Describe the difference between licensure and accreditation?
Licensure: Hospitals must be licensed by the state in which they are located. Licensure requirements vary from state to state. In some states, meeting federal standards or the standards of a voluntary accrediting agency largely fulfills licensing requirements. To obtain the licensure requirements for hospitals in a given state, a health information manager would contact the agency in that state responsible for licensure of hospitals. Often, licensure requirements are available at the state agency's website.
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Accreditation: Hospitals voluntarily seek accreditation to demonstrate to their patients, to their communities, to insurers, to managed care organizations, and to others that their organizations are providing quality care. As previously mentioned, The Joint Commission, the AOA's Healthcare Facilities Accreditation Program (HFAP), and DNV Healthcare's NIAHO program offer voluntary accrediting programs whose standards and survey processes are "deemed" to be in compliance with the federal Conditions of Participation. The majority of U.S. hospitals are accredited by The Joint Commission. Of the three accrediting programs with deeming authority (TJC, HFAP, and NIAHO), the most recent addition is the NIAHO, a program of DNV Healthcare, Inc., an international organization originating in Norway. CMS granted DNV deeming authority in 2008 (DNV, 2010). The DNV approach is based on a combination of the ISO 9001 quality management protocols and the Conditions of Participation for Hospitals (Dowling, 2008). Both The Joint Commission and HFAP perform on-site surveys every three years, whereas DNV per-forms an annual on-site survey.
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Your patient is a 43-year-old female who is 36 weeks pregnant and alert, complaining of abdominal pain. She states that she slipped on a wet floor earlier today, striking her abdomen on a kitchen chair. She did not have any acute onset of pain, but over the next hour developed lower abdominal cramping similar to menstrual pain, as well as a lower back ache. She is G4P3, has a history of CVD,
renal disease, and had abdominal surgery for a hernia four months ago. Based on this history, the patient is MOST likely experiencing: A) preterm labor. B) uterine rupture. C) placenta previa. D) Braxton-Hicks contractions.
What should be done if some violations have not been corrected, but the owner/occupant is making a conscientious effort to comply?
A. Schedule another follow-up inspection. B. Issue final notice with date for another inspection. C. Inform owner/occupant of legal action to be taken if full compliance is not attained. D. Send a letter to the owner/occupant that the follow-up inspection found that violations were corrected.