False Accreditation

Entertainment is replete with narcissists because they make great villains. Thriller-type movies often use benign, familiar characters to mask narcissism that facilitates their ability to blend in with the community, often in positions of power or prestige. In real life, when a healthcare professional is in a position to conduct procedures that can mean life or death, what assurance do we have they’re qualified to do the work? Do they have a 30-year-old degree on the wall? How does that match up to their current skillset or the advancements in medicine since then? Many professions require continuing education, and through this process, the professional not only ensures that his skillset is up to date, but they are able to prove it to the facilities in which they work, the regulatory bodies that allow them to practice medicine in the capacity they profess to be competent, and most importantly, the patient themselves. To maintain their PE stamp of authority, Professional Engineers are required to complete “continuing professional competency” to keep their license. Similarly, healthcare professionals are required to do the same. In any given medical facility, there may be a multitude of accreditations that must be aggregated, maintained, and referenced when you have a wide range of healthcare professionals in multiple disciplines with a multitude of accreditation bodies to whom they are obligated. To that end, a sound quality management system will robustly maintain these records, ensuring compliance attained through cataloging up-to-date accreditations where necessary.

The role of quality management in accreditation management

How do you know when accreditation is up to date? It’s difficult for clinicians to check their records, so many software firms have developed systems to help them keep track of their credentials. These include: • Clinical competencies — this includes evidence-based information about how a particular practice functions • Establishment of accreditation status — used by groups such as the Joint Commission, American Nurses Association, or the Accreditation Council for Graduate Medical Education (ACGME) Accrediting bodies are beginning to work towards a standards-based approach toward maintaining track of accreditations. Standards can be defined and enforced in multiple ways; some standards require that all organizations follow certain principles or accept certain types of evidence. Other criteria try to catch organizations more frequently if they don’t consistently adhere.

Primary Source Verification

The principle behind primary source verification is that it allows healthcare providers with multiple sources (for example, provider networks or individual doctor’s office visits) to attest that they did everything in accordance with their organization’s QMS policy on proof-of-concept criteria. It also helps prevent potential conflicts between two organizations’ QMS policies on proof-of-concept criteria as well as between different sites within the same organization (for example, if one provider network has higher quality standards than another provider network). But perhaps the essential function of accreditation management and primary source verification is ensuring that healthcare professionals are up to date and in compliance and capable of demonstrating competency. One established way of establishing competency is through quizzes administered by the system. With the name “quality management” in the name, one would think these systems are robust and capable of adequately capturing competency. Still, with the failures of some quality management systems to design to even the most basic of data integrity principles, there are jarring scenarios that take place instead. What would you think if a student taking an online test was notified, they answered a question wrong, asked to try again, highlighting the correct answer in the process? One would be right in questioning the student’s competency in the subject. That exact scenario plays out in some “quality” management systems, and there is no excuse for it. A function like that is entirely by design, and while young Jimmy may get away with cruising through a history class that way, healthcare professionals may get away with much worse.

Featured Articles

Featured video

Quo ea etiam viris soluta, cum in aliquid oportere. Eam id omnes alterum. Mei velit

AIH Newsletter

Quo ea etiam viris soluta, cum in aliquid oportere. Eam id omnes alterum. Mei velit