...Community Hospital is 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...
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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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...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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...The Joint Commission HCS/430 October 20, 2014 Kelly Gantt The Joint Commission The Joint Commission is independent, not for profit organization that has been around since 1951. According to the Joint Commission (2014), “The Joint Commission accredits and certifies more than 20,500 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards” (para. 1). The Joint Commission’s mission is “to continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value” (The Joint Commission, 2014, para. 1). The Joint Commission’s vision is “all people always experience the safest, highest quality, best-value health care across all settings” (The Joint Commission, 2014, para. 2). The Joint Commission evaluates and accredits health care organizations and programs in America and around the world. This organization is the United States (U.S.) oldest and largest accrediting body for health care. For a health care organization to become accredited through the Joint Commission they must have an on-site evaluation every three years and laboratories every two years (The Joint Commission, 2014). Joint Commission International (JCI) was founded in 1994 and...
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...The Joint Commission As someone who recently entered the health care workforce with very minimal knowledge about the health care world, the Joint Commission seems like a viable choice to understand why this organization is important to the health care community. To understand why it is important to have the Joint Commission in the health care system is as simple as reading rules in a classroom on the first day. By understanding its history, the services it offers, and they serve can bring a brief glimpse into what The Joint Commission is about. The Joint Commission: Brief History The history starts with the American College of Surgeons (ACS), founded in 1913 and had developed the Minimum Standard for Hospitals manual and improved standard care within 30 years. With the help of the American College of Physicians (ACP), the American Hospital Association (AHA), the American Medical Association (AMA), and the Canadian Medical Association (CMA), they joined ACS as corporate members to form the Joint Commission on Accreditation of Hospitals (JCAH) in 1951 (Joint Commission History, 2012) . Its sole purpose is to provide voluntary accreditation. The Joint Commission is administered by a 32-member Board of Commissioners that includes physicians, nurses, educators, employers, administrators, and others to bring an assorted array of experience in public policies, health care, and business whom the corporate members appoint. By 1987, JCAH changed the name to Joint Commission on Accreditation...
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...Joint Commission Meredith Hattaway Kapan University Joint Commission The role of the Joint Commission Accreditation is a process in which an entity, separate and distinct from the health care organization, usually non-governmental, assesses the health care organization to determine if it meets a set of standard requirements designed to improve quality of care. In other words, an accrediting body is an independent 3rd party that measures and rates the regulations, safety guidelines, and practices of a service or business—in this case, medical facilities. Think of it as a stamp of approval verifying the authenticity and quality of services. A restaurant in the US can’t open unless it passes certain health inspection codes, and a lawyer can’t begin practicing until he or she has passed a qualifying exam. The same is true with medical practitioners and facilities. They must demonstrate to accrediting bodies that they possess the personnel, resources, training, experience, and regulatory understanding to provide quality medical treatment to patients. Hospitals that lack accreditation are hospitals worth avoiding. However, JCAHO is not the only accrediting organization out there. There are agencies that focus on region, specialty, and country (healism.com). Which facilities can be accredited Joint Commission for the Accreditation of Healthcare Organization (JCAHO) has been accrediting Managed Care Organizations for more that 10 years....
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...The joint Commission evaluates and accredits more than 15,000 healthcare organizations and programs in the United States. The Joint Commission is an independent, not-for-profit organization that sets the standards and accrediting body for the nation since 1951. They maintain standards focused on improving the quality and safety of care provided by health care organizations. Joint Commission accreditation can be earned by many healthcare facilities. These include hospitals, doctor’s offices, nursing homes, office based surgery centers, behavioral health treatment centers, and home care providers. The Joint Commission also awards Disease Specific Care Certification to health plans, disease management service companies, hospitals and other care delivery settings that provide disease management and chronic care services. Benefits of Joint Commission accreditation and certification include: Strengthened community confidence in the quality and safety of care, treatment and services, Provides a competitive edge in the marketplace, improves risk management and risk reduction, Provides education on good practices to improve business operations, provides professional advice and counsel, enhancing staff education, enhances staff recruitment and development, it is recognized by select insurers and other third parties, and may fulfill regulatory requirements in select states. The Joint Commission has accredited hospitals for more than 50 years. The Joint Commission currently accredits...
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...Executive Summary Joint Commission Standards Compliance Prepared by: AK- Joint Commission Priority Focus Area: Communication RAFT Task 1 The Joint Commission Priority Focus area for Nightnigale included the four areas: • • • • Information Management Medication Management Infection Control Communication All these priorities focus on the national patients safety goal as the most important in patient management and treatment, and guide the hospitals toward appropriate policies and protocols to follow and to minimize any possible mistakes or patients harm. I choose the priority focus area of Communication to discuss the current compliance status of our organization concentrating on the standards, which did not meet the Joint Commission requirements, and then suggest a corrective action plan to reach the goal of full compliance with the Joint Commission Accreditation. Communication Focus Area Compliance: Current Compliance Status: Despite the written policy and emphasis on the communication between all medical staff, patients, families, some elements did not meet the Joint Commission standards including the following: 1. Reporting Critical Results within 60 minutes: Goal is 100% compliance. • • • The importance of this element in patient management makes it so critical to have a better outcome and reduce complications and bad outcomes. Our institution compliance averaged 56% to 82% depending on the month. Some of the reasons for delayed reporting was identified as follows:...
