ESSENTIAL COMPETENCIES:

REGULATORY & ACCREDITATION

COMPETENCIES FOR THE HEALTHCARE QUALITY PROFESSION

Important Notice © National Association for Healthcare Quality 2016. All rights reserved. No part of this publication may be reproduced or distributed in any form or by any means, electronic or mechanical, including photocopying, recording, scanning, any information storage and retrieval system, or otherwise, without the prior written permission of the National Association for Healthcare Quality. For permission or questions about permissible usage, contact the National Association for Healthcare Quality at [email protected] or by mail at National Association for Healthcare Quality, 8735 W. Higgins Road, Suite 300, Chicago, IL 60631.

Printed in the United States of America First Edition

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Q Essentials: Competencies for the Healthcare Quality Profession

Acknowledgments Project Sponsors Mary Huddleston, BSN RN MHSE CPHQ FNAHQ, NAHQ President, Quality Management Officer, Florida-Puerto Rico Veterans Healthcare Network Stephanie Mercado, BA CAE, NAHQ Executive Director

Project Team Leadership Carole Guinane, MBA RN, VP System Orthopaedics, Sentara Healthcare Dale Harvey, MS RN, Patient Safety Fellow, Director, Performance Improvement, Virginia Commonwealth University Health System Tony Heath, PhD CPHQ, Lean and Six Sigma Black Belt, Optum Health Linda Kloss, MA RHIA, Principal, Kloss Strategic Advisors, Project Consultant Karen Schrimmer, MA CPHQ, NAHQ Director of Competencies and Career Path Development

Work Group Coleaders Jodi Eisenberg, MHA CPHQ CPMSM CSHA, Senior Director, Accreditation Programs, Vizient, Chicago, IL Patricia Resnik, MBA RRT-NPS FACHE CPHQ, Vice President, Quality & Care Management, Christiana Care Health System, Newark, DE

Work Group Members Debra Bellitter, MBA RN CCM, Clinical Quality Consultant, OptumCare Network—Arizona, Glendale, AZ Sharon Ricksecker Brauer, MA MBA CPHQ, Director, Accreditation/Certification for Regulatory Compliance, Interpreter Contact, AMITA Health, Elk Grove Village, IL Vivian Byers, MA BS HACP CCMSCP CPHQ, Division Director of Clinical Compliance and Accreditation, Baylor Scott & White Health, Dallas, TX Jennifer Dawson, MHA DLM (ASCP) SLS QIHC QLC, Vice President, Quality & Regulatory Affairs, Sonic Healthcare USA, Austin, TX Deborah Flores, EdD MBA RN CPHQ, Joint Commission International Consultant, The Joint Commission, Oak Brook, IL Pat Ford, BS RN CCM CPHQ, Pat Ford Consulting, Edmonds, WA Catherine Gorman-King, MSN RN, Director Quality Service Line, Nuance, Avon by the Sea, NJ Sherry Mazer, MBA MT (ASCP) HACP FACHE CPHQ, Corporate Regulatory Officer, Temple University Health System, Philadelphia, PA Brittany Montecuollo, MSN RN CSHA CJCP, Enterprise Executive Director of Regulatory Services, Sanford Health, Garretson, SD Christine Nidd, MSW PMP CPHQ, Manager of Quality & Compliance, Hospice of the Northwest, Mount Vernon, WA

Roma Garg, MS, CPHQ CPPS, Lean SSGB, Manager, Clinical Excellence, Advocate Lutheran General Hospital, Park Ridge, IL Brenda Sthen, MHSA RN CPHQ, Home Health Quality Director, Community Health Services, Home Care Division, Franklin, TN Jane Smith, RN CCM PAHM SSBB, Quality Management Coordinator, BlueCross BlueShield of Tennessee, Chattanooga, TN Julie Walker, BS MT (ASCP) CPHQ, Program Coordinator, Regulatory Compliance/Quality Management Department of Stem Cell Transplantation and Cellular Therapy, MD Anderson, Houston, TX

