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Accreditations - SETMA's Accreditation, NCQA, AAAHC, TMF Health Quality Institute, URAC and Joint Commission
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NCQA Medical Home

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NCQA ’s Patient-Centered Medical Home (PCMH) 2011 is an innovative program for improving primary care. In a set of standards that describe clear and specific criteria, the program gives practices information about organizing care around patients, working in teams and coordinating and tracking care over time. The NCQA Patient-Centered Medical Home standards strengthen and add to the issues addressed by NCQA’s original program.

The Patient Centered Medical Home is a health care setting that facilitates partnerships between individual patients, and their personal physicians, and when appropriate, the patient’s family. Care is facilitated by registries, information technology, health information exchange and other means to assure that patients get the indicated care when and where they need and want it in a culturally and linguistically appropriate manner.

  • 2010-2013 Tier III Patient-Centered Medical Home
  • 2013-2016 Tier III Patient-Centered Medical Home
  • 2016-2019 Tier III Patient-Centered Medical Home

NCQA Diabetes

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NCQA developed the Diabetes Recognition Program (DRP) to provide clinicians with tools to support the delivery and recognition of consistent high quality care. This voluntary program is designed to recognize clinicians who use evidence-based measures and provide excellent care to their patients with diabetes.

The DRP Program has 11 measures which cover areas such as: HbA1c control, blood Pressure control, LDL control, eye examinations, nephropathy assessment, smoking  and tobacco use and cessation advice or treatment. 

Those who achieve DRP Recognition show their peers, patients and others in the Diabetes community that they are part of an elite group that is publicly recognized for their skill in providing the highest-level diabetes care.

  • 2010-2013 Diabetes
  • 2013-2016 Diabetes
  • 2016-2019 Diabetes

NCQA Heart/Stroke Recognition

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The Heart/Stroke Recognition Program was launched in 2003. This voluntary program is designed to recognize clinicians who use evidence-based measures and provide excellent care to persons with cardiovascular disease (CVD) or who have had a stroke.

The Heart Stroke Recognition Program (HSRP) assesses key quality performance measures that are based on national evidence based guidelines for secondary prevention of cardiovascular disease and stroke. Program measures include:

  • Blood pressure control
  • Complete lipid profile  
  • Cholesterol control
  • Use of aspirin or another antithrombotic  
  • Smoking status and cessation advice or treatment  

HSRP Recognition provides assurance that clinicians are providing high quality, evidenced-based care for their CVD and stroke patients.  

  • 2013-2016 Heart/Stroke
  • 2016-2019 Heart/Stroke

NCQA's New Distinction in Patient Experience Reporting

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NCQA developed the optional Distinction in Patient Experience Reporting to help practices capture patient and family feedback through the newly developed Consumer Assessment of Healthcare Providers and Systems (CAHPS) Patient-Centered Medical Home (PCMH) Survey. Because consumer experience is a critical component of quality of care, giving more prominence to patient engagement is a crucial change to the PCMH program.

The CAHPS PCMH Survey assesses several domains of care:

  • Access
  • Information
  • Communication
  • Coordination of care
  • Comprehensiveness
  • Self-management support and shared decision making.
  • 2014

AAAHC Medical Home

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AAAHC Medical Home Standards focus on: patient rights and responsibilities, organizational governance and administration, the patient/care team relationship, comprehensiveness, continuity, and accessibility of care, clinical records and health information. and quality of care.  AAAHC Medical Home accreditation is the highest achievement for primary care and it centers on a comprehensive review of an entire organization.

AAAHC Medical Home accreditation is a symbol of prestige which practices are truly proud of; a mark of excellence honoring the fact that an organization has adopted best practices and comply with nationally recognized standards of care. For patients, it provides comforting reassurance that they will receive high-quality care when they need it.

  • 2010-2011 Medical Home
  • 2011-2014 Medical Home
  • 2014-2017 Medical Home

AAAHC Ambulatory Care

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SETMA, LLP has achieved accreditation by the Accreditation Association for Ambulatory Health Care (AAAHC). Accreditation distinguishes this multi-specialty practice from many other outpatient facilities by providing the highest quality of care to its patients as determined by an independent, external process of evaluation.

