...Healthcare Regulatory Paper Joint Commission in Prisons Rein Denise Fox 06/04/2012 The health care industry has to have a good leadership foundation to carry out rules, regulations, and procedures. It is important for the success of any organization. In a healthcare organization, good leadership is more than just important; it is significant to the organization’s success. The Joint Commission is an organization which requires that the health care industry provides and maintains a safe environment for patients. If the health care industry does not have good leadership, the industry will suffer the consequences and not meet standards. The Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) monitors health care organizations and ensures the facilities meet standards and then awards the facilities with accreditation. When the health care facility does not meet standards of JCAHO then the public will ponder on accreditation status and if the health care facility meets quality service; as well as standards of a safe environment. The paper will include the history of JCAHO, source of authority, structure, responsibilities, and its effects on health care. The paper will also include an example of the agency which carries out JCAHO duties. The Joint Commission was founded in 1951 and the organization’s mission is providing appropriate health care for the public, by evaluating, and inspiring the organizations to surpass in providing secure and valuable care...
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...preparing for a periodic performance review by The Joint Commission. Prior to The Joint Commission coming to complete its unannounced audit, the commission sends the hospital a handbook of standards guidelines each department of the hospital is expected to meet. The accreditation is a very important process to the daily operations of the hospital. The Center for Medicare and Medicaid Services, (CMS) requires hospital to meet and operate to the accreditation standards. This assures CMS that patients, who pay for services with their Medicare or Medicaid insurance, are receiving the best of medical care. It is imperative for Nightingale to meet the Joint Commission requirements not just for the ability to collect revenue, but its symbol of accreditation hanging in the hospital lobby, tells the public the hospital has met national patient standards. The Joint Commission’s job is not to close a hospital doors, nor to deny the hospital to provide medical services. It should be used a tool for good operating standards for a hospital to conduct its business. It takes work and preparation to meet the standards and to make sure all departments are on board, but once nightingale meet the requirements it all about managing and monitoring the daily operations of standards. It is the Director of Accreditation job of Nightingale Hospital to make sure the hospital is prepared for the Joint Commission audit. It is the directors who reviews all standards and make sure each department within the hospital...
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...Executive Summary - Infection Control and Prevention Current Compliance Status for Joint Commission Accreditation Nightingale Community Hospital is committed to providing healthcare excellence, a healing environment and to be the choice for patient care. In order to continue to provide quality healthcare services in accordance with our values of safety, community, teamwork, and accountability Joint Commission Accreditation provides guidelines and standards for the Priority Focus Areas (PFA) for the welfare and quality of patient care. Infection control and prevention extends beyond treating the patient. It encompasses all who work and visit the facility including medical staff, administrative staff, volunteers, vendors, and visitors. Implementing activities and programs to control, treat, prevent and identify sources of infection will help ensure the overall satisfaction and quality of patient care. Based on previous fiscal year data Joint Commission has identified Infection Control as one of the PFAs. In order to be in compliance with the standards and guidelines of Joint Commission Accreditation five areas of Infection Control and Prevention have been identified: 1. The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. 2. Comply with either the current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines or the current World Health Organization...
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... Through our vision and mission, Nightingale Hospital strives to meet and exceed all expectations during our next Joint Commission visit. Before we address the aspects of our upcoming visit from Joint Commission, we must address the foundation of what Joint Commission is. One of the definitions of Joint Commission is, “Joint Commission Accreditation of Healthcare Organizations (JCAHO) is an organization that develops and maintains standards to promote compliance in regards to acceptable levels of care that should be given to patients” (About the Joint Commission). Accreditation from JCAHO provides Nightingale Community Hospital with the gold seal of approval signifying exceptional care. Currently Nightingale Hospital has the JCAHO stamp of approval. However we as an organization should strive to achieve a higher standard of care for our employees and patients as well as our community. With the upcoming visit from JCAHO approaching we need address the past JCAHO visit and pay attention to some of our deficiencies. Our priority focus areas for our facility will be: Information Management, Medication Management, Communication and Infection Control. The focus of this executive summary will be on Communication and the steps we are taking to address any previous shortfalls as well as current process. JCAHO has identified several standards related to the...
