GMHA welcomes board decision to move ahead with CIHQ accreditation

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There are only 3 COVID-related hospitalizations at GMH. (PNC file photo).

The Guam Memorial Hospital Authority (GMHA) is excited to begin the process of accreditation through the Center for Improvement in Healthcare Quality (CIHQ).

As the Guam community is aware, GMHA lost its accreditation in 2018. The new GMHA
administration made a commitment to regaining accreditation and continuing to provide the people of Guam the healthcare they deserve. Through the hard work of the GMH staff,
strong recruitment efforts, infrastructure investments, and other resource devotion, GMHA is ready to move forward with applying for accreditation once more.

There were three main accrediting contenders evaluated as part of the GMHA process: Det
Norske Veritas (DNV), The Joint Commission (TJC) and the Center for Improvement in
Healthcare Quality (CIHQ).

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CIHQ’s accreditation most closely resembles and aligns with the standards and Conditions of Participation (CoPs) of the Centers for Medicare and Medicaid Services (CMS).

Accrediting Organizations (AO) that work with hospitals accepting Medicare and Medicaid funding must apply for a deeming authority from the Department of Health and Human Services (HHS). This deeming authority ranges from 2-6 years, depending on the AO meeting CMS standards for surveying and other practices.

GMHA is confident in the Accrediting Organization it has chosen, CIHQ, as it has been granted by HHS the maximum deeming authority length of 6 years.

“CIHQ accredits hospitals similar in size and patient capacity as GMHA. Equally significant,
CMS itself granted its seal of approval for the CIHQ surveying and healthcare standards, giving all of us at GMHA the full confidence that we would be undoubtedly meeting all federal standards of care. Ultimately, we’re choosing what’s best for our patients and our Guam community,” said Lillian Perez-Posadas, GMHA CEO.

While GMHA was previously accredited by The Joint Commission (TJC), that Accrediting
Organization continues to deal with issues as it relates to CMS compliance and deeming
authority. As recently as July 2020, TJC was given only a 2-year deeming authority from HHS.

In their decision to more closely monitor TJC, CMS wrote, “this shorter term of approval is
based on our concerns related to the comparability of TJC’s survey processes to those of CMS, as well as what CMS has observed of TJC's performance on the survey observation. Some of these concerns stem from the level of detail TJC provides in the daily briefings it provides to facilities, as well as TJC’s processes surrounding its staff interview practices. Additionally, we are concerned about TJC’s review of medical records and surveying off-site locations, in particular for the Physical Environment condition of participation. Based on these observations and review of TJC’s processes as discussed…we remain concerned about the thoroughness of review conducted within the facilities.”

GMHA’s accrediting committee, Executive Leadership, and the Board of Trustees are confident in their decision to move forward with CIHQ, the Accrediting Organization that has a consistent and trusted CMS backing.

In addition to CIHQ basing its standards primarily on CMS’ Conditions of Participation (CoPs), to the tune of 95% similarity, they are also the most fairly and reasonably priced as it relates to surveys and membership costs. GMHA is committed to continue running a consistently financially stable institution and knowing that CIHQ caters to hospitals with similar operating budgets as our hospital, keeps GMH on track to accomplishing its financial goals.

“CIHQ’s approach to accreditation is very straightforward. The fundamental reasoning behind accreditation is to ensure that our hospital meets the CMS Conditions of Participation (CoPs). What better way to achieve that than by pursuing the organization that most closely resembles those standards?” said Danielle Manglona, Administrator of Quality, Patient Safety, and Regulatory Compliance.

“As the GMHA Board of Trustees, we are always looking out for the best interest of our
community’s healthcare. We are confident that achieving accreditation through CIHQ will
ultimately mean better alignment with CMS, allowing for the best healthcare by national
standards for every single person in our community,” said Theresa Obispo, GMHA Board of
Trustees Chairperson.

While accreditation by an AO is voluntary, GMHA knows that it’s a seal of approval, commitment, and confidence the community and GMH staff deserve, knowing they’re achieving the highest and most established healthcare standards.

GMHA says it’s “thrilled” to be moving forward with an Accrediting Body that is hands down the most recommended by hospitals operating at the same capacity as GMHA.

(GMHA Release)

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