Southeast Texas Medical Associates, LLP (SETMA) holds accreditation for ambulatory care and patient-centered medical home from the National Committed for Quality Assurance (NCQA), Accreditation Association for Ambulatory Health Care (AAAHC), URAC (formerly known as Utilization Review Accreditation Committee) and The Joint Commission on Accreditation of Healthcare Organizations.  SETMA’s Clinical Laboratory is also accredited by The Joint Commission.  (Displayed at: Providers List by Office with Accreditations).  The following is an example:

The accreditations are listed in order of SETMA’s having applied for and having achieved accreditation by each organization.  As of January, 2015, The Joint Commission has certified 136 practices in the United States and 13 practices in Texas for Ambulatory Care and Patient-Centered Medical Home.  Most healthcare providers and organizations know The Joint Commission through hospitals.  For over fifty years, The Joint Commission accreditation was required in order for hospitals and other organizations to be able to bill Medicare for the services they perform.    For the past 64 years, The Joint Commission has earned a reputation for being rigorous and demanding in its accreditation standards.

Patient-Centered Medical Home and Ambulatory Care Accreditation

The Joint Commission Standards and Requirements for Medical Home Accreditation (2013) consists of 18 chapters covering topics such as Environment of Care, Emergency Management, Human Resources, Infectious Prevention and Control, Information Management, Leadership, Life Safety Medication Management, National Patient Safety Goals, Provision of Care, Treatment and Servci3s, Performance and Improvement, Record of Care, Treatment and Services, and Rights and Responsibilities of the Individual.  Also, if a practice operates a Clinical Laboratory as part of the practice, as does SETMA, that laboratory must also be accredited every two years by The Joint Commission.  The major focus of The Joint Commission’s accreditation and certification is to promote and to evaluate quality and safety in the practice.  The Joint Commission surveyors often boast, “If you’re doing something wrong, we will find it.”

Since the advent of Patient-Centered Medical Home, The Joint Commission has begun accrediting medical practices for Ambulatory Care and for PC-MH.  Completion of The Joint Commission accreditation process gives the impression to the public that a facility has successfully implemented and guaranteed quality control standards. A facility which has completed the The Joint Commission accreditation process can then include the The Joint Commission logo and accreditation information in their company literature.

To achieve accreditation for Ambulatory and PC-MH from The Joint Commission, SETMA had to meet 1200 individual standards and measures.  In addition, during the three-year term of that accreditation, SETMA must have a plan in place to continually meet all of the standards.  After the first 18 months of accreditation, The Joint Commission may, without advance notice, visit the practice and examine the practice’s performance on any of the 18 chapters.  Therefore, SETMA’s Accreditation Team and staff have a plan for periodic reviews of SETMA’s performance particularly on the most difficult and mission critical standards.

After SETMA’s The Joint Commission survey, SETMA had thirteen measures of the 1200 which required partial correction in 45 or 60 days.  Some of those deficiencies were multiples of the same measure such as three laryngoscopes needing a second, fresh battery.  Each of those deficiencies was quickly corrected and remains so.

The Joint Commission’s Conclusion about SETMA

Both the surveyors and one of the executives at The Joint Commission commented about the philosophical foundation of SETMA’s work.  On Wednesday afternoon (March 5, 2014) one of SETMA’s executive contacts at The Joint Commission said, “I was just talking to one of my colleagues and showing him SETMA’s notebook which was prepared in response to The Joint Commission’s Standards and Requirements Chapter Seven on leadership.”  He added, “Look at this; everything they do is founded upon a philosophical foundation.  They know ‘what they are doing,’ but more importantly, they know why they are doing it.’”  SETMA is not the result of random efforts but of innovations and advances which are consistent with a structured set of ideals, principles and goals. 

It was helpful that The Joint Commission recognized this and commented on the philosophical foundation of our growth and development.  It is one of the strengths of SETMA and it is one of the principle guides to SETMA’s development history, i.e., what caused SETMA to become what it is.

Robert Wood Johnson Foundation LEAP Study conducted by the MacColl Institute

SETMA is participating in a research project with the RWJF conducted by the MacColl Institute in Seattle, Washington.  After a four day site visit to SETMA the team identified five areas of strengths observed at SETMA.  The fifth area of uniqueness identified was a surprise to them; it was SETMA’s IT Department.  The team felt that SETMA has approached healthcare transformation differently than anyone they had previously seen.  They related that uniqueness to the decision we made in 1999 to morph from the pursuit of “electronic patient records” to the pursuit of “electronic patient management.”  They were surprised to see how centrally and essentially electronics are positioned in SETMA and how all other things are driven by the power of electronics.  They marveled at the wedding of the technology of IT with clinical excellence and knowledge.  SETMA’s communication and integration of the healthcare team through the power of IT is novel, they concluded.  This is consistent with The Joint Commission’s judgment of SETMA and forms the dichotomy of philosophy and electronics which defines who SETMA is.

General Information about The Joint Commission

The Joint Commission is an organization made up of individuals from the private medical sector to develop and maintain standards of quality in medical facilities in the United States. The Joint Commission has no official connection to United States government regulatory agencies, and has no legal enforcement power; however, since many medical facilities rely on The Joint Commission accreditation procedures to indicate to the public that their particular institution meets quality standards, The Joint Commission and its policies has taken on a real importance in the medical field, despite the lack of official government sanction.

• The Mission of The Joint Commission Mission:  To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.
• The Vision of The Joint Commission: All people always experience the safest, highest quality, best-value health care across all settings.

Founded in 1951, The Joint Commission evaluates and accredits more than 20,500 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. To earn and maintain The Joint Commission’s Gold Seal of Approval„¢, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (Laboratories must be surveyed every two years.) 

The Joint Commission publishes a large body of literature designed to improve the quality of health services, and which can aid in the accreditation process for a health care facility. Although it is not necessary for any given health care organization to apply for, or complete, The Joint Commission accreditation process, to do business in the United States or elsewhere, the successful completion of The Joint Commission accreditation process gives the impression to the public that a facility has successfully implemented guaranteed quality control standards. A facility which has completed The Joint Commission accreditation process can then include The Joint Commission logo and accreditation information in their company literature.