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Hospital Accreditation

Coming in 2018

• Coming Summer, 2018

• Coming Summer, 2018

• Coming Summer, 2018

CDHi accreditation signals to patients and families a commitment to exceptional care in the treatment of Congenital Diaphragmatic Hernia. It demonstrates to the healthcare community an assurance of high quality standards, specialized equipment, and advanced education of staff members. CDHi Centers may, in turn, use the accreditation to market themselves as distinguished leaders in CDH care highlighting their commitment to state of the art of healthcare.


To ensure that people with CDH continue to experience gains in quality of treatment and quality of life, CDHi helps its accredited centers establish a standard of CDH care with specific guidelines that are based on the latest research, medical evidence, and consultation with experts.


Clinical Care Guidelines are identified for the following categories:

  1. Diagnosis
  2. Surgical Repair
  3. Respiratory Care
  4. Nutrition and GI Care
  5. Therapies (Occupational, Feeding, Speech, etc)


The accreditation, which is valid for 3 years, is evaluated on the following sections:


  1. Environmental Focus – the Center provides information about the facility and equipment available for CDH
  2. Quality Focus – the Center provides evidence regarding continuous quality improvement activities and adherence to CDHi Clinical Care Guidelines
  3. Patient & Family Focus – the Center has patients complete The Patient and Member Experience Care Survey
  4. Enrollment of patients into the CDH Study Group
  5. Encourage participation in DHREAMS and the CDH Research Survey.
    A multidisciplinary team – such as a surgeon, respiratory therapist, dietitian, feeding therapist, geneticist, genetic counselor, gastroenterologist, speech therapist, developmental pediatrician, pulmonologist/cardiologist, allergist, social worker. Other team members can include a pharmacist, physical therapist, psychologist, chaplain, a patient advocate, etc.

CDHi accreditation recognizes CDH Care Centers’ excellence in the following criteria:


  1. Promoting the mission, activities, and vision of CDHi
  2. Patient care by using the highest quality measures, processes, and structures based upon evidence and meeting CDHi Clinical Care Guidelines
  3. Training, education, collaboration, and communication supporting CDHi guidelines that contributes to a healing environment for families, patients and staff.


Accreditation categories include:


  1. Full Accreditation
  2. Provisional Accreditation
  3. Accreditation with binding contingencies (pending immediate action)
  4. Failure to meet Accreditation


There are two core processes to Accreditation which occur twice per calendar year. They are:


A. Site visits made by committee members to the candidate Center


B. Annual updates submitted by the established Centers via online renewal applications


A. Accreditation Committee


The Accreditation Committee is comprised of CDHi representatives and may include CDHi employees, volunteers, and members of the Medical Advisory Board. The Accreditation Committee meets with the full Medical Advisory Board to determine accreditation status.


The Site Visit Process


When a CDH Care Center is visited by a trained representative of CDHi, the in-person visit will typically last a day or day and a half during which the Committee does a comprehensive assessment of the center. They look at the clinic, the personnel, the facilities, and key disciplines of CDH care.


During this meeting, the representative will meet with institutional leaders (aka the CDH Clinic director, the hospital directors, etc.). They do a chart audit, hear reports about teaching, research, and quality.


Upon completion, the representative will convene with the Medial Advisory Board to review their findings. Once a decision is made, critiques based on the site visit are written down and are sent in letter form back to the CDH Care Center, at which time the CDH Care Center is notified of their accreditation status.


After revealing the accreditation status of each center, the Committee requests a response from the CDH Center. CDH Centers are given a short amount of time to respond via letter regarding the Committee’s findings. (aka, if the Committee states the Care Center is losing their accreditation, the Committee lists in the letter why the Care Center is losing their accreditation. The Care Center then has some time to write a letter back to the Committee stating their challenges and how the Committee can expect the CDH Care Center to respond.


B. Annual Updates


Since not all CDH Care Centers are visited yearly, there is an important aspect of accreditation that continues. Annual Updates are progress reports from the CDH Care Center to CDHi submitted each year. Questions are asked regarding the CDH Care Center’s strengths, weaknesses, and challenges.


If CDHi identifies a problem with one of these annual updates, such as a change to the services provided previously, the institution will be flagged for an early site visit. If there are no problems, CDHi will continue accreditation approval for their existing 3-year cycle


Anticipated outcomes of CDHi accreditation


  1. Patients are better informed about comprehensive CDH care
  2. Patients have improved access to Centers with expertise in CDH
  3. The medical community better informed about standards of CDH care
  4. Long term outcomes are improved through Clinical Care Guidelines
  5. Increased opportunities for collaboration between Centers and CDH researchers


The benefits of CDHi accreditation


  1. Accountability – patients, parents and insurance company are ensured that standards are met
  2. Ideas for improvement – host centers and site visitors benefit from visits to other CDH Care Centers
  3. Securing resources from institution – when a CDH Care Center must meet requirements set forth by the accreditation process, this engages the institution to support the CDH Care Center in meeting these requirements for fear that otherwise, the CDH Care Center will no longer be accredited (something that the host institution such as University or hospital would not want to see as the CDH Care Center attracts new patients to its facilities)
  4. Public recognition of excellent performers – CDH Care Centers can be the pride and joy for awards at their institutions. They can be a model for all other Centers
  5. CDH Care Centers are eligible to apply for research funding through CDH International
  6. CDH Care Centers are more attractive to research funders such as NIH or private foundations
  7. CDH Care Centers are easily identifiable and more attractive to expectant parents researching medical care for unborn patients

Hospital accreditation applications will become available on January 1, 2018.