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...Accreditation Audit: AFT Task 3 Western Governor’s University Abstract AFT Task 3 allows the examination of data from a patient while hospitalized at Nightingale Hospital and utilizes a tracer methodology to identify trends, patterns, and pertinent problems for healthcare improvement. We plan to develop a corrective action plan to address the organization’s improvement while maintaining compliance from a Joint Commission standard. Accreditation Audit: AFT Task 3 Nightingale Hospital is preparing to devise a mock tracer methodology to assess the organizations’ current compliance with Joint Commission Standards. A tracer methodology follows a patient through the course of care and evaluates all aspects of care (Joint Commission E-dition, 2014). This method allows a quick overview of a patient through the flow of a system in order to evaluate the effectiveness of the process flow. Our mock tracer patient is a sixty seven year old female whom recently underwent an open total abdominal hysterectomy secondary to menorrhagia and uterine fibroids. The patient presented back to the emergency room one week postoperatively with complaints of a subjective fever of 100.2 degrees Fahrenheit and incisional drainage described as yellowish-green in color. A CT scan of her abdomen was performed in the emergency room and revealed a peri-umbilical abscess. The surgical team was consulted and an incision and drainage of the abscess was performed. Infectious disease physicians determined...
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...The focus of the Joint Commission is patient care and organizational functions that are necessary to provide a high quality of care without putting patients, individuals, or residents in harm. That is why it is very important for organizations to follow the standards outlined. As Diane began to prepare for the Joint Commission visit, she found several deficiencies in Willow Bend Hospitals’ policy that needed attention. • Standard IM .02.02.01-Collection of Health Information states the hospital effectively manages the collection of health information and uses uniform data sets to standardize data collection thought-out an organization. According to the survey readiness scenario for Willow Bend, the use of abbreviations and medical terminology fall within this standard. As Diane reviewed the policies she finds a policy addressing the use of medical terms and abbreviations, but what she doesn't find is specific information as to who is responsible for maintaining the list and making it available to the end users. Diane should reach out to the IT department to see if there is a separate policy or a list of users’...
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...involvement of governmental ties, dependency of advancing technology, and the expenditures of what healthcare would bring upon the American people. This brought about the greater need for accountability for services rendered at that healthcare institution (Morrison, 2011). Healthcare regulatory agencies have also had to keep up with the evolving healthcare fields. American College of Surgeons started a standardization of practices in the healthcare fields. This later developed with various other adjoining forces into what we know today as the Joint Commission on the Accreditation of Hospitals. In 1987, this evolved into the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This accrediting agency had influences among the ambulatory care, assisted living, home health, behavioral, health, laboratories, long term care, and office based surgeries (Morrison, 2011). JCAHO was developed to set a standard of care that held these services accountable for. This helped to have hospitals provide the same level of quality care to the people they served from the community. This in turn provided safe care to the patients. During the initial stages of accrediting when JCAHO was first developed, they would base their results on hospitals self-scoring. Time passed on, hospitals grew and the status of being JCAHO accredited began to be more valuable, the assessment phase took on a new level of involvement (Morrison, 2011). The assessment phase of accrediting...
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...excellence. This executive summary of the accreditation audit is presented to the senior leadership to outline the compliance, plan of compliance and institution of the hospital under the reviewed focus area of Information Management as per the Joint Commission Standards. COMPLIANCE STATUS. The Joint Commission Standard IM 02.02.01 requires that the hospital effectively manages the collection of health information. Nightingale Community Hospital is in compliance with this standard under its patient care policy which specifies prohibited abbreviations. Its policy states that the use of abbreviations and symbols in the medical record is discouraged to prevent errors; as these can be associated with misinterpretation resulting in medical errors, and patient harm. In case the intended meaning of the abbreviation or symbol in the context of a specific order is not clear, the ordering practitioner must be contacted for clarification. This procedure demands that the elements of performance under IM 02.02.01 of the Joint Commission accreditation requirements are adhered to; 1. That the hospital uses uniform sets to standardize data collection throughout the hospital; The findings by the Director of accreditation notes that this standard is not indicated anywhere in the hospital’s policy, admission orders and national patient control goal data of its information management. 2. That the hospital...
