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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 an initiative to more effectively and efficiently address chronic health care condition, and has enhanced IHS participation in IHI’s 5 Million Lives Campaign to prevent patient harm.
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. In addition, 55 IHS and tribal facilities in the Alaska, Aberdeen, Bemidji, Oklahoma, and Phoenix Areas are using Med Marx, a national proprietary medication error reporting system, to improve medication safety. The IHS has also developed a web-based worker and patient safety adverse event reporting system called WebCident that has been deployed nationally Worker and patient adverse events, including actual and potential (near-miss errors) 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 the local and national levels to reduce risk and prevent risk errors 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 2008