Section 12.2: Accreditation Organizations & Deemed Status

Accreditation Organizations & Deemed Status

Accreditation is a voluntary self-regulatory process through which healthcare organizations demonstrate compliance with established national standards. While statutory compliance is a legal mandate, accreditation serves as a badge of quality excellence and, crucially, as a pathway to secure federal funding through the mechanism of Deemed Status. Healthcare quality professionals must understand the operational differences between primary accrediting bodies and the precise legal definition of deemed status.

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The Concept of Deemed Status

Under the Social Security Act, healthcare facilities must comply with CMS Conditions of Participation (CoPs) to receive Medicare and Medicaid reimbursement. However, CMS does not have the administrative capacity to survey every healthcare provider in the nation. To resolve this, CMS is authorized to grant Deeming Authority to national, private, non-profit accrediting organizations.

How Deemed Status Works

When a healthcare facility (such as a hospital, ambulatory surgery center, or home health agency) undergoes a comprehensive accreditation survey by an approved accrediting organization, and is successfully accredited, the facility is "deemed" to have met the Medicare CoPs.

• Voluntary Pathway: A facility chooses to pay for accreditation from an approved Accrediting Organization (AO) instead of undergoing direct, routine surveys by the State Survey Agency on behalf of CMS.
• Validation Surveys: To ensure accrediting organizations maintain rigorous standards, CMS performs random validation surveys on approximately 5% to 10% of deemed-status facilities annually. If a validation survey finds significant deficiencies that the accrediting organization missed, the facility's deemed status may be suspended, putting its Medicare reimbursement at risk.

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The Joint Commission (TJC)

The Joint Commission is the nation’s oldest and largest accrediting body, accrediting more than 22,000 healthcare organizations and programs. It holds deeming authority for hospitals, critical access hospitals, ambulatory clinics, home care services, and laboratory services.

Core Standards and the SAFER Matrix

TJC standards focus on patient safety, care coordination, medication management, infection control, and governance. Survey findings are plotted on the Survey Analysis for Evaluating Risk (SAFER) Matrix, which rates deficiencies based on:

1. Likelihood to Harm: Low, Moderate, High.
2. Scope: Immediate, Pattern, Widespread.

National Patient Safety Goals (NPSGs)

TJC establishes the NPSGs annually to address specific areas of vulnerability in healthcare safety. These goals are based on data from TJC's sentinel event database and are highly testable. Examples include:

• Patient Identification: Using at least two patient identifiers (e.g., patient name and date of birth) before administering medications, blood products, or performing procedures.
• Communication Safety: Implementing structured hand-off communications (such as SBAR) and reporting critical lab results to the responsible practitioner within designated timeframes.
• Medication Safety: Maintaining an accurate medication reconciliation process across transitions of care.
• Infection Prevention: Adhering to evidence-based hand hygiene guidelines (e.g., CDC or WHO standards).

ORYX Performance Measurement Initiative

The ORYX initiative integrates national standardized performance measures into the accreditation process. Hospitals must collect and submit clinical quality measure data (such as stroke care, perinatal care, and emergency department throughput) directly to TJC. This data is used to identify performance trends and guide the focus of onsite surveyors.

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National Committee for Quality Assurance (NCQA)

Unlike TJC, which primarily focuses on physical facilities and hospitals, the NCQA is the gold standard for accrediting managed care organizations, health insurance plans, and outpatient medical practices.

Healthcare Effectiveness Data and Information Set (HEDIS)

HEDIS is a standardized tool maintained by the NCQA consisting of over 90 measures across 6 domains of care, including:

• Effectiveness of Care (e.g., childhood immunization rates, breast cancer screening).
• Access/Availability of Care (e.g., prenatal and postpartum care visits).
• Experience of Care (utilizing the Consumer Assessment of Healthcare Providers and Systems [CAHPS] surveys).

Health plans use HEDIS data to benchmark their performance against national averages, and employers use it to select health plans for their workforces. For quality professionals in outpatient or managed care settings, HEDIS compliance drives institutional performance improvement initiatives.

Patient-Centered Medical Home (PCMH) Recognition

NCQA also administers the PCMH recognition program. PCMH is a care delivery model where patient care is coordinated through a primary care physician to secure continuous, comprehensive, and integrated care. NCQA certification as a PCMH provides clinics with financial incentives from commercial payers and CMS.

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Accreditation Association for Ambulatory Health Care (AAAHC)

The AAAHC is a highly specialized accrediting body focused exclusively on ambulatory healthcare settings, including:

• Ambulatory Surgery Centers (ASCs).
• Community Health Centers.
• Indian Health Service clinics.
• College health centers and large group practices.

Ambulatory-Specific Quality Focus

AAAHC standards emphasize peer review, quality improvement studies, and patient safety in outpatient settings where patients do not stay overnight. A key focus is on anesthesia administration safety, patient recovery protocols, and ambulatory-specific infection prevention. Like TJC, AAAHC has deeming authority from CMS for ASCs.

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Comparison of Major Accrediting Organizations

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Scenario: The Deemed Status Validation Survey

A 300-bed hospital is accredited by The Joint Commission and receives Medicare reimbursement under deemed status. Three weeks after a successful unannounced TJC survey, state public health surveyors arrive at the hospital to conduct a validation survey on behalf of CMS. During the survey, the state inspectors find widespread failure in sterile processing in the operating rooms—a finding missed by the TJC team. The facility is issued a Form CMS-2567 citing "Immediate Jeopardy" to patient safety. The facility’s deemed status is suspended. To resolve this, the quality professional must immediately coordinate a comprehensive plan of correction, undergo direct monitoring by the state agency, and prove compliance with the Medicare CoPs. This scenario highlights that deemed status is a privilege, not a permanent exemption from government oversight.