Accreditation Process : A New Concept

Eventually, the minimum standards evolved and began to encompass physical safety, equipment and administrative standards. Survey teams started to branch out across the nation in an attempt to keep up with the increased demand for accreditation. As a result, the American College of Physicians, the AMA, and the Canadian Medical Association joined the ACS to form an independent, not-for-profit organization, The Joint Commission on Accreditation of Hospitals in

The administrators Each person in charge of any program that has anything to do with nursing has an effect on the evaluation process. They must be confident that the quality and consistency of nursing is being met when they graduate students (accreditation) or hire. They must know that the programs are meeting state and Federal requirements and must continually lobby for funding to keep the flow of professional nurses coming as needed.

Healthcare is in a constant state of change with movements that impact rates, access and quality of care. Hospitals have become more competitive due to the rising cost of care delivery and the reduction in reimbursement from payers. This causes difficulty in delivering quality care to all patients, which is being measured by mandated patient perception surveys, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS scores are part of value

Credentialing from advanced practice registered nurses (APRNs) perspective is defined as “furnishing the documentation necessary to be authorized by a regulatory body or institution to engage in certain activities and use a certain title” (Hanson, 2014). Credentialing is also define from a local institutional process that consider specific documentations for APRN before they assume the practice role as APRN within their facility. In health care system, credentialing ensures individuals meet required standards of practice and is prepared to perform those duties implied by the credentials. National certification and education are considered as part of credentialing for APRN to acquire basic level of competence to practice. (Hanson, 2014)

In 2008 the Alliance for Advanced Practice Credentialing and the National Council of State Board of Nursing published specific masters educational, accreditation, licensure, credentialing, certification processes. The masters educational, accreditation, licensure, credentialing, certifications are based on a set of values steps to practice will ensure that NPs have the skills training to place themselves to serve an fundamental role in national health care reform (Graduate NursingEDU,

This paper will describe current quality outcome measures and the significance for improving medical care. Organizational accountability and transparency has improved with the emergence of Hospital Inpatient Quality Reporting (IQR) programs and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs). This article will review the role of the nurse manager in creating a culture for quality care as well as the nurse for meeting organizational and patient expectations. Organizations like The Joint Commission (JC), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare and Medicaid Services (CMS), and The American Nurses Association (ANA) have been critical in establishing standards for quality. This paper will also report on the most recent hospital statistics and steps taken to improve HCAHP scores and reduce readmission rates at the University of Tennessee Medical Center in Knoxville (UTMCK). Statistics at UTMCK will also be compared to the Tennessee and National averages found on the Medicare website Hospital Compare. The aim of this paper is to explore if healthcare system initiatives are improving quality and enhancing patient outcomes.

The Joint Commission defines the Periodic Performance Review as an assessment tool created to assist health organizations improve and monitor their performance throughout the year. This tool focuses on the processes that influence patient care and safety while providing the structure for unremitting standards fulfillment. Nightingale Community Hospital is compliant with most standards as set forth by the Joint Commission. However, upon inspection and in an effort to stay focused on compliance, our standards committee has located a few discrepancies that must be resolved to maintain our accreditation with the Joint Commission.

In order for a hospital to be eligible for reimbursement through Medicare, they have to show that they are compliant by way of the Conditions of Participation. One way to show this is by getting an accreditation through The Joint Commission who meets the Medicare Condition of Participation standards. (La Tour, 2013).

With all of the possible problems that could occur during surgery, a wrong-site, wrong-patient mistake is one that should never arise. Nightingale Community Hospital (NCH) fully understands the importance of doing away with these errors and has set up protocol to work towards this goal. While the protocol is in place, it is not fully compliant with Joint Commission (JC) standards.

procedure site; 3. A time-out is performed before the procedure. Each of these areas are critical in preventing wrong-site, wrong-procedure events from happening. The Universal Protocol sets a standard for hospitals by outlining specific principles and strategies, while encouraging teamwork and consistency among all hospital staff.

The roots of The Joint Commission began in the American College of Surgeons (ACS), founded in 1913, which eventually lead to voluntary onsite inspections of hospitals in 1918. In 1951, The American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association joined forces with the ACS to create the Joint Commission on Accreditation of Hospitals (JCAH). JCAH was formed as an independent, not-for-profit organization whose primary purpose was to provide voluntary accreditation for meeting established minimum quality standards. It was not until 1970 that the standards of quality were reformed to represent the highest achievable levels, instead of minimum necessary levels. In 1987, the company was renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which was shortened to today’s The Joint Commission after rebranding in 2007. (Stanberry, 2012)

Accreditation provides a competitive advantage in the health care industry and strengthens community confidence in safety of care and treatment. Accredited hospitals provide higher quality of care to patients. It improves risk management and risk reduction and helps in organizing and strengthens patient safety efforts. It enhances recruitment and staff education and provides education on god practices to improve healthcare operations. The paper discusses how The Joint Commission assists in having better outcomes in terms of safety in Western Medical Center Hospital. In today’s society, every health care organization should provide a proof of accreditation and are subject to a three-year accreditation cycle. The Commission develops performance standards that address some of the important elements of operation, such as patient care, infection control, medication safety, and patient rights.

The Joint Commission is a nonprofit organization that certifies more than 18,000 health care organization and programs throughout the world. Founded in 1951, the Joint Commission provides a national symbol of quality for health care as well as analyzes each organization’s commitment to meeting high quality performance standards. The Joint commission focuses on accrediting Acute Care Hospitals, ambulatory, behavior health, long term care, health care facilities, clinical laboratories, health care networks and hospice. Numerous of accreditation organization is also taking place within the United States, but the Joint commission remains the largest The Joint commission accredits 20,000 organization” which” one third are Hospitals.

At present, the accreditation is a process of review that health care organizations participate in to display the ability to meet approved criteria and standards of accreditation. Accreditation represents agencies as credible and reputable organizations dedicated to ongoing and continuous compliance with the highest standard of quality. Professional accrediting agency work together with the health care industry experts to create standards to ensure that quality is maintained throughout all aspects of an organization (Accreditation Commission for Health Care, 2008; Greenfield, Pawsey & Braithwaite, 2010). However, the on-site surveys are conducted, today unannounced, by health care industry experts. A inclusive review is conducted of organizational structure, policies and procedures, compliance with federal, state, and local laws, leadership, patients’ rights and responsibilities, fiscal operations, human resource management, provision of

Two types of data were collected through surveys, both before and after implementation of the combined approach (Sand-Jecklin and Sherman,2014). The first data was on nurses’ point of view with regards reporting process, and the second on patients view regrading nursing care. The baseline survey included 233 patients and 148 nurses, while the survey three months into the implementation period included 157 patients and 98 nurses. The final survey, 13 months into the impanation, was completed by 154 patients and 54 nurses. The patient survey also included responses from patient families. These were 70, 72, and 53 responses for baseline survey, three-month postimplementation surveys, and 13-month postimplementation surveys.