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Introduction Healthcare quality professionals (HQPs) aim to ensure that the entire healthcare system is optimized to improve outcomes. As healthcare rapidly transforms, so do the competencies required to keep HQPs relevant and in a position to lead the transformation. Today, HQPs understand the dynamics and drivers of change in healthcare. To ensure that HQPs are well prepared to serve and lead in this evolving environment, NAHQ is defining the essential HQP competencies in six areas: health data analytics, population health and care transitions, performance and process improvement, quality review and accountability, regulatory and accreditation, and patient safety. These are the Q Essentials, NAHQ’s Essential Competencies for the Healthcare Quality Profession (Figure 1). The six competency areas of the Q Essentials define the expanding and emerging HQP roles of today and tomorrow. The Q Essentials build on the industry-recognized foundational knowledge of the Certified Professional in Healthcare Quality (CPHQ) credential established in 1983.

Figure 1. Healthcare Quality Competencies Framework

QUALITY REVIEW & ACCOUNTABILITY

REGULATORY & ACCREDITATION

PATIENT SAFETY

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PERFORMANCE & PROCESS IMPROVEMENT

POPULATION HEALTH & CARE TRANSITIONS

HEALTH DATA ANALYTICS

Q Essentials: Competencies for the Healthcare Quality Profession

Current and Future Professional Development Competency Areas The six intersecting circles in Figure 1 represent clusters of HQP competence. Each cluster represents a distinct competency area. However, the areas are depicted as overlapping and interconnected because they share certain knowledge and skills. NAHQ developed the Healthcare Quality Competencies Framework to support self-learning by HQPs who want to assess and expand their competencies to better meet the changing needs of their employers or to gain new skills needed for the new roles. Because individual interests and skills vary, the intent of the framework is for ongoing professional development to lead to mastery in one area or across multiple areas over time. The areas apply to all healthcare settings across the continuum regardless of size or specialty.

Why Regulatory and Accreditation? Healthcare is one of the most highly regulated industries in the United States. The healthcare sector is well accustomed to meeting the requirements of regulatory bodies and accrediting agencies and to adopting standards that will advance the organization’s mission and goals. The Regulatory and Accreditation Q Essentials framework distinguishes regulations from accreditation and other standards because regulations are mandatory, leaving room only for discretion about how best to operationalize them. Regulations originate with governmental agencies at the federal, state, and local levels, and carry the weight of the law. Accreditation and other standards are promulgated by trusted private entities and unless deemed by a governmental agency, a healthcare organization must determine their value and how they will be adopted and used. Voluntary standards can be a powerful driver for improvement but sound processes are needed to evaluate standards and then commit to their adoption. In healthcare practice, accreditation is so essential that many accreditation requirements are equivalent to regulations. Understanding the nuanced differences between regulations, standards, accreditation, and certification, and their process implications is vital to any professional working in healthcare quality. Though these common terms are often used together, they each have different meanings and involve a variety of different processes within healthcare organization. Regulation, a principal, rule, or law is generally prescriptive. Accreditation includes recognition that an organization has demonstrated competency, authority, and credibility in meeting established standards. Certification, similar to accreditation, includes recognition that an organization or individual has met predetermined standards in a specialty area. Quality and patient safety are at the core of all healthcare regulations, accreditations, and standards. HQPs are integral to the organization’s success in achieving and demonstrating conformance to relevant regulations and standards. HQPs offer a value-added depth of knowledge and expertise that can enable a healthcare organization to successfully and effectively meet the regulations, advance standards-based practice, and sustain a culture of continuous readiness. HQPs need broad knowledge of the regulatory and accreditation environment; the ability to identify relevant statutes, regulations, and standards; and skill and expertise to oversee their successful adoption and evaluation. HQPs must prepare for the ever-changing healthcare regulatory and accreditation landscape by developing a strong foundation to identify and appropriately apply regulations and accreditation standards in a wide variety of healthcare settings.

How the Regulatory and Accreditation Competency Area Was Defined A NAHQ work group comprising subject matter experts representing clinical, academic, health plans, and healthcare consulting settings developed the competencies using a 90-day, rapid-cycle, practice-based project methodology.

