the effort required for NCQA to assess specific organization structure and operations pricing for a practice review costs 75% of the full accreditation review price preparation materials available for purchase by potential applicants	fee varies according to the type of accreditation sought by applicant fees are based on the expected effort needed to conduct a desktop and on-site review of the organizations’ operations ($4,800-$15,000, plus costs of site review)	sliding scale based on annual revenue (annual budget for public health organizations) of applicant organization application fee of $1,500 (deducted from first year’s annual fee) plus annual fees ranging from $3,150 for revenues under $1.5 million to $23,000+ for revenues above $300 million, plus $950/day/site visitor (avg. 2 days)
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Evolution/ Maintenance of System		recommendations are received on proposed standards from the Network Professional and Technical Advisory Committee, a group that includes representatives from employer, insurance, health care, consumer, and regulatory organizations review of proposed standards is conducted by the Standards and Survey Procedures Committee of the JCAHO’s Board of Commissioners proposed standards are distributed to numerous individuals in the field for comments (field review) final approval of standards is granted by Standards and Survey Procedures Committee all information included in ongoing field assessment and analysis process pilot test programs utilized, such as the Orion Project, are designed to test innovations to improve the delivery of accreditation services	proposed standards developed with input from the industry/field including employers, public purchasers, unions, provider groups, regulators, consumers, and experts in the field for each set of standards subsequent sets of standards based on fully developed sets (e.g., behavioral health standards based on MCO standards) organization founded as a result of emergence of managed care with no objective/uniform information available maintenance requires continuous revisions to ensure the program’s currency, relevance, and rigor working toward more consumer-oriented standards such as gag rules and performance measures	proposed standards developed through a consensus-building process by a broad-based task force of managed care experts revisions/modifications reflect market, purchaser, and consumer demands; undergo rigorous process every two years open and comprehensive process for developing and revising standards standards committees formed by representatives of Board and other interested external parties and experts standards sent out for public review and comment standards updated to reflect industry changes and to maintain appropriate benchmarks	CHAP has developed continuous quality improvement plan and process that is monitored quarterly, reports are reviewed by Boards of Review and Board of Directors organizations accredited by CHAP evaluate accreditation system, site visitors, training sessions, and educational offerings review and revision of standards conducted with input from consumers, experts in the field of community health and CHAP staff newly develop and/or revised policies, procedures, and standards are subject to an open review prior to implementation continually updated to improve customer service, enhance internal operations, and upgrade the range of products and services available to accredited organizations HCFA evaluates the effectiveness of the CHAP process as it relates to deeming authority revisions to the OSHA standards, Medicare Conditions of Participation, and CDC directives are incorporated into CHAP documents as necessary
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Reasons for Choosing Accrediting Body	as cited by accrediting body	comprehensive survey evaluates all major aspects of an organization’s performance including the evaluation of a significant number of health care delivery sites JCAHO credentialing streamlines the entire process by consolidating the ancillary credentialing requirements for healthcare organizations	NCQA accredits largest percentage of health plans and considered major market force for ensuring quality of services by definition of types of organizations accredited by NCQA, some organizations or range of services are more suited to NCQA accreditation	independent accreditation agency that sets standards and evaluates managed care organizations most appropriate set of credentials for preferred provider organizations and similar network-based plans recognized as preeminent body for accreditation of utilization management activities of health and workers’ compensation programs costs somewhat less than other accreditation processes modular approach to managed care accreditation programs is flexible, which allows accreditation of different aspects of managed care operations; different modules offer incentives for working toward full network accreditation	history and background in accrediting community health organizations reflects consumer-driven and community needs focus reasonable cost consultative component of CHAP accreditation recognizes and promotes the level of professionalism within the accredited organizations less hospital-based than JCAHO if organization does not choose CHAP, may not be chosen as preferred provider for insurance plans or other competitive situations (may inhibit ability to compete in market place)
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Reasons for Choosing Accrediting Body (continued)	as cited by membership organizations	historically played key presence in accreditation of hospitals, which has led to choosing JCAHO for other services and organizations by definition of the types of organizations accredited by JCAHO and its reputation in the field, JCAHO accreditation more appropriate for certain types of plans, networks, and market environments because of JCAHO’s widespread reputation and desirability of accreditation by organizations, standards can be set at optimal, but still achievable levels	built reputation as the best type of accreditation in managed care field — the "gold standard" required by number of employers choosing health plans by definition of types of organizations accredited by NCQA and its reputation in the field, NCQA accreditation more appropriate for certain types of plans, networks, and market environments	by definition of types of organizations accredited by the Commission/URAC, accreditation by the Commission/URAC more appropriate for certain types of plans, networks, and market environments Commission/URAC known for accreditation of preferred provider organizations and utilization management	accreditation program custom designed to home health care dependent on plan, type of network, and market environment
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Incentives for Accreditation	as cited by accrediting body	indicates an organization meets certain performance standards assists organizations in improving their quality of care may be used to meet certain Medicare certification requirements (deemed status) enhances community confidence enhances medical staff recruitment provides a staff educational tool expedites third-party payment often fulfills state licensure requirements may favorably influence liability insurance premiums improves quality and health care outcomes, demonstrates accountability, and increases participation in managed care and other contracted arrangements	provides a force in market to make decision based on quality not price creates better market advantage for health plans some states view accreditation as meeting requirement of external quality review purchasers value accreditation and use system versus hiring internal experts evaluation required for every organization provides standardized system	demonstrates to managed care organizations' customers and purchasers that it has been impartially reviewed and found to meet nationally recognized standards and best practices indicates to purchasers that a MCO has the necessary infrastructure and processes to promote high quality health care represents seal of approval provides consumer protection accreditation standards help define operations and services indicates compliance with various laws and regulations regarding state oversight of managed care improve quality by identifying areas for enhancement through the accreditation process and implementing recommended changes required by some purchasers states that deem accreditation can streamline compliance with regulatory processes for accredited companies	recognition of quality of services provided benchmarking establishes systems for accountability consumers and professional colleagues recognize accredited bodies as providing high quality services insurers/managed care plans more inclined to contract with accredited bodies may be used to meet certain Medicare certification requirements (deemed status) organization faces potential loss of business as payors become familiar with accreditation public recognition
