Acreditations Flashcards
Why accrededations?
To improve:
Patient outcomes
Patient safety
Employee satisfaction
Customer service
Reimbursement
Job security
Meet standards of accrediting agencies
What are some of the things that evaluations might care about
fall risk
nursing strikes
surgical outcomes
hand washing
QA: Quality Assurance
Focus on eliminating defects
CQI: Continuous Quality Improvement
Focus on Consistency in Processes
TQM: Total Quality Management
More of a style of management where you are focused on three strategies:
- CQI
- Culture, customer satisfaction
- Core values communicated
regulatory boards
Government law or rule - often paid for by the government,
Governmental Regulatory Programs history
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.
Regulatory board
State Health Department (govt pays)
Evaluated facilities~ often focused on preventing abuse and providing a clean and safe environment
NY State Office of the Professions:
licensure (licensee pays for)
Pay a fee to put “L” in the OTR/L
Centers for Medicare and Medicaid Services:
Review charts to verify quality of services (govt pays)
External Agencies as Standard Setters
NBCOT: National Board of Certification of Occupational Therapy
pass certification and put R in OTR
AOTA sets Guidelines which are enforced through the NBCOT Sanction program
Occupational Therapy Code of Ethics and Ethic Standards
Guidelines for Supervision, Roles, and Responsibilities During the Delivery of Occupational Therapy
ACOTE: Accreditation Council for OT Education
Evaluates
academic programs for a fee
Joint Commission:
Provides accreditation of Healthcare Organizations for a fee
CARF:
Commission on Accreditation of Rehabilitation Facilities for a fee
Focus of state health department
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?
DOH Focused on assuring the environment is
safe and that basic physiologic needs are met
Inspection unannounced every 9-15 months
Not voluntary => state pays for
Requirements of the NY State Office of the Professions(NYSED) to be an OT
- 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
Centers for Medicare & Medicaid(CMS) evaluates OTs for
- Mainly evaluate by chart review
- ## Strong standard setters as standards directly relate to reimbursement
Center for medicare and medicaid CMS are focused on outcomes related to
- Improvement in Function
- Improving patient safety
- Not concerned with pain (views medication as the intervention for pain management)
NBCOT:National Board for Certification in Occupational Therapy EXAM
Administer certification exam (good in all states) to validate knowledge.
NBCOT Applicants must:
Graduate from an accredited program & complete FW
Must not have a felony conviction
NBCOT recertifications happens when
Re-certification Every 3 years
What do you need to recertify for OTR/L?
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
NBCOT: National Board for Certification in Occupational Therapy recertification standards or what you need
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
ACOTE began in
1923
ACOTE is Voluntary however
if you are not accredited, graduates cannot take NBCOT exam to practice
Annual fee paid for by OT program
ACOTE acredidation is Currently 140 objective standards:
How does RSC meet objectives?
Objectives met in a minimum of two courses (syllabus)
ACOTE visit -
3 day on site visit (follows extensive self-study report)
Interview college leadership, faculty, students, fieldwork educators, and employers of our grads.
ACOTE years that they come
Outcome: 5, 7, or 10-year accreditation based on quality
Sage awarded 10 year in 2017 for Masters and 7 year for Doctoral Program!!
Joint commission
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
Joint comission started when
1917 - Hospital Standardized Program
Survey by American College of Surgeon
Focus: surgical care by physicians and nurses
Joint comission 1951
in 1979 the joint commission included
non nursing like OT
Joint Commission recently expanded to include
Encompasses more health care facilities and not just hospitals
National Patient Safety Goals (Joint Commission)
Focus on items that have a history of being problematic. Each year a new list is released
Has included things like fall prevention
2023 Hospital National Patient Safety Goals include:
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
CARF: Commission on Accreditation of Rehab Facilities been around since 1968
they accredit not for profit centers -
Medical rehabilitation centers
Adult day services
Assisted living centers
Mental or behavioral health centers
Community agencies
CARF evaluations include
Self study report
Site visits
3 year accrediation outcomes
CARF site visitis include
Internal Evaluation of Services
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)
Global Organizations
World Federation of Occupational Therapists (WFOT)
World Health Organization (WHO)
World Federation of Occupational Therapists (WFOT)
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
