Acreditations

Question 1

Why accrededations?

Answer 1

To improve:
Patient outcomes
Patient safety
Employee satisfaction
Customer service
Reimbursement
Job security
Meet standards of accrediting agencies

Question 2

What are some of the things that evaluations might care about

Answer 2

fall risk
nursing strikes
surgical outcomes
hand washing

Question 3

QA: Quality Assurance

Answer 3

Focus on eliminating defects

Question 4

CQI: Continuous Quality Improvement

Answer 4

Focus on Consistency in Processes

Question 5

TQM: Total Quality Management

Answer 5

More of a style of management where you are focused on three strategies:
- CQI
- Culture, customer satisfaction
- Core values communicated

Question 6

regulatory boards

Answer 6

Government law or rule - often paid for by the government,

Question 7

Governmental Regulatory Programs history

Answer 7

started in end of 1800’s. 1906 - national regulation of food and drugs (FDA), 1935 - social security act set standards for maternal and child standards. 1965 - medicare established.

Question 8

Regulatory board
State Health Department (govt pays)

Answer 8

Evaluated facilities~ often focused on preventing abuse and providing a clean and safe environment

Question 9

NY State Office of the Professions:

Answer 9

licensure (licensee pays for)
Pay a fee to put “L” in the OTR/L

Question 10

Centers for Medicare and Medicaid Services:

Answer 10

Review charts to verify quality of services (govt pays)

Question 11

External Agencies as Standard Setters
NBCOT: National Board of Certification of Occupational Therapy

Answer 11

pass certification and put R in OTR

Question 12

AOTA sets Guidelines which are enforced through the NBCOT Sanction program

Answer 12

Occupational Therapy Code of Ethics and Ethic Standards
Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy

Question 13

ACOTE: Accreditation Council for OT Education
Evaluates

Answer 13

academic programs for a fee

Question 14

Joint Commission:

Answer 14

Provides accreditation of Healthcare Organizations for a fee

Question 15

CARF:

Answer 15

Commission on Accreditation of Rehabilitation Facilities for a fee

Question 16

Focus of state health department

Answer 16

Focus
Environment : clean, safe to prevent falls, prevent infection
Do Patient’s have rights (Right to Refuse is a biggie)
Quality of basic physiologic care (more focused on nursing)
Are they being fed well?

Question 17

DOH Focused on assuring the environment is

Answer 17

safe and that basic physiologic needs are met
Inspection unannounced every 9-15 months
Not voluntary => state pays for

Question 18

Requirements of the NY State Office of the Professions(NYSED) to be an OT

Answer 18

• Establishes licensure ($294 for OT)
• Must be of good moral character
• 21 years of age (18y for OTA)
• Graduate from accredited OT Program
• For full license: pass national NBCOT exam
• offers temp license ($70 extra and must have a job with an identified mentor/supervisor)
• Requires 36 hours of Continuing Competency every 3 years
• 24 hours must be directly related to pertinent area of OT practice

Question 19

Centers for Medicare & Medicaid(CMS) evaluates OTs for

Answer 19

• Mainly evaluate by chart review
• ## Strong standard setters as standards directly relate to reimbursement

Question 20

Center for medicare and medicaid CMS are focused on outcomes related to

Answer 20

• Improvement in Function
• Improving patient safety
• Not concerned with pain (views medication as the intervention for pain management)

Question 21

NBCOT:National Board for Certification in Occupational Therapy EXAM

Answer 21

Administer certification exam (good in all states) to validate knowledge.

Question 22

NBCOT Applicants must:

Answer 22

Graduate from an accredited program & complete FW
Must not have a felony conviction

Question 23

NBCOT recertifications happens when

Answer 23

Re-certification Every 3 years

Question 24

What do you need to recertify for OTR/L?

Answer 24

36 Units PDU=Professional Development Units/CAU= Competency Assessment Units
Specific rules on how to verify (logs, certificates, documentation) and a maximum in each category

Question 25

NBCOT: National Board for Certification in Occupational Therapy recertification standards or what you need

Answer 25

Examples of approved PDUs/CAUs:
1 hour in course = 1 or 1.25 PDUs
Volunteer for organization that supports practice role 5 hours = 1 PDU
Quiz based on NBCOT readings 0.5 CAU per quiz
Mentor a Peer 2 hours = 1 PDU
FW supervision = Level I = 1 PDU per student,; Level II = 1 PDU per week
Presentation at a state, national or international conference
1 hour = 2 PDUs

Question 26

ACOTE began in

Answer 26

1923

Question 27

ACOTE is Voluntary however

Answer 27

if you are not accredited, graduates cannot take NBCOT exam to practice
Annual fee paid for by OT program

Question 28

ACOTE acredidation is Currently 140 objective standards:
How does RSC meet objectives?

Answer 28

Objectives met in a minimum of two courses (syllabus)

Question 29

ACOTE visit -

Answer 29

3 day on site visit (follows extensive self-study report)
Interview college leadership, faculty, students, fieldwork educators, and employers of our grads.

Question 30

ACOTE years that they come

Answer 30

Outcome: 5, 7, or 10-year accreditation based on quality
Sage awarded 10 year in 2017 for Masters and 7 year for Doctoral Program!!

Question 31

Joint commission

Answer 31

Private, not-for-profit organization
Some states require Joint Commission Accreditation as a condition to receiving Medicare Reimbursement.
NY no longer requires
3-year accreditation
Call Surveys: Unannounced site visits by a team that follow published standards

Question 32

Joint comission started when

Answer 32

1917 - Hospital Standardized Program
Survey by American College of Surgeon
Focus: surgical care by physicians and nurses

Question 33

Joint comission 1951

Question 34

in 1979 the joint commission included

Answer 34

non nursing like OT

Question 35

Joint Commission recently expanded to include

Answer 35

Encompasses more health care facilities and not just hospitals

Question 36

National Patient Safety Goals (Joint Commission)

Answer 36

Focus on items that have a history of being problematic. Each year a new list is released
Has included things like fall prevention

Question 37

2023 Hospital National Patient Safety Goals include:

Answer 37

Patient Identification (2 ways of ID)
Prevent Spread of Infection (hand hygiene)
Patient safety risk: Identify which patients are most likely to commit suicide and monitor

Question 38

CARF: Commission on Accreditation of Rehab Facilities been around since 1968

Answer 38

they accredit not for profit centers -
Medical rehabilitation centers
Adult day services
Assisted living centers
Mental or behavioral health centers
Community agencies

Question 39

CARF evaluations include

Answer 39

Self study report

Site visits

3 year accrediation outcomes

Question 40

CARF site visitis include

Question 41

Internal Evaluation of Services

Answer 41

Used to Monitor quality of services and are often driven based on potential external reviewers

Outcome Measures: Demonstrate improvement
FIM, DASH, OASIS, MDS, PDPM
Patient Satisfaction Survey
Chart Review
Direct observation of therapist competency
Safety Monitoring (environmental tours, monitors of hot pack temperature records, sample from mat surface sent to lab for cleanliness inspection)

Question 42

Global Organizations

Answer 42

World Federation of Occupational Therapists (WFOT)

World Health Organization (WHO)

Question 43

World Federation of Occupational Therapists (WFOT)

Answer 43

Established in 1952
Non-governmental organization
OTPs and student members participate through trainings, certifications, online tools, and attendance at WFOT Congress (every 4 years)
Managers can support global activities (OT Global Day of Service)
Disaster Preparedness and Response