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.
The survey process is designed to be unique to each organization, consistent, and supportive of the organizations attempts to improve healthcare performance. During the survey, the Joint Commission evaluates the performance of processes aimed to improve patient outcomes. The assessment is done by evaluating an organizations compliance with standards in the manual based on the following key functions:
Tracing care that is delivered to patients
Verbal and/or written information given to the Joint Commission
Visual observations and interviews performed by the Joint Commission surveyors
Documents provided by the organizations
“Joint Commission surveys are unannounced, with a few exceptions, such as with the Bureau of Prisons or Department of Defense facilities. An organization can have an unannounced survey between 18 and 39 months after its previous full survey. For example, if an organization’s last survey was January 1, 2009, it could have its survey as early as July 1, 2010 or as late as April 1, 2012 (18 to 39 months).”
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... internal regulatory accreditation survey which was coordinated and conducted by the Allina regulatory leads from across the system. The surveys are designed to replicate an actual Joint Commission survey by incorporating the same patient tracer methodology utilized by TJC. Non-compliant internal findings were evaluated by responsible individuals and corrective actions were put in place to bring the requirements into compliance. The internal survey findings were entered into the ARAS tool and became helpful adjuncts during the preparation of the 2010 PPR. A dedicated heart failure disease specific certification team worked diligently throughout the year to prepare the organization for a 2011 TJC certification survey. The application for heart failure program certification survey was submitted to the TJC in December 2010 with an anticipated site visit in early 2011.”
State and federal regulations, national accreditation standards, and clinical practice standards are created, and updated regularly. In addition, to these regulations, OIG publishes a compliance work plan annually that focuses on protecting the integrity of the program, and prevention of fraud and abuse. The Office of the Inspector General examines quality‐of‐care issues in nursing facilities, organizations, community‐based settings and occurrences in which the programs may have been billed for medically unnecessary services. The Office of the Inspector General’s work plan for the fiscal year 2011 highlights five areas of investigation for acute care hospitals. Reliability of hospital-reported quality measure data, hospital readmissions, hospital admissions with conditions
The Joint Commission. (2012, January 01). National patient safety goals: Medicare based long term care. Retrieved from http://www.jointcommission.org/assets/1/6/NPSG_Chapter_Jan2012_LT2.pdf
Takeda A, Taylor SJC, Taylor RS, Khan F, Krum H, Underwood M. (2012). Clinical service organisation for heart failure (Review). Cochrane Database of Systematic Reviews. Issue 9. Art. No.: CD002752. DOI: 10.1002/14651858.CD002752.pub3.
Margaret E. O’Kane is the founder and president of the National Committee for Quality Assurance (NCQA). NCQA is one of the nation’s leading advocates for improving healthcare through measurement, reporting, and accountability. NCQA is the foremost accrediting organization for health plans including HMOs, PPOs, and consumer directed plans. (Margaret) “Our goal is to increase the value of NCQA accreditation both to organizations pursuing accreditation and to the audiences who seek help in assessing the quality of health care provided by those organizations”. NCQA has developed, maintained, and expanded the nation’s most widely used health care quality tool, which is known as the Healthcare Effectiveness Data and Information Set (HEDIS). HEDIS is responsible for evaluating whether and how well
The Joint Commission is the accrediting body for all health care organizations within the United States. All facilities within the United States must be accredited by the Joint Commission in order to become licensed to provide health care services. The objective of this paper is to inform the reader about the Joint Commission. This paper will discuss the history of the Joint Commission, how they accredit healthcare organizations, and the benefits of the accrediting body.
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
External and internal influences are relevant in health care. These influences continue to affect the total operations of a health care facility. I will summarize the insights I have gained into the external influences of the new health care reform policy and quality initiatives. The recent health care reform legislation was passed in the house and senate this year. The senior vice president, that I have interviewed, states that health care reform is an “unknown” for organizations. In addition, I will research the quality improvement initiatives and how these external influences include implications for organizations and health care administrators.
The purpose of this paper is to identify a quality safety issue. I will summarize the impact that this issue has on health care delivery. In addition, I will identify quality improvement strategies. Finally, I will share a plan to effectively implement this quality improvement strategy.
Conditions of Participation was created to ensure all facilities participating in Medicare follow a set of regulations that protect the safety of Medicare recipients. In 1986 revisions were made to reinforce accreditation and certification procedures. Participating hospitals that are accredited by the Joint Commission on Accreditation of Healthcare Organizations or American Osteopathic Association have been deemed to meeting Conditions of Participation requirements on the wellbeing of Medicare Recipients. The Joint Commission on Accreditation of Healthcare Organizations also requires that the facilities are licensed by their state. (Lohr, 1990, p.
Medicare suppliers must be accredited by the Joint Commission (JC) or by a state regulated survey, which is performed by selected state agencies on behalf of the Centers for Medicare and Medicaid (CMS). As of July 2010 the CMS monitor and provide guidelines which the Joint Commission incorporates into its review processes. Accreditation consists of a in depth review of a hospital's physical plant, patient care , medical staffing and services based on quality factors and standards produced by CMS, as well as conditions of participation requirements under the Title 42, Part 482, of the United States Code.
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).
According to The Joint Commission (2014), it was founded in 1951 and is the largest accrediting agency in the nation. It is a non-profit organization governed by a group of members consisting of physicians, nurses, administrators, and a consumer advocate and educator. They focus on public healthcare to ensure that all people receive safe, effective, high quality care. The Joint Commission plays an enormous role in healthcare by setting patient safety goals and standards that facilities must abide by (The Joint Commission, 2014).
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
Once the surveys are returned to the company, they are returned to the Customer Satisfaction Action Team. This team reviews the surveys, separates them by employee and then by the results.. The results are separated by “Excellent” and “Very Good” and then “Fair” and “Poor” marks. The card members that score a “Fair” or “Poor” mark on the survey is called back by one of the team members and the issue is discussed further to find out why the survey was marked that way. The comments that the card members make on the surveys are returned to the employee’s team leaders. The team leader gives the feedback to the employee and discusses with them their best practices or opportunities that need to be worked on.
William, R. (2009, August). Improving quality and value in the u.s. health care system. Retrieved from http://www.brookings.edu/research/reports/2009/08/21-bpc-qualityreport