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Area: Regulatory and Accreditation Competency Dimensions 1. Knowledge and Application of Regulations and Standards 1.1. Demonstrate knowledge of regulations applicable to the healthcare setting, service, or process. 1.2. Demonstrate knowledge of standards applicable to the healthcare setting, service, or process. 1.3. Assess the applicability of regulations or standards. 1.4. Guide practice and operations with applicable regulations or standards. 1.5. Engage appropriate key stakeholders in the design, implementation, and monitoring of planned improvements to ensure compliance. 1.6. Provide access to and education about regulations and standards to stakeholders across the organization. 1.7. Evaluate and monitor compliance on an ongoing basis to validate sustainability. 2. Regulatory, Accreditation, and Certification Program Management 2.1. Demonstrate knowledge of regulatory, accreditation, and certification requirements and processes that are applicable to the healthcare setting. 2.2. Develop a structure and process for regulatory, accreditation, and certification programs that advances organizational goals and aligns essential resources. 2.3. Ensure achievement of regulatory, accreditation, and certification program goals and associated benefits for the organization. 2.4. Establish routine reporting processes utilizing metrics to monitor impact of participation and outcomes. 2.5. Manage survey (planned and unannounced) processes. 3. Advance a Continuous Readiness Culture 3.1. Communicate goals and education on requirements for continuous readiness. 3.2. Develop an ongoing process for evaluation. 3.3. Facilitate the development and monitoring of action plans for noncompliant findings including preparation, evaluation, and monitoring. 3.4. Implement a process for assessment and development of improvement plans and ongoing monitoring. 3.5. Develop and implement mechanisms to “hardwire” compliance and drive sustainability.

Assumptions 1. The Competency Framework (Figure 1) describes two higher levels of competency that expand current foundational healthcare quality competencies to reflect evolving job requirements. It is assumed that Proficiency Level 1 is an advanced level of competency and that Proficiency Level 2 is more advanced and specialized. 2. Any HQP working primarily with accreditation and regulation should be accomplished in the proficiencies listed under Advanced Practitioner. 3. Skills at the Master Practitioner level may be required to a varying degree by the healthcare organization, depending on the organization’s size and scope. For example, large health systems may have a centralized corporate department for accreditation and regulation and have resources to assist an individual organization within their network with compliance. A home health agency or hospice center may contract with an outside entity to oversee their compliance. 4. Master Practitioner competencies include skills that an individual HQP may attain on his or her own or from a staff or consulting team possessing some subset of the skills. 5. HQPs can learn the competencies in the framework on the job, by attending courses and workshops, or by pursuing advanced degrees. This framework is not intended to suggest a specific academic pathway. 6

Q Essentials: Competencies for the Healthcare Quality Profession

6. Practitioners can enter the field of healthcare quality with a background in healthcare or another industry. Proficiencies can be gained bidirectionally. For example, one can earn the CPHQ credential (foundational) and then gain specific expertise in one of the six competency areas. Alternatively, one can enter healthcare quality with expertise in one or more of the competency areas and learn about the broad base of healthcare quality practice on the job and by earning CPHQ certification.

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Area: Regulatory and Accreditation Dimension 1: Knowledge and Application of Regulations and Standards Description: Understand internal and external implications of and distinguish the nuances between regulations and standards applicable to the healthcare setting. Interpret and ensure compliance with regulations. Advocate for the adoption of voluntary standards when adoption will advance the mission and goals of the healthcare setting, service, or process and gain recognition meeting or exceeding a specific level of quality or standard of care. Regulations: Requirements issued by various governmental agencies to carry out the intent of legislation enacted by Congress, state legislatures, and local authorities. Compliance with regulations is mandatory by law. Standards: Evidence-based guidelines developed and established by consensus or research of an authoritative body. They are used as a guide for optimum achievement and outcomes. Compliance with standards is voluntary, though standards may be named in regulations thereby granting them legal status.

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

1.1. Demonstrate knowledge of regulations applicable to the healthcare setting, service, or process.

1.1.1a. Identify and access applicable regulations and navigate authoritative interpretive resource(s). 1.1.1b. Describe the functions and types of regulatory agencies (federal, state, local) including the approved (deemed status) evaluation agencies that impact the healthcare setting, service, or process. 1.1.1c. Recognize, understand, and articulate the impact and criticality of applicable regulations including consequences for quality and safe care. 1.1.1d. Describe the processes for finding and receiving updates on any changes to standards that impact the specific healthcare setting.

