Assess The Planning For Accreditation

1. The Joint Commission and the Agency for Healthcare Research and Quality developed standards and recommendations for healthcare organizations to employ in an effort to reduce the number of errors. In a few sentences, please discuss one recommendation.

NHS quality improvement programs main purpose is to collect and review data entered in order to recognize the opportunities to improve business operations in healthcare. To bring changes in quality, it is necessary to respond to patient’s ideas and implement them for the better results. The key issues that are to be considered for quality-improvement NHS program, as it moves forward are the needs for the patients, necessity of the funds for quality improvements, needs of the service providers and expectations of the community. Outcomes for people and also change expertise. And to improve business operations in healthcare and also recognize opportunities.

The "Duke University Medical Center" (2005) website defines “quality improvement as a formal approach to the analysis of performance and systematic efforts for improvement”. Quality improvement programs are found in a variety of industries and are constructed differently. The medical field tends to use quality management to focus on patient and staff safety, reducing medical errors, and avoiding or decreasing morbidity and mortality rates. Health care organizations have been attempting to improve the quality of care for as long as “the nineteenth-century when obstetrician, Ignaz Semmelweis introduced hand washing to medical care, and Florence Nightingale who determined

McLaughlin, C.P., & Kaluzny, A.D. (2006). Continuous Quality Improvement in Health Care, Third Edition, Jones & Bartlett Publishers, Sudbury, MA.

The surveys are meant to be specific and consistent and are not just used to evaluate the organizations for improvement but are also to educate in the best practice standards adopted throughout health care and to help staff in ways to continually improve an organizations performance. For this purpose, in 1996 the Quality Check website was launched to help the Joint Commission provide information regarding the performance of accredited organizations to consumers and organizations. Users are able to search for accredited or certified organizations; they can locate organizations by either type of service or geographical area and lists of certified organizations as well as a hospital’s performance measures can be obtained.

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

Quality management is essential to the success of the quality improvement of the health care industry. “Management uses management and planning tools to organize the decision making process and create a hierarchy when faced with competing priorities “( Ransom, et al., 2008). Quality measures should have these goals: effective, safe, efficient, patient-centered, equitable, and timely care (Quality Measures, Center for Medicare & Medicaid Services, 2011).

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.

The issue of quality improvement should be addressed with a multi-faceted approach. Once implemented, continuous oversight and monitoring must be conducted by an experienced staff member/case manager who can verify data in the EHR, as well as conduct a daily Braden Score assessment and confer with the staff nurse and physician, as needed. While HAPU/Braden

al., 2012). Trying to get the leadership motivated with adapting to TQM was a challenge in the beginning. The enthusiasm of top leaders has caused the TQM process to become effective. Although Health care has a complex adaptive system, leadership is crucial in implementing an improvement system (Sollecito & Johnson, 2013). The strengths of the TQM process were the support of the chamber of commerce, implementation of a quality improvement plan, adapting a successful way to measure improvement and development of cost effective techniques (McLaughlin, et. al., 2012). Corporate headquarters was totally involved in the TQM program with the CEO John Kausch as an active member of the Total Quality Council of the Pensacola, Area Chamber of Commerce (McLaughlin, et. al., 2012)

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.

Why would a world-renowned organization, Mayo Clinic, already know for quality embark on a quality improvement journey?

Examining planning for and effectively measuring the health care quality indicators make healthcare quality more transparent and provide information for quality improvement programs and initiatives in the healthcare system.

A quantitative study conducted by Lifvergren, Gremyr, Hellstrom, Chakhunashvili, and Bergman (2010) analyzed the experiences and from a hospital group during a three-year period after the introduction of Six Sigma. It reports on 22 large Six Sigma improvement projects, their results and influence on other improvement activities. The study shows that 75% of the completed projects reached their goals within 18 months. The average net cost savings per completed project/year was $55,300. Overall, the results showed that Six Sigma is a useful concept when trying to improve healthcare processes. They recommend that Six Sigma should be an addition to the improvement practices used in healthcare development initiatives. It was also observed that the Six Sigma program can create much organizational pull regarding quality management and improvement efforts if teamwork is applied.

The Institute of Medicine (IOM) Committee to Design a Strategy for Quality Review and Assurance in Medicare defines quality of care to be “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Ransom, Joshi, Nash & Ransom, 2008). Making sure to have current knowledge on healthcare services is crucial to the quality of care provided, and health care professionals are expected to continuously stay updated on the changing trends. The IOM later released six aims for improvement, or also known as the six dimensions of quality, which are safe, effective, efficient, timely, patient-centered, and equitable.