1. Define accreditation / health care accredi- validation is dependent on meeting pre-de-
tation termined criteria established by an accredit-
ing agency
an objective evaluation that helps measure,
assess, and improve organizational perfor-
mance
a requirement to receive reimbursement from
Medicare and Medicaid programs
2. What are the big 3 health care accrediting The Joint Commission (TJC)
agencies DNV GL
Healthcare Facilities Accrediting Program
(HFAP)
3. A goal of patient safety was established the National Patient Safety Goals, by the TJC
with the dawn of new ways to identify accrediting agency
patients. The requirement to use at least
2 patient identifiers was established by
what?
4. What were the 2018 National Patient Safe- - identify patients correctly
ty Goals? (7) -improve statt communication
- identify patient safety risks
-use alarms safely
-prevent infection
-use medicines safely
-prevent mistakes in surgery
5. What is the profile of the TJC? -acredits and certifies over 21000 health care
organizations and programs
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, COPE health scholars exam
-on site survey every 3 years
-standards for accreditation: national patient
safety goals and other leading practices
6. What does DNV GL stand for Det Norske Veritas Germanischer Lloyd SE
7. DNV GL profile accredits and certifies over 500 health care
organizations
on site surveying every year
Standards: NIAHO program- ISO 9001 & CMS'
CoPs
8. What does NIAHO stand for, what is it National Integrated Accreditation for Health
comprised of, and what does it do Care Organization
Comprised of
-CMS' CoPs
-ISO 9001 Quality Management Program
Requires that hospital establish a reasonable
means to comply with the conditions that can
be documented and monitored
9. What does ISO stand for International Organization for Standardiza-
tion
-develops international standards
-ISO90001 is a standard that sets require-
ments for quality management system
10. A quality management system defines how to meet requirements of customers -
each organization then defines their own ob-
jectives and pursues continual improvement
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