1.1.2a. Compare and contrast regulations (federal, state, local) and apply authoritative interpretive resource(s). 1.1.2b. Provide expert analysis to synthesize regulations and interpretive guidance to understand and articulate the intent and value of the regulations. 1.1.2c. Develop a process to keep the organization aware of any upcoming changes in regulations that impact it. 1.1.2d. Compare and interpret new regulations and their impact and distribute to relevant parties in a timely manner.

1.2. Demonstrate knowledge of standards applicable to the healthcare setting, service, or process.

1.2.1a. Identify and access applicable standards and navigate authoritative interpretive resource(s). 1.2.1b. Recognize and explain the impact and criticality of applicable standards including the added benefit to quality, safety, and cost-effective care. 1.2.1c. Locate updates to remain current on changes to standards that impact the specific healthcare setting.

1.2.2a. Access, compare, and contrast related standards with regulations that impact the specific healthcare setting. 1.2.2b. Provide expert analysis to synthesize standards, the interpretive guidance, and the impact on regulatory compliance to understand and articulate the intent and value of the standards. 1.2.2c. Organize an evaluative process involving stakeholders to determine services and processes that would benefit from adoption of applicable standards. 1.2.2d. Conduct a cost-benefit analysis of adopting voluntary standards and the rigorous evaluation process. 1.2.2e. Develop a process to keep the organization aware of any upcoming changes in standards that impact the organization.

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Q Essentials: Competencies for the Healthcare Quality Profession

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

1.3. Assess the applicability of regulations or standards.

1.3.1a. Perform an analysis of the regulation/standard and interpretive guidance to define and explain the applicability of the regulation to the appropriate healthcare setting. 1.3.1b. Provide interpretation and advice on the impact and implementation of the regulation or standard on care, treatment, and services within the organization, across the continuum, or within the industry. 1.3.1c. Assess the impact of alternative options for compliance with regulations/ standards.

1.3.2a. Determine the impact to the organizational setting, service, and operational areas using a risk-based approach and assist leadership in understanding its impact. 1.3.2b. Apply risk assessment tools to quantify the cost of compliance and risks associated with noncompliance.

1.4. Guide practice and operations with applicable regulations or standards.

1.4.1a. Identify the owners of the specific services or workflows, or individuals within the organization who are impacted. 1.4.1b. Assist identified owners of the specific workflows or services, or individuals within the organization by providing tools and methodologies to assess compliance. 1.4.1c. Assess policies to ensure they reflect the organization’s practice and that applicable regulations/standards requirements support full adoption. 1.4.1d. Provide analysis of compliance and assist with the development of a sustainable action plan to ensure ongoing compliance.

1.4.2a. Facilitate the process for developing tools and methodologies to assess compliance. 1.4.2b. Develop a process for early identification of areas that are not in compliance. 1.4.2c. Provide expert analysis of compliance with applicable regulations and participate in the development of a sustainable action plan for compliance. 1.4.2d. Communicate and explain the results of the assessment and the action plan for compliance to the leadership of the setting. (continued)

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Area: Regulatory and Accreditation Dimension 1: Knowledge and Application of Regulations and Standards (continued)

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

1.5 Engage appropriate key stakeholders in the design, implementation, and monitoring of planned improvements to ensure compliance.

1.5.1a. Provide input into the development, implementation, and monitoring of planned improvements to ensure alignment with the regulation or standard where gaps in compliance are identified. 1.5.1b. Develop or revise policies to support specific regulations and standards. 1.5.1c. Ensure a plan is developed to monitor compliance when gaps are identified and changes in process, people, or technology are implemented. 1.5.1d. Track progress on action plans to ensure accountability to achieve compliance within the established time frame.

1.5.2a. Engage leadership through a routine reporting process to ensure understanding and support of identified issues, actions underway, and ownership accountability. 1.5.2b. Intervene and escalate when necessary, involving senior leadership, to provide appropriate resources and hold owners accountable for actions and established timelines. 1.5.2c. Partner with network entities to support improved application of regulations or standards across like sites and the continuum of care.

