Accreditation is a process of review that healthcare organizations participate in to demonstrate the ability to meet predetermined criteria and standards of accreditation established by a professional accrediting agency (alignment with the initially determined objectives). Its aim also to encourage continuous improvement of quality rather than simply maintaining minimal levels of performance.
Accreditation promotes change and professional development in healthcare organization.
There is considerable evidence to show that accreditation programs improve clinical outcomes of a wide spectrum of clinical conditions.
The concept of accreditation and measuring are intimately linked at least at these two components: Accreditation and continuous improvement:
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As you strive to make small improvements day after day and week after week, nothing can stop you from achieving your goals”. Todd Smith
Measure the performance of healthcare accreditation system :
WhyMeasure the performance of healthcare accreditation system Provide reliable aim to provide reliable evidence on the performance and impact of accreditation. We must have an objective approach to evaluate the impact of accreditation program in three distinct areas:
The impact of accreditation on the quality and safety of healthcare delivery.
The efficiency of accreditation tools and systems for providing feedback with reliable information both to the accreditation organizations as well as all key stakeholders. The impact on the capacity development of systems.
Evaluation of the social impact on accreditation program:
Accreditation could be conceived as a steering mechanism in healthcare with its respective impact at the societal level.
Flexibility of an accreditation program to adapt to the changes in its environment and accommodate the feedback of different stakeholders could ensure its sustainability and relevance. This openness to changes could transfer the programs into a learning
2. In recent years, there has been a growing attempt to measure the performance of health care providers. The federal government and the states have published data on how hospitals are compared to acceptable clinical standards with regard to pneumonia. Explain how these data could affect the consumer decision-making process.
Nerenz, D. R. & Neil, N. (2001). Performance measures for health care systems. Commissioned paper for the center for Health management research. [PDF document]. Retrieved from Systemswww.hret.org/chmr/resources/cp19b.pdf
If patients constantly have to wait an excessive amount of time they will either leave before they receive care or could end up becoming sicker as a result. Donabedian’s three-element model structure, process and outcome have become the gold standard for defining quality measurement (Varkey, 2010). Structure relates to the health care setting, which includes the hospital policies, procedures and design. Process evaluates if the right actions were taken for an intended outcome and how well the actions were executed to achieve the outcome. Outcome focuses on the patient, it measures the patient’s condition, behavior, and response to or satisfaction with care (Varkey, 2010). Although each of these measures focus on different areas, they indicate areas that need improvement. Also, the measurement from structure and process plays an important role in the patient’s outcome. If the hospital has the right staff, equipment and
Government has developed ‘Star Ratings’ system which monitors improvements in accountability measures. The experience of the ‘Star Ratings’ system in respect of service efficiency indicates that it is prudent to act pro-actively rather than re-actively. It is vital to consider that the Government is expecting demonstrable improvements in health services rather than rhetoric alone (Radnor and Lovell, 2003).
Merwin, E & Thornlow, D. (2009). Managing to improve quality: the relationship between accreditation standards, safety practices, and patient outcomes. Health Care Managment Review, 34(3), 262-272. DOI: 10.1097/HMR.0b013e3181a16bce
To gain accreditation, TJC sets rigorous safety and quality of care standards and evaluates organizations to see whether or not they meet their standards. After the survey, TJC provid...
At its most fundamental core, quality improvement of healthcare services and resources requires disciplined attention to the measurement, monitoring, and reporting of system performance (Drake, Harris, Watson, & Pohlner, 2011; Jones, 2010; Kennedy, Caselli, & Berry, 2011). Research points to performance measurement as a significant factor in enabling strategic planning processes and achievement of performance goals (Tapinos, Dyson & Meadows, 2005). Thus, without a system of measurement that accounts for the performance behaviors of healthcare professionals, managers and administrative employees, quality improvement remains a visionary abstraction (de Waal, 2004).
