Clinical Focus on Quality

For the safety and quality of patient care, governmental and private entities have developed laws, regulations, and standards to help guide the provision of patient care. All Intermountain entities, including SelectHealth, Medical Group practices, Homecare, and hospitals have specific regulations for their areas of focus.

How do these requirements affect Intermountain? In order to provide patient care, Intermountain is required to meet many regulations and standards, including the Conditions of Participation and Conditions of Coverage developed by the federal Centers for Medicare and Medicaid Services (CMS). Healthcare organizations are required to comply with these regulations in order to participate and receive payment from Medicare and Medicaid programs. One method of assuring these "Conditions" are met is to choose to be accredited by The Joint Commission, which has been granted authority by CMS to certify a facility for participation in the Medicare and Medicaid reimbursement programs. Most Intermountain Healthcare hospitals voluntarily participate in this accreditation process.

What is The Joint Commission? The Joint Commission is an independent, not-for-profit organization that accredits and certifies healthcare entities, including hospitals, homecare, behavioral health, and ambulatory care facilities; it also provides Disease Specific Care Certification. The Joint Commission is the predominant standards-setting and accrediting body for American hospitals. The focus of accreditation is on improving an organization's ability to provide safe, high-quality care while setting performance expectations for those activities.

The survey process. The Joint Commission performs an initial accreditation survey when a facility applies for accreditation. Once accredited, a facility undergoes triennial evaluations to determine if The Joint Commission standards continue to be met. Between these accreditation surveys, the facility is expected to submit a Periodic Performance Review to The Joint Commission. CMS also contracts with state health departments to perform random periodic validation surveys of healthcare entities to assure the CMS Conditions of Participation are met and properly assessed during a Joint Commission Accreditation survey.

Additional benefits of Joint Commission Accreditation. Along with meeting the requirements for Medicare and Medicaid reimbursement, there are many benefits of Joint Commission Accreditation. They include community confidence in the quality and safety of care, treatment and services; professional advice and counsel for providing and enhancing staff education; and development of standards of practice and performance improvement tools to continually raise the bar for providing high-quality and safe patient care.

How you can learn more. When you meet with your facility leadership, ask them about:

  • The Joint Commission's Priority Focus Areas for your facility.
  • The top findings from the last Joint Commission Accreditation survey.
  • What your facility is doing to be continuously prepared for any survey.

For more information about The Joint Commission, visit www.jointcommission.org.

For more information about the Centers for Medicare and Medicaid Services (CMS), visit www.cms.gov.

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