1.6. Provide access to and education about regulations and standards to stakeholders across the organization.

1.6.1a. Distribute and explain the origin, intent, and applicability of regulations and standards. 1.6.1b. Provide “just in time” and formal training to stakeholders as needs are identified.

1.6.2a. Oversee the process of interpretation, distribution, and communication of regulations and standards. 1.6.2b. Identify regulation and standards education gaps and oversee the creation of mechanisms/programs to fill the gaps.

1.7. Evaluate and monitor compliance on an ongoing basis to validate sustainability.

1.7.1a. Participate in ongoing assessment and monitoring of compliance in partnership with the owners of the workflows, services, or individuals in the organization. 1.7.1b. Escalate appropriately the advancement of further review, analysis, and development of improvement plans if an improvement does not meet the desired level.

1.7.2a. Develop and implement a process to evaluate and monitor ongoing compliance with regulations and standards. 1.7.2b. Research best practices and publicize them along with internal successes. 1.7.2c. Share best practices with others in the industry by presenting at conferences, applying for awards, writing articles, etc. 1.7.2d. Contribute to the improvement of existing standards and the development of new standards.

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Q Essentials: Competencies for the Healthcare Quality Profession

Area: Regulatory and Accreditation Dimension 2: Regulatory, Accreditation, and Certification Program Management Description: Management and oversight structure and process for accreditation and certification program(s) to ensure the organization meets standards requirements and demonstrates an ongoing commitment to quality improvement. Accreditation: A process in which a local, national, or internationally recognized agency assesses operations and performances to determine whether a set of recognized and accepted standards are met. Certification: A formal, focused process that an organization, program, individual, or technology undergoes with an assessment by a neutral party or local, national, internationally recognized, or regulatory agency to demonstrate compliance and competency with developed standards.

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

2.1. Demonstrate knowledge of regulatory, accreditation, and certification requirements and processes that are applicable to the healthcare setting.

2.1.1a. Guide organization through evaluation of beneficial accreditation and certification programs by assessing compliance to each standard. 2.1.1b. Provide leadership and guidance in development and implementation of an infrastructure that supports high reliability and adherence with regulatory/ accreditation/certification requirements and processes.

2.1.2a. Prepare organization leadership to translate the healthcare organization mission and values to applicable programs and processes. 2.1.2b. Create an education infrastructure to maintain leadership and staff competency in the regulatory and accreditation environment. 2.1.2c. Mentor organizational personnel and outside professionals in the regulatory and accreditation process.

2.2 Develop a structure and process for regulatory, accreditation, and certification programs that advances organizational goals and aligns essential resources.

2.2.1a. Champion the value of achieving accreditation and certification; recognize and promote understanding through known effective communication channels. 2.2.1b. Assign responsibility for meeting requirements and establish continuous readiness process to allow for participation by all levels of staff. 2.2.1c. Develop processes to update organization on requirement changes. 2.2.1d. Empower front-line staff to contribute to performance improvement initiatives and corrective and preventative action planning.

2.2.2a. Align and communicate the value of the program to the organization’s mission and vision. 2.2.2b. Ensure the program reflects the complexity of the organization and services; involves all departments and services, including services under contract; and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. 2.2.2c. Align program activities to a single oversight committee with clear assignments of responsibility and accountability. 2.2.2d. Publish a continuous readiness dashboard based on mock surveys and self-assessments. 2.2.2e. Prepare organization staff members to assume leadership roles in the regulatory/accreditation process. 2.2.2f. Develop and implement an internal survey process to determine readiness and ongoing compliance. (continued)

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Area: Regulatory and Accreditation Dimension 2: Regulatory, Accreditation, and Certification Program Management (continued)

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

2.3. Ensure achievement of regulatory, accreditation, and certification program goals and associated benefits for the organization.

