August 28. Voluntary Accreditation Assessment Four PDF

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VOLUNTARY ACCREDITATION

Voluntary Accreditation Odetta Nurse Capella University BHA FlexPath 4006 Assessment #4

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2 Introduction

Accredited hospitals offer a higher quality of care to their patients. Accreditation also provides a competitive advantage in the health care industry. It strengthens community confidence in the quality and safety of care, treatment, and services. And their commitment towards patient safety at the highest quality of care. Acquiring an accreditation is a voluntary process hospitals pursue Accreditation because it is required for their organizations to receive payment from federally funded Medicare and Medicaid programs. Once a healthcare organization achieves Accreditation through The Joint Commission or another approved agency, the healthcare facility is set apart and creates a reputation for quality and safety. I will review the accrediting process, requirements and provide a summary of accrediting agencies such as the Healthcare Facilities Accreditation Program (HFAP), Healthcare Quality Association on Accreditation (HQAA) Institute for Medical Quality (IMQ). My focus will be to analyze the Joint Commission (TJC, 2020).

Accreditation in Healthcare

Accreditation in healthcare is voluntary but a very beneficial business decision in healthcare. The standards required for Accreditation are high, and to achieve that shows your patients and other healthcare facilities the organization's commitment to high standards and commitment to quality care. Although internal standards may be upheld within a healthcare organization, national and local standards are met when Accreditation is received. They are many

VOLUNTARY ACCREDITATION accrediting agencies. The most recognizable of these are. The Joint Commission, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Others agencies are the National Committee for Quality Assurance (NCQA), the American Medical Accreditation Program (AMAP), the American Accreditation HealthCare Commission/Utilization Review Accreditation Commission (AAHC/URAC), and the Accreditation Association for Ambulatory Healthcare (AAAHC). In addition, the Foundation for Accountability (FACCT) and the Agency for Healthcare Research and Quality (AHRQ) play essential roles in ensuring the quality care of healthcare.

Each accrediting body is unique in its mission, activities, compositions of its boards, and organizational histories. Each develops its accreditation process and programs and sets its accreditation standards. Accreditation is a process in which an accreditation agency conducts a systematic assessment of an organization based on a set of quality standards. This usually involves a formal survey visit at the organisation after which the accreditation agency makes a decision on the granting of accreditation status to the organisation. Accreditation has been introduced in many health systems across the world as an instrument for quality control and quality improvement The basic idea is that the target organisations improve on quality and patient safety by seeking adherence to the requirements of the accreditation standards during the process of preparing for the survey visit and/or in response to the assessment of the surveyors. Studies have reported positive outcomes of accreditation in general practice, particularly in the area of patient safety. Hospital accreditation contributed to the improvement of healthcare quality in general, and more specifically to patient safety, as it fostered staff reflection, a higher standardization of practices, and a greater focus on quality improvement. At New York Presbytarian where I work the

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positive impact of accreditation resulted from the approach the hospital adopted the the new EPIC system and implementation as well as other practices required by accreditation were already in place at the hospital, were mademore effeceint

“Accreditation is like the Grammys for your organization”, showing that you follow industry standards and best practices. But Accreditation in healthcare isn't just about reputation. Going through the accreditation process helps standardize operations, improve the quality of care, and build trust with patients and the community. Joint Commission accreditation can be earned by many types of health care organizations, including hospitals, doctor's offices, nursing homes, office-based surgery centers, behavioral health treatment facilities, and providers of home care services. Accreditation is awarded upon successful completion of an on-site survey. The on-site survey is conducted by a specially trained Joint Commission surveyor or team of surveyors who assess your organization's compliance to our standards. Accreditation for most types of organizations is a three-year award.

Accreditation Requirements

Hospitals and ambulatory surgery centers choose to voluntarily apply for accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Accreditation Association for Ambulatory Health Care (AAAHC), or the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF) as appropriate. The facilities must comply with written standards regarding the environment of care, the provision of care, and the quality of care. Regular surveys of the organization’s performance by the accrediting agency

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are intended to ensure the quality of care provided to the patients entrusted to our care. The accreditation process certifies to the health care community and the community-at-large that the facilities meet nationally accepted standards through a recognized accreditation program. Keeping up with the many rules and regulations associated with health care can be a challenge in these times of constantly increasing and changing local, state, federal, and accreditation agency regulations. The task can be made simpler by using a quality improvement process to track and enhance performance and compliance. (Burden, 2003)

Accreditation and Regulatory Compliance Both Accreditation and certification are terms used by credentialing authorities Accreditation is a voluntary process in which an agency is evaluated for compliance against a particular set of established criteria. Accreditation requires ongoing compliance with the established accreditation criteria; healthcare organization establishes some internal standards and rules for operations. But Accreditation ensures that your organization meets regulations and standards set by a recognized, external organization. In healthcare, patient trust is essential. Patients are putting their health and their lives in the hands of healthcare staff. Accreditation shows your patients that they can trust your organization to take care of them. It also demonstrates to the community that you are seeking to provide the highest quality service possible.

