Memorial Herman Northeast Summary

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.

Through medical advances in technology and practice, nurses have been afforded the opportunity to provide lifesaving care to patients. However, this lifesaving care comes with the risk of healthcare-associated infections (HAIs). Generally speaking, HAIs are infections directly related with the delivery of healthcare and are often caused by viral, bacterial or

This paper will describe current quality outcome measures and the significance for improving medical care. Organizational accountability and transparency has improved with the emergence of Hospital Inpatient Quality Reporting (IQR) programs and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPs). This article will review the role of the nurse manager in creating a culture for quality care as well as the nurse for meeting organizational and patient expectations. Organizations like The Joint Commission (JC), Agency for Healthcare Research and Quality (AHRQ), Centers for Medicare and Medicaid Services (CMS), and The American Nurses Association (ANA) have been critical in establishing standards for quality. This paper will also report on the most recent hospital statistics and steps taken to improve HCAHP scores and reduce readmission rates at the University of Tennessee Medical Center in Knoxville (UTMCK). Statistics at UTMCK will also be compared to the Tennessee and National averages found on the Medicare website Hospital Compare. The aim of this paper is to explore if healthcare system initiatives are improving quality and enhancing patient outcomes.

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.

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.

Although the accreditation can be required for insurance in some states, it is not the only non-profit organization that supplies accreditation to health facilities (Alkhenizan, 2011). Other options include the Commission on Accreditation of Rehabilitation Facilities, American Osteopathic Association, Accreditation Commission for Health Care Inc, and many others (Alkhenizan, 2011). The standards the accredited hospitals are held to are public knowledge. On their website, the have all of the things that they look for when they go to inspect the facilities and laboratories. This means that any hospital that is not accredited can look online and be proactive in taking their advice (The Joint Commission, 2016). For example, the Commission stated the record standards and said that whether a hospital is accredited or not and whether they have paper files or computer files, great care must be taken when keeping a standard in the record and when switching from written to typed records (Showalter, 2012). So, even though some hospitals are not accredited they can still enact the Commission's standards and take it upon themselves to be proactive about patient safety. The Joint Commission set the standard for care even when not accredited it pushes other facilities to be better in order to

The Joint Commission is an independent not for profit group that provides as the accreditation issuer within the United States. “…The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States” (Commission, 2017). Its purpose is to develop performance standards for accreditation programs that hospitals and other healthcare related organizations are required to pass to receive accreditation from the Joint Commission. These specifications are affirmed upon addressing vital elements of the daily operation that involve patient care, medication safety, infection control, and patient's rights. The importance

Hospital- acquired infections is also another concern for patients. The common health-acquired infections include surgical site infections, ventilator – associated pneumonia, catheter-associated urinary tract infections, blood stream and bacterial infections. Annually, these types of infections cost the U.S. about $9.8 billion. Topping the list for the most costly burden are surgical-site infections.

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.

As a hospital, quality care should be a priority for patients that are going to be treated for a sickness, or any type of procedure that is going to take place. A lot of times a patient gets an infection while they were at the hospital, on top of being treated for what they original came in for. Health facilities should be environments of healing, which they are, but they also have tons of various types of germs and infections, which grasp onto individuals that have weak immune systems/are sick. Some infections that are at hospitals are Tuberculosis, VRE, VAP, C-Diff, UTI, and MRSA. Preventive measures to stop the spread of the infections is lacking tremendously in the work and aim to provide safety for all patient’s health. The work

Hospital acquired infections are one of the most common complications of care in the hospital setting. Hospital acquired infections are infections that patients acquired during the stay in the hospital. These infections can cause an increase number of days the patients stay in the hospital. Hospital acquired infections makes the patients worse or even causes death. “In the USA alone, hospital acquired infections cause about 1.7 million infections and 99,000 deaths per year”(secondary).

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