[Source: "Accreditation Policies and Procedures" chapter of 2004 Standards for Ambulatory Care, or 2004 Comprehensive Accreditation Manual for Ambulatory Care.]
Organizational and functional integration refers to the degree to which the component is overseen and managed by the applicant organization.
Organizational integration exists when the applicant organization's governing body, either directly or ultimately, controls budgetary and resource allocation decisions for the component or, where separate corporate entities are involved, there is greater than 50% of the same governing board membership on the board of the applicant organization and on the board of the component.
Functional integration refers to the degree to which the component is overseen and managed by the applicant organization. Functional integration exists when the entity meets at least three of the following eight criteria:
- The applicant organization and the component do the following:
- Use the same process for determining membership of licensed independent practitioners for medical or professional staff
and/or
- Have a common organized medical or professional staff for the applicant organization and the component
- The applicant organization's human resources function hires and assigns staff at the component and has the authority to
- Terminate staff at the entity
- Transfer staff between the applicant organization and the component
- Conduct performance appraisals of the staff who work in the component
- The applicant organization's policies and procedures are applicable to the component with few or no exceptions
- The applicant organization manages significant operations of the component; that is, the component has little or no management authority or autonomy independent of the applicant organization
- The component's patient records are integrated in the applicant organization's patient record system
- The applicant organization applies its performance improvement program to the component and has authority to implement actions intended to improve performance at the component
- The applicant organization bills for services provided by the component under the name of the applicant organization
- The applicant organization and/or the component portrays to the public that the component is part of the organization through the use of common names or logos; references on letterheads, brochures, telephone-book listings, or Web sites; or representations in other published materials
Functional Integration Checklist - Oversight & Management
|
Organizational |
Description |
Check
Yes or No |
|
1. Governance |
Governing body controls budget & resource allocation for component. |
Yes |
No |
|
2. Shared governance |
If separate corporate entities, over 50% of governing body membership is shared. |
Yes |
No |
|
Functional Area |
Description |
Check
Yes or No |
|
1. LIP process |
Unified process for credentialing |
Yes |
No |
|
2. HR |
Organization has hiring/firing/ performance appraisal authority |
Yes |
No |
|
3. P & P |
Common policies & procedures |
Yes |
No |
|
4. Management |
Component is managed by organization |
Yes |
No |
|
5. Patient records |
Integrated patient record system |
Yes |
No |
|
6. PI |
Integrated performance improvement program, with organization authority to implement PI actions at component |
Yes |
No |
|
7. Billing |
Component's services are billed by applicant organization |
Yes |
No |
|
8. Public |
Public portrayal of components as part of parent organization through names or logos, etc. |
Yes |
No |
|
Note: Applicant organization needs minimum of one (1) "Yes" response for Organization Integration; and three (3) "Yes" responses for Functional Integration to include components as "sites" on application.
See "Inclusion Worksheet" in 2004 Request for Survey. |