Quality and quality improvement are important to any healthcare organization because these principles allows organizations to fulfill their missions more effectively. Defining what quality is may differ depending on whom is asking the question, as differing participates may have differing ideas about what quality means and why it is important. Being that quality is what unites patients and healthcare organizations, we can see the importance of quality and the need for strong policies and practices that improve patient care and their experience while receiving that care. Giannini (2015) states that this dualistic approach to quality utilizes separate measurements, conformance quality that measures patient outcomes against a set standard and
... is an abstract model that proposes an exploratory plan for health services and evaluating quality of health care. In accordance with the model, information about quality of care can be obtained from three categories: structure, process, and outcomes. In addition, not long ago The Joint Commission include outcomes in its accreditation valuations (Sultz, & Young, 2011, p. 378).
The standards of the Joint Commission are a foundation for an objective evaluation process the may help healthcare organizations measure, assess and improve performance. These standards are focused on organizational functions that are key for providing safe high quality care services. The Joint Commission’s standards set goal expectations of reasonable, achievable and surveyable performance of an organization. Only new standards that are relative to patient safety or care quality, have positive impact on healthcare outcomes, and can be accurately measured are added. Input from healthcare professionals, providers, experts, consumers and government agencies develop these standards.
In the healthcare system, quality is a major driving compartment for patient outcomes. The quality of care reflects the outcomes in a patient’s care. According to Feeley, Fly, Walters and Burke (2010), “quality equ...
...n of Healthcare Organizations (JCAHO), and the American Medical Accreditation Program (AMAP), just to name a couple. Each of the accrediting bodies is unique in terms of their mission, activities, compositions of their boards, and organizational histories, and each develops their own accreditation process and programs and sets their own accreditation standards. . "Accreditation of a health care facility or program is a symbol of quality, similar to the Good Housekeeping Seal of Approval that indicates to the public that the organization or program has met certain standards." (Goode, 2001) The accreditation proves that healthcare facility underwent the accreditation process and met all of the necessary requirements to become qualified. Accreditation has been generally viewed as a desirable process to establish standards and work toward achieving higher quality care.
The first nurse to introduce quality improvement was Florence Nightingale, who through gathering data on the positive effects of keeping adequate hygiene, nutrition and proper ventilation on the mortality rate during the Crimean War (Hood, 2014, p. 490-491). The initiatives towards improvement of quality lead to formation the Joint Commission on Accreditation of Hospitals (JCAH), which is now known as The Joint Commission (2007). The Joint Commission is non-profit organization which gives accreditation to hospitals for recognizing their efforts to deliver quality health care with an added advantage of being eligible for the Medicare reimbursement program. Moreover, the Joint Commission also rolled out the Hospital Patient Safety Goals (2013) to prevent patient safety errors. Nursing professionals are essential for health care organizations to achieve and maintain the patient-safety goals as their work directly impacts the quality and safety of the patients. For instance, using two patient identifiers during medication administration to avert errors. Nurses have the distinct skills and responsibility towards patient safety and hence the need for Quality and Safety Education for Nurses (QSEN) is the rational step towards quality improvement. Through the years, the QSEN has developed in Phases to ascertain the areas of competency requirements for nurses to deliver safe, efficient and excellent health care
In the past, assessments were popularly conducted for the purpose of accreditation, but with the growing change in the quality of education, it has become evident that assessments aren’t just products to qualification but as Sieborger (1998) identifies, is that assessment is the process of gathering and interpreting knowledge to make valid and justifiable judgements about the learners performance and the assessors ability to transfer and establish knowledge to the learners.
Understanding quality measurement is essential in improving quality. Teams need to be able to understand whether the changes being made are actually leading to improved care and improved outcomes. For data to have an impact on an improvement initiative, providers and staff must understand it, trust it, and use it. Health care organization must understand the measurement of quality provided by the Institute of Medicine (patient outcomes, patient satisfaction, compliance, efficiency, safe, timely, patient centered, and equitable. An organization cannot improve its performance if it does not know how it is performing. Measuring quality improvements is essential as it reflects the quality of care given by the providers and that by comparing performance