1. “VA Nurses: Serving Up Quality, Safety and Value”
NOVA 34th Annual Meeting
June 27, 2014
VHA External Accreditation Services and Programs
VACO Office of Quality, Safety and Value
Gloria A. Williams, RN, BSH, MHSA Director External Accreditation Services and Programs
“VA Nurses: Serving Up Quality, Safety and Value”

2. QSV Vision and Mission
Vision: Lead VHA to become the Veteran’s most trusted choice for high-quality, safe and reliable care Mission: Enhance the quality, safety, reliability and value of VHA’s clinical and business systems by enabling innovative, enterprise-wide approached to compliance, risk awareness and continuous improvement

3. QSV Components
Integrity: Accountability through verification creating an integrated, industry-standard approach to compliance with applicable laws, regulations and standards while unearthing non-compliant practices requiring improvement Compliance and Business Integrity and Quality Standards and Programs Mindfulness: Risk aware through insight Safety and Risk Awareness Reliability: High performance through improvement High Reliability Systems and Consultation Value: Value driven through validation Healthcare Value

4. QSV Organizational Structure
ADUSH for QSV
Deputy ADUSH for QSV
Compliance & Business Integrity
Business Compliance
Compliance Improvement
Compliance Systems
Quality Standards and Programs
Standards and Regulatory Governance
ISO Consultation
External Accreditation Services and Programs
Evidenced Based Clinical Practice Guidelines
Utilization & Efficiency Management
Health Systems Innovation Planning and Coordination
High Reliability
Veteran Engineering Resource Centers (VERC)
Systems Redesign & Improvement
Healthcare Value
Value Measurement & Results
Education & Program Planning
Product Effectiveness
Safety and Risk Awareness
National Center for Patient Safety (NCPS)
Risk Management
Credentialing & Privileging
Medical Legal Affairs (OMLA)

5. QSV External Accreditation Surveys and Accreditation Contracts
TJC (The Joint Commission) URAC( Call Centers) CARF (Commission of Accreditation for Rehabilitation Facilities) CSR ( Continuous Survey Readiness : Joint Commission Resources) uSPEQ (Patient Satisfaction in CARF facilities) ORYX (The Joint Commission Performance Measurement)

6. External Accreditation Programs and Services (EASP) Key Functions
Manuals, survey guides, newsletters, message boards, shared practices, quick links, and general information
Consulting Services for VISNs, Field Facilities and Program Offices
One-on-One Meetings
Accreditation Survey Notifications
Data Tracking for Accreditation survey results (Field Tracker product)
Consultation related to external Continuous Readiness strategies and education services
Data retrieval for specific needs R/T Accreditation
Information on vendor services (TJC, CARF, URAC, CSR)

7. External Accreditation Programs and Services (EASP) Key Partners
Office of the Inspector General (OIG) Government Accountability Office (GAO) 10N Operations VISN Quality Management Officers Facility Quality Managers and Accreditation Managers Consolidated Mail-Out Pharmacy (CMOP) Employee Education System (EES) Office of Acquisitions (Contracting) Accreditation Vendors

8. Overview of 2013 Accreditation Statistics
External Accreditation Survey Activity Total Visits The Joint Commission – 65 Surveys URAC – 5 Surveys CARF – 265 Surveys Numerous Educational Webinars provided to Program Offices, VISNs and Facilities by JCR

9. Just FYI…….
Deemed Status- status conferred on a hospital or other organization by a professional standards review organization in formal recognition that the organization's review, continued-stay review, and medical care evaluation programs meet certain effectiveness criteria. VHA Accreditation programs are not “deemed” but are guided by and meet CMS conditions of Participation. ACGME -Accreditation Council for Graduate Medical Education VHA facilities are required to meet standards set forth by ACGME because we are heavily involved in training the nations medical Residents The Joint Commission Nursing Home Chapter in the accreditation manual is now called the Nursing Care Centers Chapter. As of 2013 the NCC chapter now includes a section strictly devoted to VHA’s Community Living Centers including Cultural Transformation and Patient Centered Care

10. Resources and Contacts
External Accreditation Program Contacts:
Gloria A. Williams, Director External Accreditation
James W. Williams, Accreditation Program Analyst
Walter L. Smith, Accreditation Program Support
Nicholas Decetise, Accreditation Data Analyst,