Joint Commission on Accredidation of Healthcare Organizations

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

The Joint Commission focuses on certain goals each year. For patient safety and positive outcomes, hospitals are required to follow certain standards. National Patient Safety Goals were established in 2002 to help identify areas of concern with patient safety. This group is made up by a panel of experts including nurses, doctors, pharmacists and many other healthcare professionals. They advise the Joint Commission on how to address these different patient safety issues. Two goals to be discussed are improving the accuracy of patient identification and medication safety. To improve patient

"To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (Jointcommission.org, 2015). These requirements are regimented in the National Patient Safety Goals and are enforced via surveys and internal inspections to ensure that healthcare institutions abide by the safety mechanisms put in place to facilitate the optimal patient outcomes and environments.

The NSF and NICE create a means by which NHS trusts ensure the provision of quality standards by making NHS employees accountable for setting, maintaining and monitoring standards of care (DoH 1997). The National Institute for clinical excellence was founded in 1999 and consists of a number of specialized organisations: the NHS centre for reviews and dissemination, national prescribing agency, medical devices agency and institutes of public health. All aimed at creating and maintaining national standards through effective management and cost effectiveness, through audits and reviews of health policies. The commission for health improvement (CHI) aims to monitor the delivery of these standards provided by NICE and NSF through national surveys of the patients experience (Freedom D, 2002). This commission (CHI) sets out to review all NHS trusts including community care. Each NHS trust will be visited over three to four years and be reviewed to decide whether or not national standards are being met and NICE guidelines are being adhered to.

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

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.

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.

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).

The National Patient Safety Goals were first developed in 2002 by the Joint Commission. The goals are established to help guide medical organizations to focus on which areas of patient safety need improving (Hudson 2016). The first set of goals were released and put in motion in 2003, prior to 2003 there were no policies or goals for an organization to set their sights on (Hudson 2016 page 2). A panel of experts advises the Joint Commission on the development of new goals or the updating of old ones. The panel is called the Patient Safety Advisory Group and is made up of nurses, risk managers, clinical engineers, and physicians (Hudson 2016). The National Patient Safety Goals have specific goals geared toward the type of medical organizations such as a critical access hospital, home care, behavioral health, and long term care services to name a few (Hudson 2016 page 2). The National Patient Safety Goals help protect patients and make sure providers are practicing safely across the board.

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.

5. The Patient Safety Officer will train the risk assessment team members on the proactive risk assessment process and how to conduct a proactive risk assessment, including the assessment of risk, itself.

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