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...Community Hospital Joint Commission Compliance Standards for Communication Focus Area Recently there has been much media focus on preventable medical errors. Any google search will produce a multitude of news articles that all report that preventable medical errors is now the third leading cause of death in the United States. Poor communication plays a role in most if not all of these errors. In fact the Joint Commission (2012) has published that an estimated 80% of serious medical errors involve miscommunication between caregivers during the transfer of patients. While communication errors are not the sole cause, they certainly contribute to the problem and must be a consideration in every patient safety program. One particular area of preventable medical errors involving communication errors that has received widespread media attention is wrong site surgery. Chassin (2013) reported that wrong site or wrong person surgery occurs an estimated 50 times weekly in the United States. This number is hard to judge exactly as not all states mandate reporting, but the fact remains that wrong site surgery continues to occur despite concerted efforts to prevent it. All hospitals to include Nightingale must continue to place emphasis on preventing these errors. Nightingale has wisely chosen to focus on this area for the upcoming Joint Commission inspection as part of the overall communication focus in the hospital. Current Status There are three Joint Commission Standards that relate...
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...The Joint Commission is a nonprofit organization that certifies more than 18,000 health care organization and programs throughout the world. Founded in 1951, the Joint Commission provides a national symbol of quality for health care as well as analyzes each organization’s commitment to meeting high quality performance standards. The Joint commission focuses on accrediting Acute Care Hospitals, ambulatory, behavior health, long term care, health care facilities, clinical laboratories, health care networks and hospice. Numerous of accreditation organization is also taking place within the United States, but the Joint commission remains the largest The Joint commission accredits 20,000 organization” which” one third are Hospitals. The joint commission is assigned a special task to improve health care by evaluating health care of organization as well as encouraging health organizations to provide safe and effective care at the highest level. The Joint Commission believes that the only way to improve the quality of health care is to join together with other stakeholders and evaluate each health care organization. The Stakeholder consists of 29 broad members of commissioner and cooperate members such as the American Hospital Association, and the American Medical Association. In this paper I will analyzes key topics such as the Joint Commission source and its scope of authority, the structure of the Joint commission and how its responsibilities. The Joint Commission Structure ...
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...Review Accreditation Audit Case Introduction The accreditation process is designed to assist healthcare establishment to identify and enhance the patient’s safety and the quality of service delivery. This paper presents a review of the readiness Nightingale Community Hospital for accreditation audit. The paper comprises of a periodic performance review of the establishment. The review has focus of several priority areas. These areas include; assessment and care; quality improvement; patient safety, and staffing effectiveness. Trend within the hospital indicates the Nightingale has made significant progress towards fulfilling the standards of the Joint Review Commission. However, the trends in staffing effectiveness are limiting the organization’s compliance. Periodic Performance Review (PPR) The PPR is based on data collected in the Joint Commission Survey. The survey utilized the priority focus methodology to evaluate the compliance of Nightingale Community Hospital. The priority focus process is a methodology that makes use of data to establish priority areas for reviewing compliance. This process has utilized of both external and internal data to evaluate the compliance of Nightingale Community Hospital. This methodology identified several priority areas. These include; assessment and care services; quality improvement activities, and patient safety. This paper evaluates Nightingale’s compliance in these three priority areas. Compliance Status The PPR process has also...
