Joint Compliance Report

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

Health care organizations generally volunteer to seek accreditations from the Joint Commission by allowing expert surveyors evaluate their facility. The surveyors are made up of a multi-disciplinary team that spends an average of two days inspecting health care facilities. The purpose for the inspection is to evaluate a health care facilities standards, staff, regulations, policies and procedures, and quality improvement, and performance measurement. The Joint Commission surveyors generally look to see if the organizations governing board is taking part in ensuring that the facilities has facilitated safety and quality assurance program.

In 2012, the ACA found an excessive amount of readmissions of patients that were hospitalized within 30 days for the same medical conditions. This factor viewed under the ACA as a quality issue and CMS implemented value-based incentive payments based on performance in a set of quality measures. The plan is to implement a pay for performance (P4P) in formulas used by Medicare to reimbursement providers. “The objective is to link reimbursement to quality and efficiency as an incentive to improve the quality of health care, as well as reduce system-wide costs” (Shi and Singh, 2015). In addition to the P4P, nonprofit hospitals also focus on continual improvement, data and cost containment throughout the organization (Adamopoulos,

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 Department of Health and Human Services currently are the seven national accreditation organizations that offer accreditation programs that are recognized for purposes of certifying the compliance of almost 7,000 hospitals, critical access hospitals, ambulatory surgical centers, home health agencies, and hospices with Medicare health and safety standards (Lanham, 2013). These accredited health care facilities as having satisfied the health and safety standards

The Affordable Care Act (ACA) is a federal health reform legislation engineered to provide Americans with high quality, affordable cost and better access to health care [1]. To address these overarching aims, the ACA requires the secretary of the Department of Health and Human Services (HHS) to establish a National Strategy for Quality Improvement in Health Care, also known as the National Quality Strategy (NQS) [2]. The strategy sets three aims. First, to make health care more reliable,

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).

Ransom, E. R., Joshi, M. S., Nash, D. B., & Ransom, S. B. (Eds.). (2008). The healthcare quality

There are many roles of the Joint Commission in accrediting medical facilities. The Joint Commission was founded in 1951 and is the nation’s largest accrediting body in health care. They evaluate nearly 21,000 health care organizations in the Unites States. (The Joint Comm, 2016) Once an organization earns the accreditation they are re-surveyed every three years unannounced. They are responsible for making sure that healthcare facilities are up to date on all standards, policies, and procedures. “Joint Commission accreditation can be earned by many types of health care organizations, including hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services

The Joint Commision (a not-for-profit) is known as a symbol of quality for performance standard in hospitals and organization in the United States. Their purpose is to accredit and certify that nearly 21,000 health care organization are providing safe and effective care. If a hospital or organization chooses to maintain their accreditation they are provided with a manual which includes a list of chapters such as, the environment of care, leadership, provision of care, treatment and services, life safety, and information management. In each chapter, it describes specific standards/requirements that must be met to maintain compliance. The Joint Commission also addresses health record documentation standards and elements that include, legibility,

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 importance of receiving accreditation from the Joint Commission is critical for medical facilities because it represents high standards of quality assurance which

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.

Quality indicators enable the health care system to identify inferior care in both process or outcome and structure while enhancing quality improvement in health care (De Vos et. al, 2009, p.1).

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.