2.3.1a. Prepare staff members for individual participation in surveys (document review, interviews, and observation of routine procedures and patient care). 2.3.1b. Apply policies, tools, and processes to prepare for and achieve the desired status. 2.3.1c. Escalate implementation of performance improvement activities to address areas of opportunity. 2.3.1d. Work in partnership with agency surveyors to guide them through the organization and meet with appropriate individuals, as needed.

2.3.2a. Develop and implement internal processes to continuously assess the program in anticipation of the changing landscape and priorities of the organization. 2.3.2b. Celebrate organization success through internal channels of communication. 2.3.2c. Celebrate organization successes externally by writing journal articles or sharing the experience at trade shows and with local media. 2.3.2d. Create avenues to share lessons learned internally and externally.

2.4. Establish routine reporting processes utilizing metrics to monitor impact of participation and outcomes.

2.4.1a. Collaborate with crossfunctional teams to identify and prioritize data elements to be collected and reported utilizing synergies to decrease resource needs and ensure data integrity, consistency, and usefulness. 2.4.1b. Identify areas for improvement based on data analysis and demonstrate proficiency in tracking, analyzing, and utilizing data to drive performance improvement processes. 2.4.1c. Implement processes to streamline data collection efforts. 2.4.1d. Apply data evaluation tools to develop processes that enhance the patient experience to drive better patient outcomes. 2.4.1e. Collaborate with relevant crossfunctional teams to ensure systems and practices are updated in a timely manner to support change.

2.4.2a. Implement processes based on data collection that would result in organization surpassing requirements of accreditation/regulatory standards. 2.4.2b. Provide leadership and guidance in the organization for decisions to participate in national recognition programs related to regulatory and accreditation standards. 2.4.2c. Implement continuous improvement efforts in collaboration with the organization’s departments. 2.4.2d. Implement processes based on data collection to meet the organization’s mission, goals, and values of patient safety and quality.

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Q Essentials: Competencies for the Healthcare Quality Profession

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

2.5. Manage survey (planned and unannounced) processes.

2.5.1a. Demonstrate understanding of the process and implications of the various compliance survey types (routine cycle, validation, for cause, unannounced). 2.5.1b. Prepare survey application and application updates with input from all key stakeholders. 2.5.1c. Assist with onsite, electronic, or mailing readiness preparations and survey activities (document review and practice review) on the day of survey. 2.5.1d. Compile internal audit/survey/ tracer reports to communicate findings. 2.5.1e. Schedule audit/survey/tracer close-out meetings with key stakeholders. 2.5.1f. Participate in exit conferences and coordinate the delivery of the findings.

2.5.2a. Provide oversight for presurvey, during the survey, and postsurvey activities, ensuring timely application submission, document preparation, survey planning, improvement plan processes, and tracking of compliance with timely submission. 2.5.2b. Create and monitor the infrastructure for onsite survey visits (logistics and hosting considerations): surveyor workroom, command center, conference rooms, and human resources. 2.5.2c. Compile and analyze overall audit/survey/tracer reports by prioritizing them by severity to communicate findings. 2.5.2d. Identify key trends of findings and prepare executive summaries. 2.5.2e. Lead exit conferences and deliver key trends and findings. 2.5.2f. Oversee the coordination, timely submission, and monitoring of corrective action plans. 2.5.2g. Monitor intracycle activities and ensure the submission of ongoing reporting requirements per defined time periods.

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Area: Regulatory and Accreditation Dimension 3: Advance a Continuous Readiness Culture Description: Oversight of the infrastructure, processes, and activities that demonstrate an organization is in compliance with applicable regulatory and accreditation requirements and therefore is in a perpetual state of readiness for inspection for any of these requirements.

Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

3.1. Communicate goals and education on requirements for continuous readiness.

3.1.1a. Assess which regulations and standards apply to an organization/ business unit. 3.1.1b. Gain knowledge of where/how to access standards, guidelines, and regulations. 3.1.1c. Build database of standards, guidelines, and regulations. 3.1.1d. Perform research when questions on requirements arise. 3.1.1e. Conduct training/education to key stakeholders on applicable requirements. Emphasize the “why” behind the requirement to ensure full understanding of the intent/impact.

