Q&A: Pursing new certifications or accreditations

Q: How do you and your organization decide whether to pursue new certifications or accreditations? Do you have a formal process? Have you created (or found) a tool used for the evaluation? Who ultimately makes the decision on whether to pursue (such as an individual administrator, senior leadership, or a committee)?

A: While we don’t have a formalized written process, we do follow some guiding principles. Evaluate the driving force behind the certification:

• Payor-driven: For example, Ventricular Assistive Device Implantation and Lung Volume Reduction Surgery require certification to obtain reimbursement.
• Market-driven: Advanced Primary Stroke Certification is a very good example of this. There is currently no reimbursement tied to this, but there is a significant push in the market place to differentiate your facility as a certified stroke center. We will see this further expand as the Comprehensive Stroke Certification grows.
• Regulation-driven: Additionally, in some markets, like Chicago there is legislation. In 2009, Illinois established a network of specialist stroke centers, ambulances direct patients to certified facilities.

For those programs that don’t necessarily fit into any of the above categories, the primary questions are “Why?” “At what cost?” and “What is the return on investment?” For our organization, we have not chosen to seek many additional certifications at this time, however, we have instructed some of those programmatic areas that have inquired to established their program using the disease-specific certification standards. With the movement in the healthcare market relative to reimbursement, we may see more requirements for certification. The standards are fairly foundational and seem to be a good way to manage a program consistently with the hospital accreditation standards.

- Jodi Eisenberg is the manager of accreditation, clinical compliance, and policy management at Northwestern Memorial Hospital in Chicago. She is the chair of the Association for Healthcare Accreditation Professionals (AHAP) and also a contributing editor to Briefings on The Joint Commission. If you’d like to hear more from Jodi on obtaining certifications, consider attending her session “Get certified: Improving your hospital’s disease specific care” at this year’s AHAP conference.

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