Joint Commission Essay

Preparing for The Joint Commission, Nightingale Community Hospital reviews areas of compliance and non-compliance. A periodic performance review, which is a self-evaluation, is utilized by Nightingale Community Hospital, to prepare for The Joint Commission. The Joint Commission has eighteen accreditation requirements. (Commission, 2013) The periodic performance review found the hospital to be compliant and non- compliant in the following areas:

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

I chose the monopolistically structured JCAHO (Joint Commission on Accreditation of Healthcare Organizations). They are the only organization that determines whether hospitals or medical facilities are up to their standards enough to receive reimbursement from Medicare and Medicaid. “The Joint Commission is a monopoly because it has unique statutory protection in the USA and collects $113 million in annual revenue; it is the only organization in the USA of this nature” (Joint Commission Requirements, 2009). This revenue is mainly from the fees it charges US hospitals for evaluating their compliance with federal regulations.

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.

The Joint Commission is an agency that maintains partnership with the government to help improve the standards of health care within the United States. The Joint Commission accredits health care organizations and health care programs by setting standards to help improve the quality and safety of health care. The Joint Commission work closely and collaborates with government officials and legislation by ensuring health care organizations in the United

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.

However, the organizations achieve regulatory and accreditation compliance of each organization will help each organization by making sure that they are in compliance with up to date information and laws to better serve the patients and staff. For instance it will offer different services like Awareness, Education and Organization, which helps to create the awareness, obtain executive management commitments. It will also offer Assessment and Risk Analysis, Training, documentation and ongoing monitoring. By making sure each employee receive the necessary classes and training they will be successful in achieving the organizational performance in which is set by the organizational team. By improving the overall organizational performance different things can be done from appraising and rewarding the necessary employees that do go over and beyond for the organization. Also, by making sure everyone is doing the necessary jobs in which need to be done by following the plan in which is set regarding the organizations.

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.

Since it’s founding in 1951, The Joint Commission has set standards and completed evaluations and accreditations for over 20,000 health facilities. Though not a government agency,The Joint Commission has a great level of authority in the field of healthcare and approval from the organization is often required by local health departments and CMS. Receiving the Commission’s seal of approval also goes a long way with potential clients familiar with the high standard of

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).

Both the DNV and Joint Commission are organizations that conduct inspections and accreditations. Accreditations have an impact on the way hospitals operate only because a hospital makes critical decisions of how it treats diseases, assigns clinical staffing and stores its medications.

The Joint Commission was founded in 1951 with the goal to provided safer and better care to all. Since that day it has become acknowledged as the leader in developing the highest standards for quality

In any continuous quality improvement effort, measurement is the key element (Sollecito, & Johnson, 2013). “Measurement and statistical analysis are used to assess the impact of an improvement effort” (Sollecito & Johnson, 2013). To Measure the impact of the program, the hospital utilized a departmental quality improvement assessment with a scoring matrix for self-assessment (McLaughlin, et. al., 2012). The scoring matrix consisted of five category ratings which each department head had to complete. Univer4sal Charting and Resource Utilization were also used for measurement (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.

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.