3.1.2a. Provide requirement oversight by serving as a subject matter expert for organization on regulatory/accreditation/ certification requirements. 3.1.2b. Prepare and monitor an operating budget for regulatory and accreditation surveys and continuous readiness activities. 3.1.2c. Develop and provide training/ education to staff/physicians/leaders/ board members on applicable requirements. 3.1.2d. Align various agencies’ requirements to the organization’s policies, procedures, and protocols.

3.2. Develop an ongoing process for evaluation.

3.2.1a. Participate in readiness activities as an internal auditor, surveyor, or tracer leader. 3.2.1b. Conduct staff interviews. 3.2.1c. Conduct role playing activities as an auditor or surveyor.

3.2.2a. Develop tools/templates to use for the audits/surveys/tracers that are tailored to the worksite or type of employee. 3.2.2b. Develop internal survey/tracer/ audit schedule and procedure. 3.2.2c. Lead readiness activities as the internal preparedness team leader. 3.2.2d. Train others to perform internal audits/surveys/tracers.

3.3. Facilitate the development and monitoring of action plans for noncompliant findings including preparation, evaluation, and monitoring.

3.3.1a. Support and assist with the preparation of an action plan in response to internal survey or audit report results with corrective/preventive action. 3.3.1b. Oversee implementation of the action plan. 3.3.1c. Develop data collection tools for auditing/monitoring measures of success/ compliance with standards.

3.3.2a. Develop tools and templates to use for the action plan including monitoring. 3.3.2b. Develop methods for communicating the action plan and monitoring process and subsequent results to key leaders and stakeholders. 3.3.2c. Analyze the results of action plan monitoring to validate their effectiveness. 3.3.2d. Develop a repository for the findings, action plan, and monitoring results for review by the organization or for use during regulatory surveys.

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Proficiency Levels and Descriptors Definition (observable behaviors)

Proficiency 1: Advanced Practitioner

Proficiency 2: Master Practitioner

3.4. Implement a process for assessment and development of improvement plans and ongoing monitoring.

3.4.1a. Complete the tool/template that documents compliance with regulatory requirements. 3.4.1b. Maintain knowledge of how the organization complies with regulatory/ accreditation requirements. 3.4.1c. Define measures of success for monitoring compliance with requirements including development of operational definitions (numerators, denominators, and exclusions) and determinants of appropriate sampling.

3.4.2a. Develop and implement a tool for documenting regulation and accreditation compliance. 3.4.2b. Develop and implement a method for transparency and communication of the compliance results (e.g., dashboards or scorecards). 3.4.2c. Present evidence of compliance when needed.

3.5. Develop and implement mechanisms to “hardwire” compliance and drive sustainability.

3.5.1a. Implement a process to ensure continuous readiness is a part of everyday workflow. 3.5.1b. Conduct continuous readiness rounding throughout the organization (different process than the tracer survey process). 3.5.1c. Conduct open informational forums for organization leaders and staff.

3.5.2a. Develop and implement a process to make continuous readiness a part of everyday workflow. 3.5.2b. Create and facilitate presentations for board, senior leader, and medical staff focused on continuous readiness themes including resources essential for team success. 3.5.2c. Develop a sustainable rounding process for all levels of the organization that promotes dialogue and sharing. 3.5.2d. Foster a culture of accountability where self- and other reporting of noncompliance is encouraged and rewarded.