Status as an accredited organization means SETMA, LLP has met nationally recognized standards for the provision of quality health care set by AAAHC. More than 5,000 ambulatory health care organizations across the United States are accredited by AAAHC. Not all ambulatory health care organizations seek accreditation; not all that undergo the rigorous on-site survey process are granted accreditation.

“When you see our certificate of accreditation, you will know that AAAHC, an independent, not-for-profit organization, has closely examined our facility and procedures. It means we as an organization care enough about our patients to strive for the highest level of care possible.”

Ambulatory health care organizations seeking accreditation by AAAHC undergo an extensive self-assessment and on-site survey by AAAHC expert surveyors - physicians, nurses, and administrators who are actively involved in ambulatory health care. The survey is consultative and educational, presenting best practices to help an organization improve its care and services.

  • 2010-2011 Ambulatory Care
  • 2011-2014 Ambulatory care
  • 2014-2017 Ambulatory care

Texas Physician Practice Quality Improvement Award

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The purpose of the award is to formally recognize Texas physician practices for their dedication and commitment to providing high quality patient care and improving outcomes.  The goals of the award program are to: align with statewide quality improvement efforts of TMF Health Quality Institute, Texas Medical Association and Texas Osteopathic Medical Association; improve quality of care for patients through reliable delivery of preventive services and maximized use of health information technology; and recognize high performing physician practices for their quality improvement work.

The Texas Physician Practice Quality Improvement Award program is based on four major components: adoption of health information technology; regular use of population care management methods; participation in data reporting quality initiatives; and top performance on nationally recognized clinical outcomes measures

  • 2012
  • 2013
  • 2014

URAC

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PC-MH with EMR Distinction

OUR MISSION is to promote continuous improvement in the quality and efficiency of healthcare management through processes of accreditation, education, and measurement.

URAC, an independent, nonprofit organization, is a well-known leader in promoting healthcare quality through its accreditation, education, and measurement programs. URAC offers a wide range of quality benchmarking programs and services that model the rapid changes in the healthcare system and provide a symbol of excellence for organizations to validate their commitment to quality and accountability. Through its broad-based governance structure and an inclusive standards development process, URAC ensures that all stakeholders are represented in establishing meaningful quality measures for the entire healthcare industry.

  • 2014-2017

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 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.

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PC-MH

The Joint Commission's Primary Care Medical Home (PCMH) Certification focuses on care coordination, access to care, and how effectively a primary care clinician and interdisciplinary team work in partnership with the patient (and when applicable, their family). The Joint Commission introduced PCMH Certification for accredited ambulatory care organizations in 2011, for accredited hospitals and critical access hospitals in 2013, and in 2014 a Behavioral Health Home (BHH) Certification option for organizations accredited under the behavioral health care program.

For Complete Facts

  • 2014-2017

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Ambulatory Care

The Joint Commission's Ambulatory Care Accreditation Program was established in 1975, and today more than 2,100 freestanding ambulatory care organizations are Joint Commission-accredited. These organizations generally fall into the broad categories of surgical, medical/dental, diagnostic/therapeutic services, and episodic care, and represent a variety of settings.

For Complete Facts

  • 2014-2017

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Laboratory Accredited

The Joint Commission has been evaluating and accrediting hospital laboratory services since 1979 and freestanding laboratories since 1995. Today, The Joint Commission accredits about 1,500 organizations providing laboratory services. These organizations represent almost 2,000 laboratories with Clinical Laboratory Improvement Amendment (CLIA) certification.

For Complete Facts

  • 2014-2016
  • 2016-2018

SETMA I
2929 Calder
SETMA II
3570 College
Mark A. Wilson Clinic
2010 Dowlen
Nederland
2400 Highway 365
Orange
610 Strickland Drive
Lumberton
137 N LHS Drive

409-833-9797 888-833-0523

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