HIMA 3030 Chapters 15 and 16

Chapter 15



The act of granting approval to healthcare organizations with the approval being based on whether the organization has met a set of voluntary standards developed by the accreditation agency.


A state's act of granting a healthcare organization or an individual healthcare practitioner permission to provide services of a defined scope in a limited geographical area.


The act of granting approval for a healthcare organization to provide services to a specific group of beneficiaries.

Compulsory review

Reviews that are performed to fulfill legal or licensure requirements.

Voluntary review

Reviews that are conducted at the request of the healthcare facility seeking accreditation or certification.

Joint Commission on Accreditation of Healthcare Organizations

The most visible organization responsible for accrediting healthcare organizations since the mid-1950's that seeks to determine whether organizations seeking accreditation are continually monitoring and improving the quality of care they provide.

Commission on Accreditation of Rehabilitation Facilities

A private not-for profit organization committed to developing and maintaining practical customer-focused standards to help organizations measure and improve the quality, value, and outcomes of behavioral health and medical rehabilitation programs.

National Committee for Quality Assurance

A private, not-for profit organization that is dedicated to improving quality of healthcare by assessing and reporting on the nation's managed care plans along with accreditation of management behavioral health organizations and credentials verification f

Conditions of Participation

A federal standard that every organization that provides services to Medicare and Medicaid beneficiaries must demonstrate its compliance with. For facilities, it covers issues related to medical necessity, level of care, and quality of care.

True /False
The joint commission recently surveyed an acute care hospital. The hospital just received the survey report and the accreditation decision. Triennial Exception Rules should be first addressed by the hospital leaders.


True /False
AHA registration is mandatory for health care facilities.

False (mandatory licensure)

True /False
The Joint Commission requires health care facilities manage the environment of care by implementing seven (7) various safety plans, which must be evaluated at least annually.


True /False
HEDIS gathers data in measures of quality.

True (also measures access and member satisfaction - employer health plans)

True /False
The U.S. federal government's CMS substitutes compliance of its Conditions of Participation requirements to hospitals that already have accreditation awarded by various other agencies that include Joint Commission, CARF, AOA, or AAAHC. This is


True /False
The Joint Commission on-site survey process incorporates tracer methodology which emphasizes surveyor review by means of patient tracers only.

False (both patient & systems tracers)

Chapter 16



Pertains to the care services provided to each patient.


Summarizes the experiences of many patients regarding a set of aspects of their care.


Uses aggregate data to describe the experiences of unique types of patients with one or more aspects of their care.

Data repository

Technology used to facilitate PI activities and long-range strategic planning.

Information warehouse

Allows organizations to store reports, presentations, profiles, and graphics interpreted and developed from stores of data for reuse in subsequent organizational activities.

Comparative performance data

Data whereby the organization can compare its performance with the performance of similar organizations to assure the organization is performing up to industry standards or help the organization identify opportunities for improvement.

List seven U.S. quality measurement organizations and give a description of each:

1. AHRQ, Agency for Healthcare Research and Quality - improving patient safety.
2. AQA, Ambulatory Care Quality Alliance - patient safety and healthcare quality.
3. CMS, Centers for Medicare and Medicaid Services.
4. HQA, Hospital Quality Alliance - quali

List the Joint Commission information standards (include the IM number in front of the standard).

IM.01.01.01: The organization plans for managing information.
IM.01.01.03: The organization plans for continuity of its information management processes.
IM.02.01.01: The organization protects the privacy of health information.
IM.02.01.03: The organizati