Hospital Accreditation

Below is a list of hospitals who work with the CDH Study Group.  Other information will be added to the columns shortly.

CDHi Accreditation has been postponed until the World Health Organization publishes it’s global Standard of Care for Congenital Diaphragmatic Hernia.

CDHi’s Clinical Care Guidelines encompass the following categories:

1. Diagnosis: Guidelines are established to ensure accurate and timely diagnosis of Congenital Diaphragmatic Hernia (CDH), facilitating prompt and effective treatment.
2. Surgical Repair: Specific guidelines are identified to ensure optimal surgical intervention, addressing the intricacies of CDH surgical repair.
3. Respiratory Care: Guidelines are designed to provide comprehensive respiratory care, addressing the unique challenges associated with CDH patients’ respiratory needs.
4. Nutrition and GI Care: Specific guidelines are outlined to address the nutritional and gastrointestinal care requirements of CDH patients, aiming to optimize their overall health and development.
5. Therapies (Occupational, Feeding, Speech, etc): Comprehensive guidelines are established to encompass various therapeutic aspects, including occupational therapy, feeding therapy, speech therapy, and more, to enhance the well-being and functionality of CDH patients.

CDHi Center of Excellence accreditation, valid for 3 years, is granted based on the following standards:

1. Environmental Focus: Centers provide detailed information about their facilities and the availability of specialized equipment tailored to CDH care.
2. Quality Focus: Centers present evidence of their commitment to continuous quality improvement efforts and adherence to CDHi’s Clinical Care Guidelines, ensuring the provision of high-quality care.
3. Patient & Family Focus: Centers actively engage patients in the treatment process by having them complete The Patient and Member Experience Care Survey, prioritizing patient and family experiences and feedback.
4. Research Participation: Centers actively contribute to advancing knowledge in the field of CDH by enrolling patients into the CDH Study Group and encouraging participation in DHREAMS and the CDH Research Survey.
5. Multidisciplinary Team: Accredited Centers assemble a multidisciplinary team of specialists, including surgeons, respiratory therapists, dietitians, feeding therapists, geneticists, genetic counselors, gastroenterologists, speech therapists, developmental pediatricians, pulmonologists/cardiologists, allergists, and social workers, to provide comprehensive care to CDH patients. Other team members, such as pharmacists, physical therapists, psychologists, chaplains, or patient advocates, among others, may also contribute to the care process.

CDHi Center of Excellence accreditation is a recognition of a Center’s excellence based on the following criteria:

1. Alignment with CDHi’s Mission: Accredited Centers actively promote and align with the mission, activities, and vision of CDHi, demonstrating a shared commitment to the well-being of CDH patients and their families.
2. Patient Care Excellence: Accredited Centers prioritize patient care by implementing the highest quality measures, processes, and structures, based on evidence and adherence to CDHi’s Clinical Care Guidelines. This ensures that patients receive the best possible care, fostering positive outcomes.
3. Training, Education, Collaboration, and Communication: Accredited Centers actively support CDHi guidelines by engaging in training, education, collaboration, and effective communication among staff, patients, and families. These efforts contribute to a healing environment that enhances the overall experience for patients and their families.

The accreditation categories include:

1. Full Accreditation: Centers meeting all the rigorous criteria receive full accreditation, reflecting their exceptional commitment to CDHi’s standards.
2. Provisional Accreditation: Centers with certain requirements yet to be met may be granted provisional accreditation, signaling their progress toward full accreditation.
3. Accreditation with Binding Contingencies: Centers may receive this status, pending immediate action to address specific issues before full accreditation can be granted.
4. Failure to Meet Accreditation: Centers failing to meet the required standards may not receive accreditation.

The core processes to obtain and maintain CDHi Accreditation are as follows:

A. Site Visits: Accreditation Committee members conduct site visits to assess new and existing Centers, typically occurring once every three years. These visits allow for a comprehensive evaluation of the center’s compliance with accreditation criteria.

B. Annual Updates: Established Centers are required to submit annual updates via online renewal applications, ensuring ongoing compliance with accreditation standards and facilitating continuous improvement in care and services.

A. The Accreditation Committee:

The Accreditation Committee comprises representatives from CDHi, which may include employees, volunteers, and members of the Medical Advisory Board. It convenes with the full Medical Advisory Board to determine the accreditation status of a Center.

The Site Visit Process:

During a site visit conducted by a trained CDHi representative, the assessment typically spans one to two days. The Committee conducts a comprehensive evaluation of the Center, taking into account factors such as the clinic environment, personnel, facilities, and various aspects of CDH care.

Meetings with institutional leaders, including the Center director and hospital directors, take place during the visit. The representative completes a chart audit and reviews reports related to education, research, and quality within the Center.

Following the site visit, the CDHi Medical Advisory Board reviews the representative’s findings. Subsequently, any critiques or feedback resulting from the visit are conveyed to the Center via a formal letter, notifying the Center of its accreditation status.

Upon receiving the accreditation status, Centers are required to respond via letter, confirming their acceptance of the accreditation or appealing any denial/loss of accreditation. The Centers are given a designated time frame to provide written responses addressing the Committee’s findings. If, for instance, the Committee informs the Center of potential loss of accreditation, the reasons for this decision are outlined, and the Center may respond with plans for improvement to retain their accreditation.

B. Annual Updates:

Accredited Centers submit Annual Updates every year to ensure compliance with CDHi Clinical Care Guidelines. These reports assess the Center’s strengths, weaknesses, and challenges.

If any issues are identified in an Annual Update, such as changes in provided services, the Center is flagged for an early site visit. However, if no issues are identified, CDHi grants continued accreditation approval for the Center’s existing three-year cycle, ensuring continuity in upholding the highest standards of care for CDH patients.