THE UHMS ACCREDITATION COUNCIL ANNOUNCES NEW CRITERIA FOR FACILITY ACCREDITATION WITH DISTINCTION

The Accreditation Council (AC) of the UHMS has formally approved a new set of objective criteria that must be met for a hyperbaric facility to be accredited With Distinction (WD).  There are now nine, differentially weighted focus areas (ranging from 1 to 2 points) that are assessed in making a WD award determination.  For a hyperbaric facility to be accredited WD, the facility must achieve a minimum score of 6 out of the available 10.5 points.  To qualify relative to a given WD criteria, criteria #1-#5 must be actively met at the time of the survey.  For criteria #6-#9, the facility must demonstrate it has met the criteria at some point within the preceding three-year period (within four years for facilities that were previously accredited with distinction).  The UHMS Board of Directors has determined that qualification for criteria #1 shall be mandatory for all facilities considered for WD recognition.  The balance of the required points may be obtained by meeting any combination of the remaining eight criteria.

Note that these new WD criteria will be applied to all accreditation surveys conducted after January 1, 2018.

The new WD criteria and associated point values are as follows:

#1. The hyperbaric facility Medical Director is certified in Undersea and Hyperbaric Medicine by the American Board of Emergency Medicine (ABEM), the American Board of Preventive Medicine (ABPM), or the American Osteopathic Conjoint Committee of Undersea and Hyperbaric Medicine (AOCUHM). (1 point – compliance with this element is mandatory)

#2. Through either direct provision or established formal procedures for inter-facility cooperation, ensure that all patients being seen and treated by the HBO2 facility seeking accreditation are afforded, when medically indicated, timely access to HBO2 therapy on a 24-hour per day, seven-day per week basis. (2 points)

#3. As evidenced by patient treatment records documenting the incorporation of critical care monitoring, ventilator management and/or IV infusion support during the performance of hyperbaric treatments and, concurrently, a review of existing provider credentialing files, the HBO2 facility has an adequately equipped chamber and the appropriately trained and experienced staff to provide HBO2 care to critically ill patients. (1.5 points)

#4. All eligible nurses and technicians providing clinical HBO2 care to patients are CHRN/CHT certified. (1 point)

#5. Active hyperbaric facility engagement in a Quality Improvement program (to include Process Improvement) that is:

  1. Initiated by the hyperbaric facility;
  2. Designed to create improvements in the quality of hyperbaric patient care or safety; and
  3. Evidenced by accumulated metrics, data, or impact assessments from ongoing or completed Quality Improvement projects. (1 point)

#6. Members of the hyperbaric facility deliver HBO2-focused presentations at local, regional, national or international conferences. (1 point)

#7. Hyperbaric medicine-related publication in textbooks, peer-reviewed journals, or other professionally referenced documents. (1 point)

#8. Provision of instruction in Undersea and Hyperbaric Medicine.  To satisfy this criterion, one or more of the following must be in place and exercised on a recurring basis:

  1. An ACGME-approved Undersea and Hyperbaric Medicine Fellowship; or
  2. Educational programs that support clinical rotations, clerkships or electives for students or staff (i.e., physicians, nurses, technologists, respiratory therapists, etc.), so long as the programs have:
  3. A developed course content;
  4. Are approved by the governing body or through a collaborative education agreement with an academic institution; and
  5. Are overseen and presented by qualified instructors (i.e., UHM board-certified physicians, certified hyperbaric registered nurses, certified hyperbaric technologists); or
  6. Educational courses, lectures and presentations that either:
  7. Are ACGME-, NBDHMT- or UHMS-approved for CEU/CME credits in Undersea and Hyperbaric Medicine; or
  8. Provide training that can be applied in support of formal qualification by a UHM certifying board (e.g., ABMS, NBDHMT). (1 point)

#9. Research in the field of hyperbaric medicine that is conducted both:

  1. Under an IRB-approved human use, IACUC-approved animal use or institutionally-approved equipment test and evaluation protocol; and
  2. With the intent to publish or present in UHM professional venues. (1 point)

Direct questions to the Quality Assurance & Regulatory Affairs office of the Undersea and Hyperbaric Medical Society via email at tom@uhms.org or beth@uhms.org; or call +1-210-404-1553, ext 105; fax +1 (210) 404-1535.

 

 

 

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