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When community members see that your organization is accredited, they know that you have voluntarily undergone the process of meeting rigorous standards. This increased confidence brings in more patients and can help your organization build partnerships within your community. Hospitals pursue Accreditation because it is required for their organizations to receive payment from federally funded Medicare and Medicaid programs. (R1 RCM, 2020) The term certification is synonymous with the term accreditation. However, the two terms have very different meanings. The two processes seem to be very similar, so it can be challenging to understand the differences. Certification, like Accreditation, is a voluntary process. Certification provides written assurance that a person, product, or process conforms to specified requirements and standards. Accreditation, is an attestation made by a third party. For example, a joint commission accredited outpatient clinic can be certified programs or services like ophthalmology or diabetes. These programs in the community both require evaluation by the joint commission. This covers compliance with the standards and recommends improvement if needed., earning them the joint commission seal of approval. (Accreditation and regulation: Can they help improve patient safety? 2009)

Accreditation is a continual process and does not end when credentials are obtained. The initial survey process ensures that the health care facility or organization has established high standards for safety and quality, and another survey is not performed with prior notice. During this time, the health care facility is expected to uphold the same standards and ensure they maintain the highest quality of care. Joint Commission surveyors visit accredited health care

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organizations a minimum of once every 36 months (two years for laboratories) to evaluate standards compliance. This visit is called a survey. All regular Joint Commission accreditation surveys are unannounced. (Joint commission FAQs)

For an organization to maintain, their accreditation they must continue to operate by the accreditation standards of care, after they have attained their Accreditation. The first accreditation survey can take a short period. The accreditation agency will have to complete another one three years after the first one. This means that every healthcare facility that has been given the accreditation credentials has to work hard towards maintaining them, especially since they are up for another survey. This can be achieved only if the organization sets up a routine survey that will enable them to maintain the compliance standards in the healthcare organization. The organization can ensure compliance by hiring quality care managers to implement annual compliance rounds to help them analyze if they are maintaining standards. If not implement the changes needed to meet, annual rounds should be done at various times in the year to establish their compliance towards accreditation requirements.

Staff should annually review the accreditation compliance standard during a staff meeting or staff training. Such as AHT Annual Health Training. Keep the team aware of the significance of maintaining the accreditation credentials, enable them to know the specific standards that the agency expects from the organization allowing it to meet the high-quality standards expected by joint commissions. This will encourage open communication with staff, addressing areas that need improvement and highlighting areas that the company is already doing well. Routinely briefing of the accreditation compliance will keep staff minds fresh on the quality standards

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required to maintain Accreditation which will help the following accreditation survey be more accessible and complete as they are aware of the requirements and what is expected by the accreditation agency. The best practice is to keep the staff aware of the significance of maintaining the accreditation standards and know the specific standards that the agency expects from the organization. Annual huddled encourages open communication between employees, which will aid in the addressing of areas that the organization needs to improve and highlight areas that the company is already doing well at my hospital. This practice is called safety Fridays

Accreditation has many benefits; being accredited goes a long way in making your health care organizations adapt better and standard facilities for a better remark from the accreditation bodies. This uplifts and effective operation of the healthcare, but it also equally encourages better patient care and management. (iDealmedhealth, 2021) Transparency is facilitated by Accreditation because each healthcare organization is expected to reach a set standard when Accreditation is achieved. Competition among the health care system and other organizations, one of the things that give a health care system edge over others is Accreditation. (2021).

Another benefit of Accreditation is that Accreditation Helps facilities avoid Recovery Audit Contractor (RAC) issues by developing a plan to link quality patient care with RAC strategies, including improved documentation, better risk stratification, and improved processes; another is Financial benefits are twofold: Increased volume leads to increased revenue, and Medicare payments to accredited hospitals are maintained due to appropriate patient status placement Defines risk stratification to ensure proper order of patients based on clinical

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presentation and initial response to treatment Reduces the liability of missed Mis by using a consistent risk stratification approach for the ACS patient based on research and best practices. Accreditation Improves relationships and integrates processes with EMS and Dispatch Services, thus reducing Door-to-Balloon times, but the primary benefit of being accredited is that it increases trust with consumers. What is regulatory compliance? Regulatory compliance is when businesses follow state, federal and international laws or regulations relevant to operations. Regulatory compliance is when businesses follow state, federal and international laws or regulations relevant to operations. Regulatory compliance, in fact, deals with a set of guidelines that the law requires organizations to follow. Regulatory compliance in Healthcare is all about a healthcare organization's adherence to laws, regulations, guidelines, and specifications relevant to its business processes. Violations of regulatory compliance regulations often result in legal punishment including federal fines.Jun 7, 2019 It might involve, for example, observing rules set forth by the Occupational Safety and Health Administration (OSHA) to ensure a safe work environment for employees. Another example of regulatory compliance regulations include HIPAA), The Standards for Privacy of Individually Identifiable Health Information (“Privacy Rule”) establishes, for the first time, a set of national standards for the protection of certain health information. The U.S. Department of Health and Human Services (“HHS”) issued the Privacy Rule to implement the requirement of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).1 The Privacy Rule standards address the use and disclosure of individuals’ health information—called “protected health information” by organizations subject to the Privacy Rule — goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's