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Resources Accreditation Association for Ambulatory Health Care, Inc. (2015). Accreditation handbook for ambulatory health care. Skokie, IL: AAAHC. Brown, D. S. (2012). Q Solutions: Essential competencies for the healthcare professional: Regulation, accreditation and continuous readiness. (3rd Ed.). Glenview, IL: National Association for Healthcare Quality. Cairns, C. S. (2014). Verify and comply: A quick reference guide to The Joint Commission and NCQA standards for credentialing. (4th Ed.). Danvers, MA: HCPro Healthcare Marketplace. Calloway, S. D. (2010). The CMS hospital conditions of participation and interpretive guidelines. Brentwood, TN: HCPro. Clark, J. & Forbes, H. (2015). The Joint Commission mock tracer made simple. (17th Ed.). Brentwood, TN: HCPro. Eisenberg, J. (2015). The survey coordinator’s handbook. (17th Ed.). Danvers, MA: HCPro, Healthcare Marketplace. Eisenberg, J. L. (2011). Chapter leader’s guide to leadership: Practical insight on Joint Commission standards. Danvers, MA: HcPro, Healthcare Marketplace Joint Commission Resources. (2011). More mock tracers. Oak Brook, IL: Joint Commission Resources Joint Commission Resources. (2014). Toolkit for new accreditation professionals. Oak Brook, IL: Joint Commission Resources. Porche, R. (2015). Joint Commission and CMS crosswalk, comparing hospital standards and CoPs. Oak Brook, IL: The Joint Commission. The Office of the Federal Register. Federal regulatory materials, laws, rules, and regulations. Accessed at: http://www.ofr. gov/?AspxAutoDetectCookieSupport=1 UHC Continuous Patient Readiness Advisory Group. (2010). Continuous patient readiness: A best practice for safe, high-quality patient care. Chicago, IL: University Health System Consortium

Website Resources Accreditation Association for Ambulatory Health Care: www.aaahc.org Accreditation Commission for Health Care: www.ahc.org Agency for Healthcare Research and Quality: www.ahrq.gov Agency for Healthcare Research and Quality, Patient Safety Organizations: www.pso.ahrq.og Alliance for Quality Improvement and Patient Safety: www.allianceforqualityimprovement.org American Association of Blood Banks: www.aabb.org/sa American College of Radiology: www.acr.org/Quality-Safety/Accreditation American National Standards Institute: www.ansi.org Association for Professionals in Infection Control and Epidemiology: www.apic.org Center for Improvement in Healthcare Quality: www.cihq.org Centers for Disease Control and Prevention: www.cdc.gov Centers for Disease Control and Prevention State or Territorial Health Departments: www.cdc.gov/mmwr/international/relres.html Centers for Medicare & Medicaid Services: www.cms.hhs.gov Clinical Laboratory Improvement Amendments: www.cms.hhs.gov/clia Code of Federal Regulations: www.hhs.gov/ohrp/humansubjects/guidance/45cfr46.html College of American Pathologists: www.cap.org Commission of Office Laboratory Accreditation: www.cola.org Commission on Accreditation of Rehabilitation Facilities, International: www.carf.org Community Health Accreditation Program: www.chapinc.org Det Norske Veritas National Integrated Accreditation for Healthcare Organizations (NIAHO): www.dnvaccreditation.com Emergency Medical Treatment and Active Labor Act: www.cms.gov/EMTALA Federal Register: www.ofr.gov

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Q Essentials: Competencies for the Healthcare Quality Profession

Healthcare Facilities Accreditation Program: www.hfap.org Institute for Safe Medication Practices: www.ismp.org  National Academy for State Health Policy: www.nashp.org National Committee for Quality Assurance: www.ncqa.org National Department of Labor, Occupational Safety and Health Administration: www.osha.gov National Institutes for Health: www.nih.gov National Practitioner Data Bank: www.npdb.hrsa.gov National Quality Forum: www.qualityforum.org National Sanitation Foundation: www.nsforg/regulatory Quality Care Finder: www.medicare.gov/quality-care-finder/index.html Quality Improvement Organizations: www.cms.gov/QualityimprovementOrgs Quality Net: www.qualitynet.org The Joint Commission: www.jointcommission.org United States Environmental Protection Agency: www.epa.gov URAC: www.urac.org U.S. Department of Health and Human Services: www.hhs.gov U S. Food and Drug Administration: www.fda.gov

Essential Competencies: Regulatory and Accreditation

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Notes

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Q Essentials: Competencies for the Healthcare Quality Profession

Q

ESSENTIALS To support healthcare qualit y professionals in your work, NAHQ is developing resources based on the

ESSENTIAL COMPETENCIES Continue to Explore Q Essentials. Attend Learning Labs to increase your proficiency of the Essential Competencies. Learn about career opportunities through At Work Profiles from your peers who are working in the field. Examine our resources to expand your knowledge of the Essential Competencies.

Visit www.nahq.org/Qessentials to learn more.

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