Hospital Accreditation

1. Policies & Procedures
   A system governing body may wish to adopt identical policies and procedures for many aspects of a hospital's operations across all of its hospitals within the system. It has the flexibility to do so, but the documentation of such policies and procedures must be clear that the governing body has chosen to apply them to specifically named hospitals. Also, each hospital must be able to present for inspection the system governing body policies and procedures that clearly apply to that hospital.
   For example, a system-level policy on managing patient grievances must specifically state to which hospitals the policy applies. It cannot simply be labeled as "ABC Health System Policy on Grievances".

2. Quality Improvement Program
   Although a health system may choose to operate a quality assessment/performance improvement (QAPI) program at the system level which standardizes indicators measured across system hospitals, each separately certified hospital in the system must have a QAPI program that is specific to that hospital.
   For example performance metrics addressing medication errors should be constructed in such a way that data is broken out for each hospital within the system. Likewise analysis and actions on data should be hospital specific.

3. Department Operations
   Departments of separately certified hospitals with one system governing body may not be operationally integrated. For example, if a system has chosen to operate three separately certified hospitals in relatively close proximity to each other rather than to have them certified as one multi-campus hospital, then each hospital must have its own nursing service.
   It may not have one integrated nursing service with one Director of Nursing who manages one nursing staff for all three hospitals. The system cannot maintain one integrated schedule that assigns nursing staff among the different hospitals. The system also cannot move them back and forth between hospitals on an ad hoc, as needed basis, as if they were one hospital.

4. Governance
   A hospital system also has the option to form several governing bodies, each of which is responsible for several separately certified hospitals.
   However, Medicare payment requirements at §§412.22(e) - (h) are applicable to certain types of hospitals, i.e., non-grandfathered Hospitals-within-Hospitals and Hospital Satellites. In such cases where the hospital system owns both the tenant and the host hospital, using a single governing body for both hospitals would jeopardize the payment status of a hospital (tenant) that is being paid by Medicare under a payment system excluded from the Hospital Inpatient Prospective Payment System (IPPS).

About the Author

Richard Curtis RN, MS, HACP
RN, MS, HACP