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...oncology, cardiology, etc. Nightingale has four core values: safety, community, teamwork, and accountability. Nightingale’s vision is that patients, employees, physicians, volunteers, and community choose Nightingale’s as the hospital to receive care or to seek employment. To create a healing environment, with a passionate commitment to healthcare excellence is the goal of Nightingale. The next anticipated Joint Commission visit is about 13 months away. Over 20,000 health care organizations in the United States are accredited and certified by the Joint Commission. To receive accreditation from the Joint Commission is recognized nationwide as a symbol that certain performance standards of quality have been reached. A three-year accreditation cycle is standard for all member health care organizations. A two-year accreditation cycle is standard for laboratories. The Joint Commission provides the organization’s accreditation decision, the date the organization was awarded accreditation, but it does not provide the organization’s findings public. There are four Joint Commission focus areas for Nightingale and they are: Information Management, Medication Management, Communication, and Infection Control. This paper will focus on the area of communication for Nightingale. The way information is exchanged and delivered between individuals, departments, or organizations is the process of communication. There are three standards when it comes to communication. The first standard is...
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...The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has long been the designated accreditation agency for hospitals and other health care facilities. In 1997, JCAHO added quality measurement requirements to existing requirements for participation in the accreditation process for hospitals and long-term care facilities in an initiative called ORYX. In 2003, The Joint Commission launched project activities to examine Children’s Asthma performance measures for inclusion in the ORYX performance measurement initiative. This work was conducted in collaboration with national children’s health care organizations, particularly, the National Association of Children’s Hospitals and Related Institutions (NACHRI), Child Health Corporation of America (CHCA), and Medical Management Planning, Inc. (MMP). An advisory panel was convened to...
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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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...Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Sandy Markert HCS/212 March 31, 2013 Corinne McTier Joint Commission on Accreditation of Healthcare Organizations (JCAHO) The Joint Commission on Accreditation of Healthcare Organizations or JCAHO was founded in 1951 as a private nonprofit organization that established guidelines for the running and management of hospitals and health care facilities in the United States. According to its website (n.d.), JCAHO’s primary mission is, “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value.” Through its onsite surveys, JCAHO accredits approximately 20,000 healthcare programs and facilities each year nationwide. The groundwork for the establishment of JCAHO began in 1910 when Ernest Codman, M.D. recommended an “end result system of hospital standardization” (The Joint Commission, n.d.), a process in which patients were tracked to determine if the treatment they received while in the hospital was successful or not and thus could be used to treat similar cases. In 1913 the American College of Surgeons (ACS) was established and adopted Dr. Codman’s “end result” system and by 1918 it began inspecting hospitals. These initial surveys determined that only 89 of the 692 facilities it inspected at the time met the minimum...
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...The Joint Commission on Accreditation of Healthcare Organizations, JCAHO, is a not for profit professional standard setting agency that was founded in 1951. It was formed to determine compliance with standards designed to ensure quality care to patients. The JCAHO early standard requirements reflected a minimal standard of care. Later it expected hospitals to strive for the highest quality standard of care. In the late 1980’s the JCAHO developed the indicator measurement system . These indicators focused on the outcomes of clinical care rather than standards of the hospital processes and departmental structures. In 1998 the JCAHO required hospitals to submit intra hospital outcome measures . The JCAHO reviews healthcare facilities, policies and procedures, training, competency and formulary. It reviews the pharmacy practice, drug use and records of a health care system. The JCAHO reviews for compliance and changes in regulations. It makes recommendations and can change or upgrade its standards for hospital, pharmacies or other health systems. It conducts these reviews every 3 years and may conduct random inspections if they get a complaint. In an attempt to change the perception of it’s reviews as a 3 year event, the JCAHO also conducts random reviews to ensure that standards are being met everyday and not just during scheduled reviews. The JCAHO reviews and accredits many health care organizations, but mostly home care organizations. JCAHO expects quality and...
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...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 Standards of Universal Protocols (UP) are: UP 01.01.01Conduct pre-procedure verification process UP 01.02.01Mark the procedure site UP 01.03.01Perform a Time-Out before the procedure. To determine NCH compliance, hospital documentation was used for comparison with the Joint Commission, Elements of Performance. The following chart specifies which documents were used to show areas in need of improvement. Nightingale Community Hospital Documentation| Compared with|(UP) Elements of Performance| Pre-Procedure Hand-Off check listSite Identification and Verification (UP) (Sub heading) Preoperative Verification Process||UP.01.01.01Description # 1Description # 2| Site Identification and Verification (UP) (Sub heading) Marking the Operative/Invasive Site||UP. 01.02.01Description # 5| Safety Report Time-Out Graph||UP. 01.03.01Description #1 | Compliance Status Executive Summary and Findings according to the Joint Commission, Elements of Performance. UP.01.01.01 Not in compliance. #1 Implement...
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...The Nightingale Hospital is 13 months away from our next Joint Commission inspection. Although the overall state of compliance for the organization is good, there are several areas that have been identified as “Priority Focus Areas” due to a past history of nonconformities. All these areas are related to Information Management and Record of Care, Treatment, and Services, in particular: A utilization of standardized terminology, definitions and abbreviations, as described in Joint Commission Accreditation Standard IM.02.02.01 Maintenance of complete and accurate medical records for each patient as described in RC.01.01.01. This standard was also identified by JACHO as top compliance issue for the industry. Conducting of Medical Record Audits as described in RC.01.04.01 The areas listed above as Priority Focus Areas for Nightingale Hospital have been evaluated using Internal Audit data. The following findings have been documented: 1. The overall compliance with IM.02.02.01 is satisfactory, with two areas identified as needed improvement: a. The Hospital maintains an active Patient Care Policy for use of prohibited abbreviations, with a separate Addendum listing unacceptable abbreviations, their intended meaning, as well as recommended best practices. Although the list contains the majority of prohibited abbreviations, the following abbreviations listed in IM.02.02.01. were not included: QD, q.d., qd, Q.O.D., QOD, q.o.d, qod. b. The instances of unacceptable abbreviations...
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