Assignment 7 - Quality Improvement and Cost Reduction Through Accreditation

Question 1

_____ is the formal declaration by a designated authority that an organization, service or individual has demonstrated competency, authority or credibility to meet a predetermined set of standards.

Answer 1

Accreditation

Question 2

_____ is to provide a means by which to evaluate a product, service, individual, organization or system against established standards or measures.

Answer 2

The purpose of accreditation

Question 3

A secondary and more recent goal in some applications, notably health care, is to provide a basis for:

Answer 3

quality improvement initiatives.

Question 4

organizations, services and professional behavior in health care are shaped by an increasing variety of government and nongovernment bodies related to but independent of each other.

Answer 4

“nodal governance;”

Question 5

Accreditation in health was first initiated in the United States through the work of the American College of Surgeons, which in 1917 developed the ________

Answer 5

“Minimum Standards for Hospitals.”

Question 6

an external reviewer, with or without health care experience, uses a generic set of quality standards to assess the presence or absence of organizational quality activities. This model is endorsed by the International Organization for Standardization, which accredits organizations in many diverse industries, including health

Answer 6

audit model

Question 7

There are external and internal motivations that drive health care organizations to seek accreditation.

• External motivation comes from _____
• The internal impetus comes from _____

Answer 7

• governments, insurers and consumers requiring that organizations undertake efforts that demonstrate outcomes that advance high-quality and safer health care
• staff members who make up the health organizations.

Question 8

Accreditation agencies, involving many of their stakeholders, have constructed a self- governing system. It is a system responsive to the conduct and culture of those being regulated; this approach has been labeled ______

Answer 8

“responsive regulation.”

Question 9

As one would expect, failure to meet the requirements of a mandatory standard will result in an organization _______

Answer 9

not being accredited

Question 10

As would be expected, accreditation standards examine several distinct areas. Accreditation standards cover (4):

Answer 10

• infrastructure
• organization
• service
• continuum of patient care issue

Question 11

Is there a strong correlation between accreditation and clinical quality measures?

Answer 11

Its questionable at present

Question 12

_____ is noted as being a critical issue in the discipline of accreditation and in health care more broadly. Being able to conduct consistent assessments, interpretations and judgments, individually and collectively, is a challenge for professionals working in many areas of health care.

Answer 12

Reliability

Question 13

Reliability in surveying has been shown to be promoted or undermined by the presence of the following six factors:

Answer 13

• (1) The accreditation program, including documentation requirements for organizations and survey teams
• (2) Member relationship with the accrediting agency and survey team
• (3) Accreditation agency personnel
• (4) Surveyor workforce renewal
• (5) Management of the surveyor workforce
• (6) Survey dynamics’ effect on the reliability of surveys directly and indirectly

Question 14

Reliability in accreditation is a concern for accreditation agencies and organizations that have been or are considering going through the accreditation process.

In assessing reliability, it is important to distinguish between intra- and inter-rater reliability.

• _________ is high when the assessments made by an individual surveyor or survey team are consistent from case to case.
• ______ is high when assessments made by different surveyors or survey teams are consistent with one another.

Answer 14

• Intra-rater reliability
• Inter-rater reliability

Question 15

Health professionals who act as volunteer surveyors derive four benefits from this activity: (4)

Answer 15

• (a) Exposure to new methods and innovations in other health organizations;
• (b) Opportunity to engage in a unique form of professional development;
• (c) Opportunity to acquire expertise to enhance quality within the institutions in which they are regularly employed; and
• (d) Opportunity to contribute to the process of quality improvement and enhance public health in organizations beyond their regular employment.

Question 16

There are several challenges facing accreditation stakeholders. Among these challenges are the following: (6)

Answer 16

Question 17

Why is the classification of accreditation programs as “voluntary” often misleading?

Answer 17

In many cases, health care organizations are required by external stakeholders to demonstrate efforts at improving quality and safety, including through participation in an accreditation program.

Question 18

Accreditation programs are currently to a large degree focused on assessing the organizing and delivery of care. The standards have been termed __________ as they focus on how care is delivered rather than the outcomes of the activity.

Answer 18

“process indicators,”

Question 19

The necessity to expand the evidence base for accreditation is pervasively noted in the literature. _____ _____ —is necessary to provide a firmer foundation for accreditation programs.

Answer 19

Securing more empirically derived findings

Question 20

The challenges facing accreditation stakeholders are significant and include the following:

Answer 20