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ACCREDITATION ACHIEVEMENTS

ISSUE

The voluntary accreditation of facilities demonstrates the high level of quality of services being provided to American Indian and Alaska Native communities. All Indian Health Service (IHS) and tribally operated hospitals are accredited by The Joint Commission or certified by the Center for Medicare and Medicaid Services (CMS). Most large clinics and many smaller clinics are accredited by The Joint Commission or the Accreditation Association for Ambulatory Health Care (AAAHC). In addition, most youth regional treatment facilities are either accredited by The Joint Commission or the Commission on Accreditation of Rehabilitation Facilities.

BACKGROUND

Quality improvement processes within health care organizations are an important means of improving performance, enhancing the quality of services, and improving patient safety. The IHS measures the quality of its services against community, federal, and national standards of care and performance. Accrediting organizations such as The Joint Commission, AAAHC, and CMS conduct reviews of IHS and tribal health facilities to assess the quality of care and services provided. IHS has also engaged in a formal partnership with the Institute for Healthcare Improvement (IHI) that has enhanced performance improvement education, activities, and awareness nationally. It has also fostered the development of initiatives to more effectively and efficiently address chronic health care conditions.

SITUATION

The IHS and its tribal contractors would benefit from system-wide programs for monitoring performance and improvement as well as patient safety in greater detail. With national systems, the higher risk practice areas in our hospitals and clinics could be monitored and analyzed while sharing the best programs with all facilities to improve local performance. To that end, the IHS has developed a clinical information reporting system to passively extract clinical GPRA indicators and other clinical data, generating performance reports for IHS Areas and their Service Units and tribal programs.

The IHS has also developed a web-based worker and patient safety adverse event reporting system called WebCident that has been deployed nationally.  Worker, visitor, and patient-related errors and adverse events can be reported, analyzed, trended, and reviewed electronically, 24 hours/day, 7 days per week.  When data is entered by any employee, WebCident automatically generates graphic and table reports for review.  The information is used proactively by leaders, clinicians, and others at local, regional, and national levels to reduce and prevent risk, errors and adverse events throughout the system.

OPTIONS/PLANS

The IHS is a uniquely complex and potentially beneficial setting in which to explore and validate selected performance improvement measures and technologies.

ADDITIONAL INFORMATION

For referral to the appropriate spokesperson, contact the IHS Public Affairs Staff at 301-443-3593.

June 2009