Professional Resources Committee Summary Chart

NIHD Professional Resources Committee: Web Page (Chart)
Final Draft: November 14, 2015 (S. Ziel)
Professional Resource
Medicare Conditions of
Participation and Conditions
of Coverage
The Center for Medicare &
Medicaid Services (CMS)
develops Conditions of
Participation (CoPs) and
Conditions for Coverage (CfCs)
that health care organizations
must meet in order to begin and
continue participating in the
Medicare and Medicaid programs.
These health and safety
standards are the foundation for
improving quality and protecting
the health and safety of
beneficiaries. CMS also ensures
that the standards of accrediting
organizations recognized by CMS
(through a process called
"deeming") meet or exceed the
Medicare standards set forth in
the CoPs / CfCs.
Medicaid and CHIP refers to the
Ambulatory Surgical
Centers (ASCs)
Community Mental
Health Centers
Rehabilitation Facilities
Critical Access
Hospitals (CAHs)
End-Stage Renal
Disease Facilities
Federally Qualified
Health Centers
Home Health Agencies
Hospital Swing Beds
Intermediate Care
Facilities for
Individuals with
Intellectual Disabilities
Organ Procurement
Organizations (OPOs)
Portable X-Ray
Programs for AllInclusive Care for the
Elderly Organizations
Clinics, Rehabilitation
Agencies, and Public
Health Agencies as
Providers of Outpatient
Physical Therapy and
Pathology Services
Psychiatric Hospitals
Religious Nonmedical
Health Care
Rural Health Clinics
Long Term Care
Transplant Centers
Medicaid Program: Delivery
combination providers,
institutional setting, and health
care benefit resources as a
"delivery system". States have
choices in their approach to
delivery system design under
the Medicaid and CHIP
National Fire Protection
Association (NFPA) 101 Life
Safety Code requirements
This page provides basic
information about Medicare
and/or Medicaid provider
compliance with National Fire
Protection Association (NFPA)
101 Life Safety Code (LSC)
requirements and includes links to
applicable laws, regulations, and
compliance information.
The LSC is a set of fire protection
requirements designed to provide
a reasonable degree of safety
from fire. It covers construction,
protection, and operational
features designed to provide
safety from fire, smoke, and
panic. The LSC, which is revised
periodically, is a publication of
NFPA, which was founded in
1896 to promote the science and
improve the methods of fire
The basic life safety from fire
requirement for facilities
participating in the Medicare and
Medicaid programs is compliance
with the 2000 edition of the NFPA
LSC. CMS partners with State
Agencies (SA) to assess facilities
for compliance with the LSC
requirements. SAs may enter into
sub-agreements or contracts with
the State Fire Marshal offices or
other State agencies responsible
for enforcing State fire code
The Big Three: A Side by Side This NAMSS article compares
and contrasts the “Big Three”
Matrix Comparing Hospital
accreditation agencies for
Accrediting Agencies
hospitals: The Joint
Commission (TJC), Healthcare
Facilities Accreditation Program
(HFAP) and Det Norske Veritas
Healthcare, Inc. (DNV).
The Joint Commission (TJC)
An independent, not-for-profit
organization, The Joint
Commission accredits and
certifies more than 20,500
health care organizations and
programs in the United States.
Joint Commission accreditation
and certification is recognized
nationwide as a symbol of
quality that reflects an
organization’s commitment to
meeting certain performance
The Joint Commission (TJC):
State-by-State Recognition of
Accrediting Bodies
The Joint Commission’s various
programs are recognized and
relied on by many states in the
states’ quality oversight
activities. Recognition and
reliance refers to the
acceptance of, requirement for,
or other reference to the use of
Joint Commission accreditation,
in whole or in part, by one or
more governmental agencies in
exercising regulatory authority.
Recognition and reliance may
include use of accreditation for
licensing, certification or
contracting purposes by various
state agencies.
Healthcare Facilities
Accreditation Program
Healthcare Facilities Accreditation
Program (HFAP) is authorized by
the Centers for Medicare and
Medicaid Services (CMS) to
survey all hospitals for
compliance with the Medicare
Conditions of Participation and
Originally created in 1945 to
conduct an objective review of
services provided by osteopathic
hospitals, HFAP has maintained
its deeming authority continuously
since the inception of CMS in
1965 and meets or exceeds the
standards required by
CMS/Medicare to provide
accreditation to all hospitals,
ambulatory care/surgical facilities,
mental health facilities, physical
rehabilitation facilities, clinical
laboratories and critical access
hospitals. HFAP also provides
certification reviews for Primary
Stroke Centers.
HFAP's surveying process and
standards benefit from oversight
by a wide range of medical
professionals, including both
allopathic and osteopathic
Det Norske Veritas Healthcare,
Inc. (DNV).
Det Norske Veritas Healthcare,
Inc. (DNV) is authorized by the
Centers for Medicare and
Medicaid Services (CMS) to
survey hospitals and critical
access hospitals for compliance
with the Medicare Conditions of
Participation and Coverage. DNV
also offers certification programs
for infection risk programs and
both primary and comprehensive
stroke centers.
