...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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...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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...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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...A1. Sentinel Event On the evening of September 14, 2011 a sentinel event occurred at Nightingale Hospital. According to Joint Commission, a sentinel event is characterized as an unexpected occurrence involving death or serious injury mother proceeded physical), or the risk thereof (http:www.jointcommission.org). A three year old child was accompanied by her mother for an outpatient procedure scheduled for September 1, 20111. The mother proceeded to register the child for the procedure and was provided details regarding anticipated length of surgical time and physical assessment. The pre-operative nurse was informed by the mother of the child that she needed to run an errand but left contact info(i.e. cellphone number) with the child’s nurse in the event the surgical procedure was to end sooner than expected. Unfortunately, the pre-operative nurse did not chart this pertinent information in the patients chart, it was documented on a sticky note attached to the chart. Post-surgery, the child was taken to the recovery area with care assumed by a recovery team without sight of mother. The father of the child presented to the recovery room and began hugging the child and was able to verify child’s name, date of birth, and was listed on face sheet in chart as father of the child with proper identification. Discharge instructions were provided to the father and the child was released in the fathers’ care. Approximately two and a half hours later, the mother arrived to the unit to...
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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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...experience for all. Overview In order to reach the aforementioned goals, values and commitments, Nightingale Community Hospital must be in compliance of regulatory agencies which outline specific, goaloriented sets of standards. The Joint Commission is one such agency that provides assistance and support to health care facilities to ensure that certain standards are met, education for implementing new standards and feedback of current healthcare practices as part of the accreditation process. According to Facts about Hospital Accreditation (2014), the “Joint Commission standards address the hospital’s performance in specific areas, and specify requirements to ensure that patient care is provided in a safe manner and in a secure environment (p. 1).” This agency uses a Priority Focus Process methodology to identify areas within healthcare organizations which have a significant impact on patient safety and quality of care. One of these areas that Nightingale Community Hospital would like to focus on is communication. According the O’Daniel and Rosenstein (2008), “Lack of communication creates situations where medical errors can occur. These errors have the potential to cause severe injury or unexpected patient death…More specifically, the Joint Commission cites communication failures as the leading root cause for medication...
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...can cost a facility or hospital millions even billions of dollars each year. Medical malpractice not only will cost money but it can also hurt a hospital or facility reputation for treatment for patients. Medical malpractice cases require stringent and comprehensive clinical review, and hospitals always employ medical experts to review their cases. The clinical issues are always analyzed, but often overlooked is the evaluation of the corporate responsibilities of the hospital involved in the matter. It is becoming increasingly likely that the hospital will be included in the claim as plaintiff attorneys are very aware that courts are finding corporate negligence as a factor in many claims, and more and more states are recognizing corporate negligence as a contributing issue (Steinberg, Becker Hospital 2012). Dr. Steinberg states “As a consultant and expert witness, I see many cases that could be avoided with some thoughtful review and analysis. Typically, the cases I review are either related to the hospital not following Joint Commission standards, either by ignoring required policies and procedures, or physician credentialing and privileging...
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...Johnniece Harris Long Term Care Facility Joint Commission Accreditation Long term care facilities use Joint Commission Accreditation as a benefit to show the quality and commitment to the health care organization. A long term care facility that is Joint Commission accredited will have a more appealing look to reimbursement centers and to the patient and families that they care for. Having this accreditation is also a risk management tool. The likelihood of a bad outcome is reduced if a facility is accredited by the Joint Commission. There is a team put together to come up with accreditation standards and to make sure facilities stay compliant with these standards. Performance is evaluated to ensure standards are followed. Joint Commission accreditation has been around for many years. Most Long Term Care facilities today are not joint commission accredited. There are eligibility requirements that must be met in order for facilities to become accredited. A facility has to have beds licensed by the state as nursing home beds, excluding intermediate care facilities specializing in care for individuals with mental retardation and other developmental disabilities. Beds designated as long term care beds under a hospital license, excluding beds belonging to a long term acute care hospital and hospital swing beds. Beds, units or facilities certified by Medicare or Medicaid as skilled nursing facility beds. Beds, units or facilities designated as long term care by a governmental...