Incentives for Accreditation (continued)	as cited by membership organizations	AAHP encourages consumers/purchasers to check with accrediting bodies before choosing a health plan hospitals and other health care facilities gain status as validation that the care they deliver is of high quality having system in place leads to better outcomes prior to national standards, no framework existed for improving quality of care better risk level (for clients seeking services) associated with accredited organizations	AAHP encourages consumers/purchasers to check with accrediting bodies before choosing a health plan having system in place leads to better outcomes prior to national standards, no framework existed for improving quality of care better risk level (for clients seeking services) associated with accredited organizations	AAHP encourages consumers/purchasers to check with accrediting bodies before choosing a health plan accredited organizations have a competitive advantage over non-accredited organizations having system in place leads to better outcomes prior to national standards, no framework existed for improving quality of care better risk level (for clients seeking services) associated with accredited organizations	having system in place leads to better outcomes prior to national standards, no framework existed for improving quality of care better risk level (for clients seeking services) associated with accredited organizations
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Disincentives for Accreditation	as cited by both accrediting bodies and membership organizations	financial investment personnel investment for process standards are continually updated and require organizational resources and time to maintain accreditation status standards are very structure-oriented (particularly for hospitals) and do not necessarily guarantee services need to devote time and effort to developing partnership roles with health plans and employers process needs to be further streamlined regulating process limits control of outcomes particular market pressures organizations may choose not to seek JCAHO accreditation because its services do not match the services the accreditation system is designed to evaluate	financial investment personnel investment for process standards are continually updated and require organizational resources and time to maintain accreditation status need to devote time and effort to developing partnership roles with health plans and employers particular market pressures if organization does not choose NCQA, may not be viable organization or NCQA accreditation may not match needs of organizations	financial investment personnel investment for process standards are continually updated and require organizational resources and time to maintain accreditation status need to devote time and effort to developing partnership roles with health plans and employers	financial investment of process personnel investment for process
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
System Characteristics Applicable to Public Health	as cited by accrediting body	None cited.	states do not need to maintain accrediting function themselves for health plans operating within the state NCQA’s development of performance measures (HEDIS 3.0) has occurred in collaboration with development and implementation of accreditation process 1999 accreditation standards will incorporate performance measures certification program allows credentialing of functional portions of organizations partnership between an accreditation organization and government agency can save time, save money, and improve the quality of the review	feasibility, time efficiency, and quality improved by public/private partnerships accreditation indicates that the organization has the infrastructure and resources to accomplish its objectives helps define the core elements of what organizations should be providing/accomplishing	CHAP covers entire range of organizations in terms of size and services accreditation indicates demonstrated ability to maintain system and updated to reflect changes in the field quality-related incentives analysis of community interaction involved in accreditation process accreditation of services of public health organizations dates back to 1965 and sets precedent
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
System Characteristics Applicable to Public Health (continued)	as cited by membership organizations	range of services accredited by JCAHO cover many functions and services of health departments accreditation system shows accountability and assures public of quality services provided states don’t need to maintain accrediting function themselves for health plans operating in state public seeks, for their own personal assurance, useful information about the quality and value of care being provided	nationwide system provides objective measures of quality of organizations and services offered accreditation system shows accountability and assures public of quality services provided government agency delegating authority for reviews saves state resources	national system streamlines accreditation process and provides uniform accountability while allowing flexibility in the way organizations operate accreditation system assures public of quality services provided	accreditation system shows accountability and assures public of quality services provided
		Joint Commission on Accreditation of Healthcare Organizations (JCAHO)	National Committee for Quality Assurance (NCQA)	American Accreditation Healthcare Commission/URAC (Commission/URAC)	Community Health Accreditation Program (CHAP)
Lessons Learned	as cited by accrediting body	None cited.	market demand exists for accreditation of hospitals and health networks, but not as much for integrated delivery systems recognition does not make accreditors a policing agency building contacts in the field lends value to the accreditation process (worked with AAHP to build standards) promoting quality is a collaborative effort Board of Directors composed of primary constituencies provides balanced leadership and guidance for the organization’s, and its programs,’ ongoing development	market demand exists for high quality services as judged by accreditation of health networks accreditation is an extensive process and organizations seeking it must be serious about meeting the standards formal and public accreditation (information available to the public) extends credibility of self-assessment process	accreditation is a process not an event individuals involved in developing standards need to be working in field to relate accreditation system to real practice
Lessons Learned	as cited by membership organizations	recognition does not make accreditors a policing agency accreditation and the use of standards is fundamentally a risk-reduction activity high quality data needed to substantiate the accreditation process understanding the standards is helpful in obtaining and complying with accreditation hallmark of successful accreditation programs is that they are voluntary, credible, and recognized both within and external to the industry being accredited

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