Health Guidelines Revision
Committee (HGRC)
The Health Guidelines Revision
Committee (HGRC) is a select
multi-disicplinary consensus body
of more than 120 clinicians,
administrators, architects,
engineers, and representatives
from authorities having jurisdiction
that is convened to revise and
update the Guidelines for Design
and Construction of Health Care
Facilities. As a group, HGRC
members are experts on the many
issues addressed in the Guidelines.
The participation of individuals with
such a wide range of expertise
helps make the document one that
truly reflects a variety of clinical,
administrative, engineering, and
design concerns that is indeed
based on interdisciplinary
consensus. This consensus is
developed through a public process
that includes three meetings of the
full HGRC generally held over a
two-year period.
Facility Guidelines Institute
The Facility Guidelines Institute
(FGI), a not-for-profit corporation,
was founded in 1998 to provide
continuity in the facility guidelines
revision process, function as a
contractual coordinating entity, and
enhance the content and format of
Guidelinespublications that
encourage and improve their
application and use. Click the link to
the right to read a letter from the
FGI president discussing recent
FGI activities.
The 2015 Facility Guidelines
Institute’s (FGI) Guidelines for
Hospitals and Outpatient
The FGI Guidelines are divided into
four parts.
Part 1 contains chapters that
address considerations applicable
to all hospitals and outpatient
facilities, except as noted or
modified in specific facility chapters
in the remaining parts.
Part 2 addresses facilities where
inpatient care is provided, with
chapters devoted to general
hospitals, critical access hospitals,
psychiatric hospitals, rehabilitation
facilities, and children’s hospitals.
Part 3 addresses facilities where
outpatient care is provided.
Part 4 contains the full text of the
American Society of Heating,
Refrigerating and Air-Conditioning
Engineers (ASHRAE) Standard
170-2013: Ventilation of Health
Care Facilities.
Center for Health Design
The Center for Health Design
(CHD) was formed in 1993 by a
small cadre of pioneering
healthcare and design
professionals committed to
advancing a singular idea – that
design could be used to
improve patient outcomes in
healthcare environments. Our
passion proved contagious.
Today, we’re a far-reaching,
international community leading
the effort to improve the quality
of healthcare facilities
worldwide, as well as
environments for healthy aging.
Center for Health Design:
Knowledge Repository
The Knowledge Repository, a
centerpiece for all healthcare
design research, papers,
articles and references, allowing
users to search publications by
types of publications, terms,
design category, outcome
category, environmental
condition category or setting,
and provides the number of
references available for each
defined category. Users can
also conduct searches by
entering a key word in the
search box. The results appear
with the most recent references
at the top of the page.
Easy-to-use key point
summaries for select references
are available and allow users
the ability to easily and quickly
review important concepts
found in each of these articles,
such as findings and design
implications. Additional key
point summaries provided by
Research Design Connections
will continue to be added.
Designed as a living library, this
repository provides a one-stop,
complete source of healthcare
EBD research, and as such will
continue to grow and develop
as healthcare design evolves.
For researchers, it increases the
visibility, usage and impact of
their work. For users, it
provides a complete source of
healthcare design research.
Center for Health Design:
Learning Tools and
U.S. Department of Veteran
The Center for Health Design
offers many learning tools and
resources to help you design
and build hospitals, clinics,
doctor’s offices, wellness
centers, and residential care
facilities with improved
satisfaction rates, increased
safety, fewer medical errors,
better medical outcomes and a
healthier bottom line.
The Center for Health Design
also offers an Evidence-Based
Design Accreditation and
Certification (EDAC) program.
The Office of Construction &
Facilities Management (CFM) is
Affairs; Office of Construction
and Facilities Management;
Technical Information Library
responsible for the planning,
design, and construction of all
major construction projects
greater than $10 million. In
addition, CFM acquires real
property for use by VA elements
through the purchase of land
and buildings, as well as longterm lease acquisitions.
Through the construction and
real property programs, CFM
delivers to Veterans, high
quality buildings, additions,
large scale renovations, and
structural enhancements. CFM
also manages facility
sustainability, seismic
corrections, physical security,
and historic preservation of VA’s
The Technical Information
Library (TIL) is The Source for
VA's electronic Design and
Construction Information. The
TIL contains nearly 2,500
documents covering all aspects
of VA facility development, from
planning through construction to
occupancy. The TIL document
collection represents the
institutional knowledge resulting
from the more than 50
continuous years of the VA
construction program.
Academy Health: Advancing
Research, Policy and Practice
Academy Health is a leading
national organization serving
the fields of health services and
policy research and the
professionals who produce and
use this important work.
Together with our members, we
offer programs and services that
support the development and
use of rigorous, relevant and
timely evidence to increase the
quality, accessibility, and value
of health care, to reduce
disparities, and to improve
health. A trusted broker of
information, AcademyHealth
brings stakeholders together to
address the current and future
needs of an evolving health
system, inform health policy,
and translate evidence into