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...Community Hospital (NCH) is currently preparing for its triennial Joint Commission survey which is expected in approximately 13 months. The Joint Commission primary focus areas for NCH are Information Management, Medication Management, Communication, and Infection Control. The primary focus area outlined in this summary is Communication. The Joint Commission has three standards in which NCH is evaluated. Currently, NCH is non-compliant with standards UP.01.01.01 and UP.01.02.01. They are: * UP.01.01.01 - Conduct a pre-procedure verification process. * UP.01.02.01 - Mark the procedure site. As stated in the policy "Site Identification and Verification (Universal Protocol)," the Preoperative / Preprocedure verification is a five step process. This process needs to be expanded to meet the minimum standard of care. The following corrective actions must be immediately implemented. The patient must be properly identified at the time of admission. The admissions staff will require the patient to provide proper identification while verbally verifying their name and date of birth. If the patient is unable to verify their identity, a family member or other legal representative must be able to identify the patient. Identification bands will be verified and placed on the patient as the patient is being admitted. Confirmation of the patient’s identity must be established and documented. Transferring responsibility for care of the patient to another caregiver must be documented...
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...Gateway launched a program that was aimed at increasing the awareness of the benefits of full-term delivery, and reducing the number of elective deliveries between 37 and 39 weeks gestation (Gateway Medical Center, 2015). The problems with delivering babies at this point of gestation is the increased risk for respiratory distress, jaundice, and hypoglycemia that could result in death before the child’s first birthday (Gateway Medical Center, 2015). With effective leadership surrounding this process improvement, the hospital has been able to reduce the number of deliveries to less than 5% for the last 6 months (Gateway Medical Center, 2015). The hospital has also become a member of the Joint Commission (Gateway Medical Center, 2015). The Joint Commission accreditation will conduct surveys to evaluate the facility’s compliance with national standards (Gateway Medical Center, 2015). These improvements can only be achieved by having strong leadership within the hospital. The executive staff of Gateway Medical Center has been able to give the employees the tools needed for process improvements, and is working towards making the community members more comfortable with their level of...
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...transfusing patients, maintaining a healthy patient care environment by complying with the Center for Disease Control (CDC) and World Health Organization (WHO) hand hygiene guidelines, continuing evidence-based best practice to prevent or reduce the risk of catheter-associated urinary tract infections (CAUTI), identifying patients at risk for suicide. Within the rest of the accreditation requirements the facility was compliant with the following elements: EM-emergency management HR-Human Resources IC-Infection Prevention and Control IM-Information Management MS-Medical Staff PI-Performance Improvement RI-Rights and Responsibilities of the Individual TS-Transplant Safety Trends of noncompliance within the healthcare system From the list of recorded finding there are several trends identified in which the hospital is will need to address to meet the Joint Commission (JC) standards. The list is divided into direct and indirect impact. There are 4 indirect impact issues that need to be addressed and 1 direct impact issue. Indirect Impact Trends Verbal Orders-Verbal orders are not being authenticated within the 48 hours on several units. The hospital audits should show a 100% compliance regarding verbal orders. The audit shows the hospital has not been compliant during the past 12 months. The highest percentage was 90%. On 3E, 4E, ED, PI data and telemetry are the area where improvements need to be made. Clutter in the hallway-Clutter in the hallways creates a risk to patients...
