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Role of the joint commission accreditation in healthcare
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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.”
1. How might you evaluate the CPOE implementation process at University Health Care System? Give examples of different methods or strategies you might employ.
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.
The initial presentation of Parts 1 and 2 of this FiSuR to Council representatives is also part of the quality control process. The intention is to optimise the value added by survey activity from both a local and regional perspective. Once feedback from Council has been gained, recommendations and a thorough analysis of the findings will be provided.
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
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.
The Joint Commission is an autonomous and non-profit organization in the United States that specifically oversees charitable accreditation programs for healthcare bodies and hospitals. These organization works by developing performance standards that aims to address critical elements of the healthcare operations, including medication safety, patient care, consumer rights and infection control. As a trusted body in the U.S. healthcare systems, most state administrations mandate healthcare organizations to receive Joint Commission’s accreditation as a prerequisite for licensing as well as Medicaid refund. Its accreditation as well as certification has gained a nationwide recognition as an emblem of quality that mirrors its
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.
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.
Third, ASC’s should know that the information within these ASC surveys (and non-ASC surveys) guide the Department in determining whether to grant or deny CON applications. Where a provider has failed to submit a survey, the Department and the parties are forced to ignore that provider in any decision or argument made. The absence of a survey will unfairly help or harm parties seeking CON approval from the Department. Simply put, if a survey does not exist, each party will use that fact for its own advantage in any litigated CON
Good leadership, fostering a culture of change and safety, team work are essential in implementing quality improvement and risk management in the organization. Leaders and the governing body must demonstrate commitment to the processes and define their expectations for all stakeholders. Leadership team should make sure that the team’s attention is focused on the core business of the organization, which is to provide care and treat patients in a safe and high quality clinical environment. There are different tools that can be used for quality improvement that also applies to analyzing risk issues. These are measurement of quality, benchmarking, RCA, FMECA, and so
Constitutional Commission A (hypothetical) Constitutional Commission is considering how (if at all) constitutional conventions might be incorporated into the draft of a new constitution of the United Kingdom. What options face the Commission on what to recommend about conventions, and which course of action would be preferable? In order to accurately assess the incorporation of Constitutional conventions into the draft of a new Constitution of the United Kingdom, one must firstly look at the definition and nature of constitutional conventions. A succinct definition is that a convention is a constitutional practice or way of behaving which is considered to be binding on
According to the Commission on Global Governance (1995), global governance refers to “the sum of the many ways individuals and institutions, public and private, manage their common affairs. It is the continuing process through which conflict or diverse interests may be accommodated and cooperative action may be taken”. Some main actors involved in the process of global governance include states, international organizations (IOs), regional organizations (ROs) and non-governmental organizations (NGOs). Global governance implements in various issue areas including security, economic deelopment, environmental protection and so on. Different states and organizations have different or even conflicting interests. Yet as globalisation continues and the world becomes more inter-connected than ever before, global governance or cooperation among different actors is increasingly taking a more significant role in the international stage. Some critics view global governance quite negatively as they believe that the current system lacks efficiency and effectiveness. In this paper, however, I shall argue that global governance is carried out more effectively in maintenance of world security and promotion of economic development while less effectively in environmental protection and preservation. Thus, despite limitations of the existing mechanism, global governance is still largely a postive development in world affairs.