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Regulatory and Accreditation Standards for QI Implementation

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  • Category: Insurance

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Many health care organizations receive accreditation from several agencies performing quality review. In health care organization, regulation and accreditation are not identical. “Regulation involves rules that must be followed, while accreditation is a seal of approval certifying that an organization or individual has met specific standards. In practice, in health care, accreditation is frequently plays an essential role”(Rebecca N. Warburton, 2009) for improving quality and safety. Health care regulatory standards for health care organizations evolve from the U. S. Department of Health and Human Services (HHS), the Centers for Medicare and Medicaid Services (CMS) and other agencies. The HHS regulates health care organizations through laws and policies and CMS regulates the research, education, and medical practices include human research protections, health information privacy, health information technology standards, and Medicare and Medicaid services for the health care organization. These minimum health and safety standards led to quality care and protect the health and safety of the patients.

The CMS standards must be met to qualify for Medicare and Medicaid certification and receipt of appropriate reimbursement and funding. “Accreditation is a formal process by which a recognized body either governmental or nongovernmental assesses and recognizes that a health care organization meets pre-established performance standards. Accreditation standards are usually regarded as optimal yet achievable and are designed to encourage continuous improvement efforts within accredited organizations”(hciproject, n.d., 2012) The federal Patient Protection and Affordable Care Act (ACA) provides for the establishment of American Health Benefit Exchanges (Exchanges).

“An Exchange must offer only qualified health plans (QHPs) certified by the Exchange to qualified individuals and qualified employers. To participate in an Exchange, QHPs are required to meet accreditation standards and must implement a quality improvement strategy”(National Association of Insurance Commissioners,2012). As part of a national quality strategy, exchanges will provide quality improvement strategies, quality and cost ratings, and data for patient satisfaction. The reason of these requirements for health care is to improve quality of care, “ensure that QHPs are on promoting quality improvement, and improve transparency so that consumers can compare plans based on quality as well as price”(National Association of Insurance Commissioners, 2012).


Dlugacz, Y. D. (2006). Measuring health care: Using data for operational, financial, and clinical improvement. San Francisco, CA: Jossey-Bass. Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (2008). The Healthcare Quality Book: Vision, Strategy, and Tools (2nd ed.). Chicago, IL: Health Administration Press. AQIP Home. (n.d.). The Higher Learning Commission – Home. Retrieved December 25, 2012, from http://www.ncahlc.org/AQIP/AQIP-Home/ Exchanges Plan Management Function: Accreditation and Quality White Paper. (n.d.). National Association of Insurance Commissioners. Retrieved December 24, 2012, from www.naic.org/documents/committees_b_rel Warburton, R. N., & PhD. (n.d.). AHRQ WebM&M: Morbidity and Mortality Rounds on the Web. AHRQ WebM&M: Morbidity and Mortality Rounds on the Web. Retrieved December 25, 2012, from http://www.webmm.ahrq.gov/perspective.aspx?perspectiveID=74 Accreditation | USAID Health Care Improvement Portal. (n.d.). HCI | USAID Health Care Improvement Portal. Retrieved December 25, 2012, from http://www.hciproject.org/improvement_tools/improvement_methods/approaches/accreditation

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