Meet the accreditors.

OBRA surveys have been on the nursing home scene for several years now. While it may be too much to say that nursing homes are used to them, most are at least familiar with the concept involved. Now, though, a new quality assurance player is entering the scene, particularly for facilities venturing into post-acute care. The "new kid on the block" is, of course, managed care.

Recently, managed care payers have begun to use their own credentialing process. Now, when a managed care payer initiates a contract, the provider must also undergo credentialing in order to implement or continue the contractual agreement. Almost every credentialing form contains questions about accreditation, usually phrased thusly: "Do you have the following accreditations?:

* Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

* The Rehabilitation Accreditation Commission (CARF)

* "Other"

Many nursing homes have obtained JCAHO and/or CARF accreditation, but many more have not. For facilities wondering how these quality assurance tools might figure into their futures, I interviewed Christine M. MacDonnell, National Director, Medical Rehabilitation Division of the Commission on Accreditation of Rehabilitation Facilities (CARF) and Mary Tellis-Nayak, RN, MSN, MPH, Director, Long Term Care Accreditation for JCAHO.

How does your organization contribute to improving or monitoring the quality of provider services?

MacDonnell: "In 1995 CARF initiated a three-year plan to study, with the field, the concepts of outcome information in relation to standards, accreditation process, public disclosure and report cards for medical rehabilitation providers. For now, however, a CARF-accredited program predetermines what it believes to be acceptable levels of performance. When they fall below these levels of quality performance, the organization sets in motion an action plan that will bring the organization's performance up to an optimal level. Improvements may be in the areas of planning, finance, treatment effectiveness, program efficiency, customer satisfaction, etc. CARF standards assist an organization with creating systems that will keep them involved in partnerships with consumers and purchasers, keep them on top of the data concerning their programs, make them accountable for their performance, and have a continuous quality system in place that is used dynamically, not just once a year."

Tellis-Nayak: "JCAHO standards are helpful in motivating organizations to go beyond the minimum. Though any survey is, in effect, a snapshot of care at the time of the survey, an accredited organization is required to have an ongoing program for systematically improving performance. JCAHO requires an organization to establish a plan to design systems, measure their performance and make improvements. Assessment of data involves not only comparisons with oneself over time, but use of comparative databases where these have been established. Initial surveys require a four-month track record, and re-accreditation requires that this system is ongoing. External agencies currently do not have the capability to monitor outcomes on an ongoing basis, but JCAHO standards require that organizations continually monitor themselves, analyze their data and correct processes producing negative outcomes.

"The use of outcome data and standards performance data will be helpful to JCAHO in identifying the relationship between accreditation and performance. The goal will be to identify standards that support outcomes. The ideal for the survey would be its assisting and organizing to identify specific activities and processes producing negative outcomes. This will be included in the JCAHO survey process by the end of this century."

How would you like to see your organization interface with post-acute care providers over the next five years?

MacDonnell: "Post-acute care is a recognized portion of the rehabilitation continuum of care and will be looked at with ever-increasing emphasis, as health care moves out of traditional settings and more into the home and community.

"Over the next five years CARF will continue to work with the field in identifying the necessary changes that need to occur to keep pace with the systems that deliver rehabilitation care in a variety of settings. Our development of standards is being reviewed at the Board level to shorten the development and revision stages, as well as to improve our ability to review individual standards, rather than whole sections. We realize that, as health care systems become more integrated, the standards will have to proactively address the changes that occur."

Tellis-Nayak: "Over the next five years, JCAHO will work with post-acute integrated delivery systems to evaluate their performance across the continuum. It will be possible by then to identify core standards across settings, and view patient assessment throughout the continuum of care."