Chapter 3
performance
Terms
Accrediting body organization
or entity that establishes
standards for accreditation
Certification confirmation by
an entity that an organization
complies with the
predetermined standards
Certifying body organization or
entity that establishes
standards for certification
Compliance adhering to
requirements of a standard
Deemed status as accrediting
organization approved by CMS
with compliance with the
Medicare conditions of
Participation
Guideline voluntary guidance
and direction to practitiooners
Healthcare Facilities
Accredication Program (HFAP)
American Osteopathic
Associations (AOA) accrediting
body for hospital operations
The Joint Commission principal
accrediting organization for
hospital operations and health
care org
Law legally binding
requirement imposed by
legislative body
National Integrated
Accreditation for Healthcare
Organizations ( NIAHO)
- Det Norske Vertitas (DNV),
accreditation org for hospital
operations
Performance improvement
continuous measurement,
analysis and improvement of
Quality improvement a formal
approach to the analysis of
performance, systematic
approach to improve it
Regulation governmental
order having force of law
Rules authoritative
recommendations meant to
guide behaviours
Standard statement that
defines the performance
expectations, often reflects best
practices
Survey key component in the
accreditation process
INFLUENCE BY EXTERNAL BODIES
a. Health-system Certification and
Accreditation Programs
Centers for Medicare and
Medicaid Services (CMS) to
participate in the federal
Medicare program
- Federal agency that
administers health-related
programs such as the
Medicare prog.
- Administers:
Childrens Health
Insurance Program (CHIP)
Health Insurance
Portability and
accountability (HIPAA)
Conditions of Participations
(CoPs) healthcare org must
meet
Joint Commission, HFAP, NIAHO
accredited organizations are eligible
automatically to participate in the
Medocare program
 - They qualify an organization
to participate in the
Medicare program
Joint Commission
- Joint Commission
International
- Joint Commision on
Accreditation of Healthcare
Organizations (JCAHO)
- Independent, not for profit
organization dedicated to
improving safety and quality
health care
- Founded in 1951
- Engages in activities
concerning the advancement
of healthcare safety and
quality
- Principal accrediting body for
hospital operations and
other health care
organizations
Standards establish
performance expectations for
entities, describes what needs
to be done
National Patient Safety Goals
(NPSGs) address specific
patient safety
- Accreditation is 3 years
American Osteopathic Association
(AOA)
Healthcare Facilities
Accreditation Program (HFAP)
- Principal accreditation
agency for osteopathic
medical colleges and health
care facilities
- Accreditation for 3 years
Det Norske Vertitas (DNV)
National Integrated
Accreditation for Healthcare
Organizations ( NIAHO)
- Integrate requirements
based on the CMS Conditions
of Participation with
International Organization
for Standardization (ISO)
9001 Standards.
ISO 9001 standards global
principles designed to provide
assurance that quality is
embedded in supplier-customer
relationship
NIAHO designed to facilitate
the development of a Quality
Management System for health
care organizations
- Accreditation is 3 years
NOTE: The Joint Commission, HFAP,
NIAHO accredit health organizations
not departments or services.
PREPARATION FOR AND
ACCREDITATION SURVEY VISIT
Comprehensive Accreditation
Manual for Hospitals (CAMH)
published by the Joint
Commission
- Includes
accreditationpolicies and
procedures, accreditation
participation requirements,
latest standards, compliance
information etc
Accreditation Requirements for
Healthcare Facilities (ARHF)
published by AOA for HFAP
National Integrated
Accreditation for Healthcare
Organizations (NIAHO)
Accreditation Requirements:
 Interpretative Guidelines and
Surveyor Guidance published
by DNV for NIAHO
FEDERAL STATE LAWS AND
REGULATIONS
Laws imposed by an authority
Sets laws governing health-system
pharmacy:
1. Food and Drug Administration
(FDA)
- Responsible for protecting
the public health by assuring
the safety, efficacy, and
security of human and
veterinary drugs, biological
products.etc.
Food, Drug, and Cosmetic Act
sets labeling requirements for
food, prescriptions and over the
counter drugs and cosmetics.
2. Drug Enforcement
Administration (DEA)
- Prepares for the prosecution
of those who violate the
controlled substances laws
and regulations
3. Occupational Safety and Health
Administration (OSHA) assure
safe and healthful working
conditions for working men and
women, conducts periodic
workplace inspections to ensure
that workers are kept safe in
their jobs
Competence Assessment Tools
for Health-System Pharmacies
contains materials for assessing
OTHER AGENCIES
pharmacy staff competence in
handling hazardous materials
4. National Institute for
Occupational and Health
(NIOSH) responsible for
conducting research and
making recommendations for
the prevention of work related
injury and illness
5. Centers for Disease Control and
Prevention (CDC)
- Promoting quality life thru
the prevention and control of
disease, injury and disability
6. Office of Inspector General
(OIG)
- Protect the integrity of
certain governmental
programs and the health and
welfare of the beneficiaries
of those programs
7. Environmental Protection
Agency (EPA)
- Responsible for developing
and enforcing regulations
pertaining to environmental
laws and issues
8. Office for Civil Rights (OCR)
Civil Rights Act of 1964 deals
primarily with the humans
relations management
prohibiting discrimination in
employment hiring, promotion,
compensation, and treatment of
protected employee groups.
STATE BOARDS OF PHARMACY
- Regulate pharmacy practice
through this
- They set licensure
requirements for individuals,
pharmacies, and some
health care org.
Americans with Disabilities Act
(ADA)
 - Protects the rights of
Americans with physical and
mental disabilities
NONGOVERNMENTAL STANDARDS-
SETTING ENTITIES
1. United States Pharmacopeia
(USP)
- Nongovernmental, standards
setting organizations that
advances public health by
ensuring the quality of
medicines, food ingredients
etc, proper use of
medications and verifying
ingredients in dietary
supplements.
United States Pharmacopeia
and National Formulary
published by USP
USP Chap 795 non sterile
compounding
USP Chap 797 for sterile
compounding
2. National Fire Protection
Association (NFPA) reduce the
worldwide burden of fire
3. Institute of Medicine (IOM) of
the National Academies non
governmental, not for profit
organization that provides a
vital service by working outside
the framework of government
to ensure scientifically informed
analysis and independent
guidance
PHARMACY PROFESSIONAL
ORGANIZATIONS
1. American College of Clinical
Pharmacy (ACCP) professional
and scientific society that
provides leadership, education,
advocacy, and resources
enabling clinical pharmacists to
achieve excellence
2. American Pharmacists
Association (APhA) national
professional society of
pharmacists
- Provides info, education ,
and advocacy to empower
its members to improve
medication used and
advance patient care
3. American Society of Consultant
Pharmacists (ASCP)
professional association
representing senior care
pharmacists
4. American Society of Health-
System Pharmacists (ASHP)
professional org for pharmacists
practicing in health systems