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...The Joint Commission has set accreditation standards in such places as General Hospitals, Nursing Homes, Behavioral Hospitals, and Labs that evaluate the safety and care provided by these institutions. The Joint Commission will come to a facility unannounced, this will help the and do a comprehensive onsite evaluation where they look at the patients experience in that facility and will focus on how that facility can improve their operational systems these improvement will help in the care and safety of the patients they are caring for. The standards that the commission have developed are based on feedback with patients as well as healthcare professionals and governmental agencies. The Joint Commission and the HIT professionals work in conjunction with one another to make a medical facility safe for the patients, as well as protect the facility. According to The Sentinel Alert Event a publication published by The Joint Commission , “As health IT adoption spreads and becomes a critical component of organizational infrastructure, the potential for health IT-related harm will likely increase unless risk-reducing measures are put into place.” The Joint Commission suggest there are three crucial areas where action need to be taken in order to reduce further harm caused by a faulty systems...
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...Continuous Accreditation Compliance - Task 4 AFT2 Accreditation Audit October 31st, 2014 Continuous Accreditation Compliance - Task 4 Nightingale Community Hospital (NCH), like many other health care facilities, uses a Periodic Performance Review (PPR) as an assessment tool that assists in examining performance on a consistent basis to ensure compliance with Joint Commission standards. A PPR concentrates attention on procedures, methods, and processes that contribute an environment that provides for proper care and emphasizes patient safety. NCH has shown to be 100% compliant with the majority of standards including: Infection Prevention and Control, Right and Responsibilities to Patients, Human Resources, Transplant Safety, Emergency Management, and Performance Improvement. During the last inspection NCH was found to be non-compliant in the following areas: National Patient Safety Goals, Record of Care, Environment of Care, Nursing, Treatment and Services, Leadership, Life Safety, Provision of Care, and Universal Protocol. Trending Areas of Concern The PPR revealed numerous issues in all areas of NCH. In order to address issues that affect patient safety and accreditation it is necessary to focus on issues that are found to be present in several areas of the facility. These patterns and trends of non-compliance often expose a weakness in policy, procedure, or training that needs to be addressed in order to ensure patient safety and accreditation compliance...
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...Accreditation Audit AFT Task 1 Roland Helmuth Western Governors University Accreditation Audit AFT Task 1 Medication Management A. Compliance Status I will be reviewing three specific areas dealing with medication management. They are the following with the correlating Joint Commission Standard following each one: 1. The hospital plans its medication management process, (MM.01.01.01). 2. Label all medications, medication containers, or other solutions on and off the sterile field, (NPSG.03.04.01). 3. Reduce the likelihood of patient harm associated with the use of anticoagulation therapy, (NPSG.03.05.01). In review of standard MM.01.01.01, I see that Nightingale Community Hospital (NCH) has a policy that speaks directly to this standard. The elements of performance are met by the policy that is in place and includes further information to make this important standard compliant with Joint Commission standards. In review of standard NPSG.03.04.01, I do not find the NCH has a policy that addresses this. Seeing that NCH has surgical and sterile procedures performed at its facility this standard needs to have a policy in place. The basis of this is patient safety related to the five rights of medication administration; Right patient, Right medication, Right dose, Right route and Right time. Even in a controlled environment of a surgical suite, this is vital to any procedure performed. In review of...
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...A. Compliance Status The following executive summary focuses not only on the identified gaps in the current process, but also the corrective action plan to support compliance in the noted areas of the Communications Standards as provided by The Joint Commission, (National Patient Safety Goals, 2013). The high risk associated with surgical procedures performed on the wrong site has driven a risk mitigating approach to the processes involved for these procedures. The goal is to prevent harm to patients having a surgical procedure. The following summary is the current compliance status if the Priority Focus Area of Communication for Nightingale Community Hospital. After review of the specific areas identified in the Priority Focus Area, the following have been identified as requiring further attention: time-outs are routinely performed prior to every procedure (UP 01.03.01) and procedure site is marked (UP 01.02.01). Based on the evaluation of the Nightingale Community Hospital National Patient Safety Goals for Communications the current compliance rate related to the Universal Protocol Time-Out processes performed hospital wide indicate a 95% to 100% compliance rate for the year. The graph provided in the Nightingale Community Hospital National Patient Safety Goals Communication assessment provides limited information as these are hospital wide percentages. No unit specific evaluations of performance have been provided in the report. Upon review of the Site Identification and...
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