Regulation And Accreditation Strategies Paper

"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.

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.

The main objective of healthcare professionals is to provide the best quality of patient care and the highest level of patient safety. To achieve that objective, there are many organizations that help improve the quality of care. One of the best examples is the Joint Commission. Unfortunately, the healthcare system is not free from total risks. In healthcare activities, there are possible errors, mistakes, near miss and adverse events. All of those negative events are preventable. But, it is clear that errors caused in healthcare result in thousands of deaths in the United States.

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.

The Joint Commission. (2015, June 3). Accreditation Requirements. Retrieved from The Joint Commission E-edition: http://e-dition.jcrinc.com/MainContent

JCAHO (Joint Commission on Accreditation of Healthcare Organizations) Joint Commission Standards. 2000. Retrieved from www.jcaho.org/standard/jcstandards.html

Regulation placed upon the healthcare system only seek to improve safety and security of the patients we care for. The enactment of the Health Insurance Portability and Accountability Act (HIPPA) and the enactment of Meaningful Use Act the United States government has set strict regulations on the security of health information and has allotted for stricter penalties for non-compliance. The advancement of electronic health record (EHR) systems has brought greater fluidity and compliance with healthcare but has also brought greater security risk of protected information. In order to ensure compliance with government standards organizations must adapt

Legislations and regulations are essential to have and follow in the working environment, it ensures safe practice for the workers and safety, protection and stability to people that are in their care.

"With Joint Commission certification, we are making a significant investment in quality on a day-to-day basis from the top down. Joint Commission accreditation provides us a framework to take our organization to the next level and helps create a culture of excellence,” said Winnie Cullens, Accreditation Coordinator. “This is our fourth Joint Commission certification for our organization, and it shows that we are committed to maintaining excellence and continually improving the care we provide.”

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

department has a Deputy Commissioner who has to report to the Commissioner of the FDA.

Accreditation is the formal declaration by a designated authority that an organization, service, or individual has demonstrated competency, authority, or credibility to meet a predetermined set of standards (Gapenski). Accreditation is most notably found in healthcare organizations and is world-wide. Accreditation is different from licensure in that licensure is for and individual that works within a healthcare organization and accreditation is for a healthcare organization as a whole. All healthcare entities are accredited by an accreditation agency and adhere to quality and safety standards,

Implementing all of these standards and policies within a company is certainly not an easy thing to do, and therefore it is imperative to understand whether or not your company will need it or not. In fact, it is easy to say that any company working within the federal healthcare system, whether it be insurance, practice, healthcare education, or many others, will need this sort of regulation used efficiency internally in order to prevent federal violations, which will be entirely detrimental to your reputation and ability to produce a

In order for a hospital or facility to gain accreditation from the Joint Commission, there are several areas of requirement that the hospital or facility must meet. Nightingale Community Hospital has met the requirements in the following areas; Accreditation participation requirements, this requirement is important to maintain compliance in this area due to the fact that a this requirement must be maintained throughout the entire time of the hospital having accreditation, Emergency Management, this area of requirement ensures proper safety and security of the hospital, including fire safety, hazardous materials and waste, medical equipment as well as utilities, Human Resources this requirement is referring to the proper handling and hiring

* The concept of accreditation in health, this is process of review that health care organizations participate in to demonstrate that the ability to meet predetermined criteria and standard of accreditation by a professional accrediting agency.