Question:

I’ve never quite understood hospital accreditation.  Is it the same as a regulation?  What do TJC, HFAP, and DNV stand for anyhow?  And why are they important?

Answer:

Accreditation is different from regulation.  Regulation comes from governmental entities.  On the federal level, the Centers for Medicare & Medicaid Services (“CMS”) set the regulations to which hospitals need to comply in order to be a Medicare participating hospital.  CMS issues the Medicare Conditions of Participation (“CoPs”) that must be met.  On the state level, usually the state’s department of health issues hospital licensing regulations that the hospital must meet in order to stay licensed.

In contrast, accreditation is a process and outcome by which a hospital voluntarily undergoes a review by an accreditation organization.

The Joint Commission is the oldest of the three accrediting bodies.  Its roots run back to the early 1900s when the American College of Surgeons created its Hospital Standardization Program.  The Joint Commission on Accreditation of Hospitals (“JCAH”) began in 1951, created by the merging of the Hospital Standardization Program with similar programs run by the American College of Physicians, the American Hospital Association, and the American Medical Association.  The JCAH changed its name in 1987 to The Joint Commission on Accreditation of Healthcare Organizations (“JCAHO”), and then slimmed down, name-wise, in 2007 to “The Joint Commission.”

The Healthcare Facilities Accreditation Program (“HFAP”) was originally created in 1945 to conduct an objective review of services provided by osteopathic hospitals.  The HFAP is an accreditation program of the American Osteopathic Association.

DNV Healthcare, Inc. (“DNV Healthcare”) is the third provider of hospital accreditation.  DNV Healthcare is a subsidiary corporation of Det Norske Veritas (the original “DNV”), an independent Norwegian foundation that has as its primary purpose the safeguarding of life, property and the environment.  The Original DNV goes back to 1864 and is quite global.  DNV Healthcare is the most recent of the accrediting bodies in terms of accrediting U.S. hospitals.

Why would any hospital voluntarily agree to be accredited by any of these organizations?  Because accreditation by The Joint Commission, HFAP, or DNV Healthcare provides “deemed status” – automatic recognition that the hospital has complied with the Medicare CoPs and so remains or becomes a Medicare participating hospital.

But, while “deemed status” comes with any of these accrediting bodies, each of these organizations have different approaches and standards by which they review and accredit hospitals.  The differences among these organizations run from large conceptual differences to differences in the details.  Which accrediting body to use, if any, is an important decision for any hospital.

To learn more about accreditation, its benefits, its costs, and many other important issues, please join us on June 4, 2013 from 1:00 to 2:00 p.m. (Eastern Time) for Grand Rounds – Accreditation:  What Physicians Need to Know!