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health and well being. The Privacy Rule covers a health care provider whether it electronically transmits these transactions directly or uses a billing service or other third party to do so on its behalf. Health care providers include all “providers of services” (Secretary & (OCR), 2013) Regulatory rules has increased since the turn of the century, regulatory compliance management has become more prominent in a variety of organizations. The development has led to the creation of corporate, chief and regulatory compliance officer and compliance manager positions. The complienecr officer primary job function is to ensure the organization conforms to stringent, complex legal mandates and applicable laws. Some Important Regulations in United States Health Care system are Healthcare Quality Improvement Act of 1986 (HCQIA) .The Healthcare Quality Improvement Act (HCQIA) provides immunity for medical professionals and institutions during conduct assessments. The law originated partially due to a Supreme Court ruling involving abuse of the physician peer review process. Medicare. The Medicare program provides insurance coverage for almost 50-million American citizens. In 1945, President Harry Truman rallied Congress for funding to insure all United States citizens. (Assistant Secretary for Public Affairs (ASPA), 2021) The Paperwork Reduction Act (PRA)3 of 1980 was designed to help mitigate the administrative burden generated by new regulations by providing an objective assessment of the impact a proposed or final rule has on public reporting requirements. (Assistant Secretary for Public Affairs (ASPA), 2021) Medicaid. ... The Medicare program provides insurance coverage for almost 50-million American citizens. In 1945, President Harry Truman rallied Congress for funding to insure all United States citizens. (Assistant Secretary for Public Affairs (ASPA), 2021)

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Children's Health Insurance Program (CHIP) ... The Medicare program provides insurance coverage for almost 50-million American citizens. In 1945, President Harry Truman rallied Cogress for funding to insure all United States citizens. Hospital Readmissions Reduction Program (HRRP) The Hospital Readmissions Reduction Program (HRRP), an Affordable Care Act initiative, requires the Centers for Medicare and Medicaid Services (CMS) to reduce payouts to care facilities that experience excessive patient readmissions. Affordable Care Act of 2010 In March 2010, president Barak Obama sanctioned the Affordable Care Act (ACA), a somewhat modified version of the all-inclusive coverage imagined by presidents since the early 1900s. The act requires most U.S. citizens to apply for health insurance coverage, levying a penalty for individuals who fail to secure insurance but making exceptions for a few protected groups. Under the law, enterprises that employ more than 200 workers must provide health insurance coverage. Health Insurance Portability and Accountability Act (HIPAA) of 1996. The Health Insurance Portability and Accountability Act (HIPAA) protects America workers by allowing them to carry health insurance policies from job to job. The Patient Safety and Quality Improvement Act (PSQIA) protects health care workers who report unsafe conditions. [6] Legislators created the law to encourage the reporting of medical errors, while maintaining patients’ confidentially rights. To ensure patient privacy, the HHS levies fines for confidentially breaches. (Assistant Secretary for Public Affairs (ASPA), 2021)

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Accreditation Best Practice The best practices the Joint Commission identified are those that are considered ‘new’ to the surveyors, meaning they’ve never seen these exact practices, policies or protocols before,” says Meredith Foxx, Associate Chief Nursing Officer of Advanced Practice Nursing and Nursing Quality and Practice. Research shows that incorporating patient safety and care quality as a part of the patient experience inproves outcome A recent study in JAMA Surgery shows that negative patient experience reports are often tied to adverse surgical outcomes. Implementing best practices Such as Do not disturd lights. “Implemented on various inpatient nursing units, such as the pediatric ICU and medical-surgical units, “Do Not Disturb” lights, which are red in color, are located outside the doors to patient rooms. When lit, the lights indicate that a nursing caregiver is in the room with a patient and should not be disturbed. (PatientEngagementHIT, 2017)

Studies also show not engaging in best pratices cause negative patient experience. These patient experiences were largely tied to surgical complications, medical complications, and readmissions.To reduce negative patient experiences, the researchers advised providers to focus on better patient-provider communications. Patients who trust and can speak freely to clinicians are more likely to express a care preference or safety concern. Quality patient care start and end with quality treatment and patient safety. (PatientEngagementHIT, 2017)

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Other A...