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...The Joint Commission Noelle Cunningham HCS 430 April 15, 2013 Norman Greene The Joint Commission The Joint Commission continually seeks to improve health care for the public (The Joint Commission, 2013). The Joint Commission began in 1910 as an evaluation process called “the end result system of hospital standardization” to determine successful treatments of patients. Over the next 40 years, The Joint Commission evolved into a collaboration system. In 1951, several stakeholders, such as the ACP, the AMA, the AHA, and the CMA, join to create the Joint Commission on Accreditation of Hospitals (JCAH). This organization serves to provide voluntary accreditation for health care agencies. This accreditation system inspires health care organizations to “provide safe and effective health care of the highest quality and value” (The Joint Commission, 2013, para. 3). Therefore, by evaluation and accreditation of more than 20,000 health care organizations, JCAHO is the nation’s oldest and largest accrediting agency in health care. Thus, to earn and maintain JCAHO’s “Golden Seal” of approval, an organization must submit to an on-site survey every three years. Structure and Role The source of JCAHO’s authority comes from a government of 32 members on the Board of Commissioners. Among the members are administrators, physicians, nurses, quality experts, educators, and labor representatives. These members bring a diversity of experience in public policy, business, and health care...
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...Write an essay discussing the following 1. The role of the Joint Commission in accrediting medical facilities The Joint Commission was designed to help to improve the quality of patient care by assisting international health care organizations, public health agencies, health ministries and others evaluate, improve and demonstrate the quality of patient care and enhance patient safety in more than 60 countries. The Joint Commission seeks to continuously improve health care for the public as well as the primary standard in the healthcare industry. 2. Which facilities can be accredited? Upon doing a review of the type of facilities that receive accreditation from Joint Commission accreditation, I’ve found over ten . Joint Commission accreditation can be earned by health care organizations such as hospitals, doctor’s offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. I also noticed those facilities such as behavioral health care organizations, addiction services; rehabilitation centers, group practices, office-based surgery centers and other ambulatory care providers; and independent or freestanding clinical laboratories . 3. What are the goals of the Commission? The purpose of the Joint commission is to minimize data collection efforts while using the data to improve the health care delivery process. The joint Commission uses National Patient Safety Goals when determine if goal are...
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...Regulatory Agency Paper University of Phoenix HCS 430 October 22, 2012 This paper will better inform how the Joint Commission Accreditation of Healthcare Organizations (JCAHO) came into existence. The JCAHO is responsible for the accreditation of healthcare organizations nationwide. JCAHO’s goal is to ensure that specific guidelines are meet and that the organizations operate in a safe manner for their patient’s and its employees. The Joint Commissioned Accreditation of Healthcare Organizations (JCAHO) came along side of the American College of Surgeons (ACS) which established its program in the early 1900’s until 1952. This agency was responsible for on-site inspections of hospitals. Only a few hospitals meet the requirements of the minimum standard. The start up of JHAC was governed by Arthur W. Allen who sat on the chairman of the American College of Surgeons (ACS) (Saulf, 2005). In 1952 the ACS officially transfers its hospital Standard Program to JHAC this was the start of hospital’s accreditation. In 1953 JHAC publishes their standards for hospital accreditation. As time moves on congress passes the social security amendments in 1965 making this one of the hospital’s provision to be in compliance with the Medicare conditions for the hospital’s to participate in the program. In 1971 the accreditation for long term care is established. The social security act amended that the Secretary of the U.S.Department of Health and Human Services (DHHS) validate JHAC findings...
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...AFT Task 3 As our Joint Commission audit approaches, Nightingale Community Hospital has conducted a tracer patient survey to assess our compliance. The tracer methodology tracks a selected patient's care from admission to discharge, allowing us to evaluate our systems of providing care and to ensure that we are meeting the Joint Commissions standards of providing safe, quality healthcare. Our tracer patient was a 67 year old female who presented with a fever and drainage five weeks after an open hysterectomy. She was admitted for a suspected postoperative infection,. She underwent another surgery to treat the abscess that formed from the initial surgery and had a central line inserted for long-term antibiotics. She is scheduled to go home with home health overseeing her antibiotic therapy. This tracer patient has shown that there are areas of our patient care that we need to improve upon in order to be in compliance with the Joint Commission standards. According to The Joint Commission (2014) compliance with standard PC.01.02.03 requires that a history and physical examination be done within 24 hours of inpatient admission and prior to surgery. In the case of this tracer patient, the history and physical was completed more than 72 hours after admission. Further, this patient underwent surgery two days after admission, prior to the completion of a history and physical exam. The history and physical examination is a very important tool in a patient's care....
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