The Joint Commision: Not-For-Profit

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 accordance with this the hospital makes sure we follow guidelines laid down by Joint commission Standards. The compliance includes four areas…Information management, Infection control, Communication and Medication Management. The Goal here is patient safety and providing patients with safe and effective care of the highest quality and value.

As shown, communication is a critical to hospital’s patient safety. The Joint Commission is a regulatory agency that makes hospital think about

The Priority Focus Area of Communication includes 3 Joint Commission (JC) standards relative to Universal Protocol. These 3 standards, which are components of the National Patient Safety Goals, are aimed at ensuring the correct

Willow Bend Hospital’s compliance does indeed have multiple deficiencies and is in need of review as many were updated in 2009 and 2010. All information on deficiencies would be found on the latest updated version of the Joint Commission Information Standards. This should be located within the Corporate Compliance/Risk Manager’s office. As this information is not currently available to this writer without a subscription and fee, I must use the information available to me. So expansion and explanation of policy details are limited.

The responsibilities of the Joint Commission are to set standards to help improve the quality of health care services and provide safety guidelines for health care organizations. Their mission as a nonprofit organization is to continuously improve health care (The Joint Commission, 2010). The Joint Commission accredits and certifies health care organizations by surveying facilities to ensure health care standards, performance measurements, safety guidelines have been implemented and carried out for better patient. The Joint commission sets standards and guidelines in compliance with federal laws to evaluate health care services.

The Joint Commission has targeted solution tools (TST) applicable to the Joint Commission standards and National Patient Safety Goals covering; value-based purchasing/pay for performance (P4P), healthcare-acquired conditions, hospital readmissions, risk reduction, staff education. There are more tools The Joint Commission provides which are: Leading Practice Library, Standards BoosterPak, Core Measure Solution Exchange, Portals:HAI, High Reliability, and Trasitions of Care, FSA and Intracycle Monitoring Process,

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.

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

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

As the Joint Commission aims to nationally improve health care systems through health care organizations collaborations, it publishes recommended patient safety goals. As stated by the Joint Commission, “the first obligation of health care is to “do no harm””. The Joint Commission’s 2015 National Patient Safety Goals for hospitals include : Identify patients correctly; Improve staff communication; Use

Nightingale Community Hospital (NCH) has thirteen months until their next Joint Commission audit. This report will evaluate Nightingale Hospital’s compliance in The Priority Focus Area of Communication using the Universal Protocol Standards from the Joint Commission Handbook. “The Universal Protocol was created to address the continuing occurrence of wrong site, wrong procedure and wrong person surgery and other procedures in Joint Commission accredited organizations” (Joint Commission, 2013).

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