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Accreditation

Is your hospital ready for an unannounced Joint Commission or CMS survey?

For more than two decades, NRI has been the premiere source of performance measurement services for the nation's psychiatric hospitals—work that sits at the center of Joint Commission accreditation and CMS certification. Through the Behavioral Healthcare Performance Measurement System (BHPMS) and our partnership with Fields & Associates, we help inpatient psychiatric hospitals achieve, demonstrate, and maintain compliance year-round—not just at survey time.

In today's healthcare environment, psychiatric hospitals must be ready for unplanned Joint Commission and CMS visits at any point in the survey cycle. Our approach combines the trusted data analytics and performance metrics of NRI with the clinical and survey expertise of Fields & Associates, giving your organization both the evidence and the readiness to succeed.

We have found four factors critical to successfully achieving and maintaining Joint Commission accreditation and/or CMS certification:

  • The ability to comply with standards — identifying your core compliance leaders and ensuring their education and current, contemporary knowledge of standards.

  • The ability to know if/when you are (or are not) in compliance — using a compliance information dashboard and the processes to monitor, analyze, and act on the improvement opportunities it reveals.

  • The ability to demonstrate compliance — designing and implementing periodic mock tracers across all areas of the hospital and at least one full, facility-wide mock survey per survey cycle.

  • The ability to maintain continuous survey readiness — establishing a three-year schedule of compliance-related education, evaluation, and simulation activities focused on your areas of greatest vulnerability.

Our accreditation services include:

Performance Measurement & Reporting

  • Collection and reporting of performance measure data to meet Joint Commission requirements

  • Data-driven reports and dashboards to monitor compliance and quality of care

Joint Commission Survey Readiness

  • Comprehensive assessments for standards compliance

  • Standards clarification and training

  • On-site education and training

Joint Commission Mock Survey

  • Mock surveys and mock tracers

  • Clinical case consultation and quality-of-care evaluation

Joint Commission Post-Survey

  • Performance improvement principles and tools

  • Ongoing compliance planning

Treat Your Treatment Plans

  • Treatment Plan Training Bootcamp

  • Documentation Performance Review

We invite you to partner with NRI on accreditation and survey readiness. To request a service quote, call 703-738-8160 or email [email].