Accreditation Requirements And Standards Of Accreditation

In 1918, the ACS began implementing their Hospital Standardization Program to inspect hospitals and enforce minimum standards. The initial inspection results were troubling, of 692 hospitals assessed, only 89 met the minimum standards (Chassin & O'Kane). Over the years, the program began to show significant improvement in the quality of care. By 1950, the Hospital Standardization Program accredited over 3,200 facilities across the country. Today, accreditation promotes a continuous cycle of quality improvement, rather than sustaining minimal levels of performance

The third long-term goal of a health care organization like a hospital is remain compliant and achieve and maintain accreditation. This can be achieved through other long and short-term goals. If the short-term goals of self-assessments, education, and implementation of quality improvement processes are put into place, the organization can be successful with their quality management program. Upper-level management will need to address this success and work to ensure that the policies and procedures put into place are maintained.

This paper will propose how TriCity Medical Center will monitor performance, achieve regulatory and accreditation compliance, and improve overall organizational performance. It will describe ways TCMC will communicate with leadership to ensure alignment of organizational goals and gain buy-in from staff to achieve compliance with the standards and requirements issued by regulatory and accreditation bodies. Also it will determine how compliance with the regulations and development of risk- and quality-management systems for the organization contributes to the organization’s overall performance-management system.

Organizations across the board monitor performance in order to be profitable, and make their stakeholders happy, including healthcare organizations. The following paper will address similarities along with differences among three specific healthcare organizations; long-term care, VA hospitals, and community/public health systems. We will also discuss how each organization monitors performances, and how each organization achieves regulatory and accreditation compliance. Communication with leadership in order to align organizational goals, and compliance with regulations and development of risk and quality management systems will also be addressed.

The health restructuring dispute has centered on compensating providers particularly more when delivering quality care to their patients than for enhancing the volume of services they provide (Ries, 2014) Accountable care organizations (ACOs) is a single proposed way of altering compensation methods to accomplish this objective by generating encouragement to enhance care coordination and clinical integration (Thygeson, Frosch, and Carman, 2014).

The Joint Commission accredited Holy Cross hospital and Shady Grove’s, and the scores given based on quality improvement goals/measures in these areas:

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.

When looking at the role of the Joint Commission their mission comes to mind; they state that their mission is to constantly improve health care for the masses, while considering connections with stakeholders, by looking at the health care organizations and compelling them to strive to give safe and effective care of the greatest quality. Though this is their overall mission they update their standards every year (The Joint Commission, 2016). These updates may add a new safety feature or amend a current safety feature or staffing problem or even looking at the sound system in a hospital (The Joint Commission, 2016). The whole role of the commission in giving these accreditations out is to ensure that hospitals are providing the utmost care

The way we practice healthcare and healthcare organizations are changing due to the pressure to reduce costs, improve the quality of care and to meet rigorous guidelines. This change has forced health care professionals to examine we evaluate our overall performance. Paradise Hospital, Inc. has not had any service improvements since 1995. A physician named Avedis Donabedian (2005) proposed a model for assessing health care quality based on structures, processes, and outcomes. He defined structure as the environment in which health care is provided. This is known as the organizational characteristics such as the measurement of staffing ratios and the number of hospital beds. The process is described as the method by which health care is provided. This represents the communication and interaction seen between doctor and patient. The necessity for the tests and procedures performed. The outcome is defined as the consequence of the health care provided, was there a desirable or undesirable effect.

When rethinking the regulatory framework for health insurance in the wider context of a health financing strategy, the Government may also want to reposition the responsibility for accreditation. It is currently done separately by NHIF and NSSF-SHIB programs. This looks like duplication and is the cause of strain on providers. Moreover, MOHSW is also engaged in the implementation of its quality improvement strategy and cooperating in the “certification towards accreditation” program. It is therefore advisable to consider the mandating of accreditation of all health services providers to an independent body (state agency or NGO) and adjusting the NSSF and NHIF Acts and related subsidiary regulations

Glickman, S., Baggett, K., Krubert, C., Peterson. E., & Schulman, K. (2007). Promoting quality: the health-care organization from a management perspective. International Journal for Quality in Health Care.

Quality measures are strategies that gauge, evaluate or compute health care processes, results, discernments, patient insight, and administrative structure. In addition, quality measures are frameworks that are connected with the capacity to deliver first-class health care and/or that are able to identify with one or more quality objectives for medicinal services. These objectives include: compelling, protected, effective, quiet focused, impartial, and opportune consideration. Quality measures can be used to measure quality improvement, public reporting, and pay-for-reporting programs specific for health care providers (CMS.gov, 2016). There are an assortment of quality measures in which health care organizations can use to determine the status of the care they are delivering. Many are appropriate, but few are chosen for this research paper. Among them are: National Health Care Surveys, Hospital IQR Programs, Scorecards, and Political, Power, and Perception/Data for Decision-making tools.

Time and again, hospitals are often called upon to improve the quality of its various health care activities in order to better serve patients and immediate communities. A quality improvement plan thus helps in the selection of high priority areas and the utilization of evidence-based practices in conducting the improvement (Berenguer et al., 2010). In view of the healthcare improvement needs of Sunlight Hospital, this paper seeks to classify and justify five measurements of quality of care in a hospital, specify the four main features in a health care organization that can be used in the design of a quality improvement plan, and suggest the salient reasons quality of care would add value and create a competitive advantage

Quality is one of the most essential elements of healthcare. As stated by the Agency of Health Research and Quality, “Everyday, millions of Americans receive high-quality health care that helps to maintain or restore their health and ability to function” (Agency of Health Research and Quality, 2014). Improvements have become vital to the success of health care organizations and in the Healthcare Quality Book, it is explained that quality in the U.S. healthcare system is not at the standard that it should be (Ransom, Joshi, Nash & Ransom, 2008). Although this has been a reoccurring issue, attempts to fix the insufficiency have been less successful than expected.

Quality is something that every health care agency strives to achieve. The Institute of Medicine (IOM) suggests that health care organizations develop a culture of safety such that an organization's care processes and workforce are focused on improving the reliability and safety of care for patients (Groves, Meisenbach, & Scott-Cawiezell, 2011). In order to address an issue related to health care quality, it is important to look at the frameworks that will analyze an organization and identify opportunities to improve performance. The purpose of this paper is to provide a description of an organization and an analysis of the following: mission, vision and values, strategic plan, goals,