Write a 1,250-1,500-word essay about quality improvement. Include the following points in your essay:
Evaluate which accrediting body would be most appropriate for your health care organization.
Summarize the requirements to obtain accreditation.
Based on your research and experience, what performance or quality metrics could you focus on for a quality improvement project to present to the accrediting body?
How does the quality performance financially impact the organization?
Include at least three references, INCLDING THE TEXTBOOK.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.
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Quality Improvement Essay
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Quality Improvement Essay
Patient safety and healthcare quality have a great influence on the choice of healthcare delivery processes in healthcare organizations. While poor-quality health care services and increased cases of medical errors can prevent healthcare organizations from obtaining reimbursement from insurers, it is important to note non-adherence to patient safety and healthcare quality standards set by the accrediting body can make hospitals lose accreditation. Losing accreditation causes huge financial impacts for healthcare organizations and limits their ability to bill federal payers (Penner, 2017). Numerous agencies in the United States have the authority to accredit healthcare organizations by establishing standards to direct their healthcare delivery processes (Clancy et al., 2021). The purpose of this quality improvement essay is to evaluate the accrediting agency that would be the most appropriate for my healthcare organization, summarize the requirements for obtaining accreditation, outline the performance metrics to focus on in a quality improvement project, and discuss the financial impacts that quality performance has on healthcare organizations.
Accrediting Body
The nature of services that a healthcare organization provides determines the accrediting agency that it will choose to authorize its existence. The accrediting body that would be the most appropriate for my healthcare organization is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), commonly known as the Joint Commission (The Joint Commission, 2022a). The Joint Commission is an independent agency that offers an unbiased evaluation of healthcare organizations to establish whether the services that they offer achieve the desired quality standards. The mission of the Joint Commission 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, 2022a).” The reason for choosing the Joint Commission is that the agency bears a global symbol of quality improvement and will be the most appropriate to assess the services of the organization.
The organization will enjoy numerous benefits when it allows the Joint Commission to evaluate its services and provide accreditation. For example, since the Joint Commission utilized evidence-based practice standards to shape clinical practice, its accreditation will create a high-performance bar for the organization to ensure that they apply recommended interventions to promote healthcare quality and patient safety. Besides, the organization will benefit greatly from the intensive review conducted by the Joint Commission, taking advantage of the organization’s background. Notably, the Joint Commission normally makes public those organizations that meet the desired accreditation standards. In this respect, a Joint Commission accreditation will increase communication and enhance collaboration between the organization and other like-minded facilities thereby facilitating knowledge sharing regarding issues that affect patient safety and healthcare quality (The Joint Commission, 2022b). Most importantly, the Joint Commission accreditation will increase the organization’s access to support services, tools, and resources for continued quality improvement.
Requirements to Obtain Accreditation
Organizations must meet the requirements that are set by the Joint Commission to be able to receive accreditation. Although there are general eligibility requirements that all organizations must meet, the Joint Commission has set conditions specific for facilities based on the types of services that they are providing (The Joint Commission, 2022c). In this respect, the organization that is seeking accreditation will have to meet the eligibility requirements for a Nursing Care Center to be able to receive accreditation from the Joint Commission. Prior to accreditation, the Joint Commission conducts an eligibility assessment to establish whether the facility meets all the set requirements.
The organization will have to meet all the seven eligibility requirements documented by the Joint Commission in order to obtain accreditation from the agency. First, the Nursing Care Center must be based in the United States or within its territories. For a facility that is located outside the United States, it must be operated by the United States Congress Charter or by the United States government. Second, the facility must be identified as a skilled nursing facility or as a nursing home. Besides, it must have beds for long-term care provided by the government, the state, or supplied by Medicare/Medicaid. Third, the facility must evaluate and improve the quality of healthcare services it offers to patients (The Joint Commission, 2022c). Fourth, the facility must be able to clearly identify the types or nature of services it is providing to patients. Fifth, it must provide healthcare services outlined in the Commission’s standards. Sixth, the facility must serve a patient population of at least five patients/residents and must have at least two active patients at the time when the survey is done. The seventh and the final requirement is that if the Nursing Care Center has up to 18 beds, the facility must have at least three residents or patients at the time it is requesting for accreditation and at least two active ones at the time when the survey is done (The Joint Commission, 2022c). The organization must be ready to meet the costs involved in the accreditation process.
Performance or Quality Metrics for a Quality Improvement Project
The Joint Commission utilizes specific performance or quality metrics to establish whether an organization is fit for accreditation. According to Stanhope and Lancaster (2021), nurses encourage quality improvement in their organizations by ensuring that their facilities are meeting the performance or quality measures set by accrediting agencies. In the current scenario, the nurse should ensure that a quality improvement project is performing well in the set metrics before presenting it for accreditation by the Joint Commission. The set metrics are quality measures that produce the greatest positive effects on patient outcomes. The specific criteria that the measures must meet include; demonstrate evidence-based practice support, be a measure that indicates an improvement in patient outcomes, a measure that indicates effectiveness in improving patient outcomes, and a measure with little or no chance of causing adverse events (The Joint Commission, 2022d). Measures that apply to healthcare organizations also apply to quality improvement projects that might require accreditation.
The measures that the nurse will focus on for a quality improvement project before presenting it to the Joint Commission for accreditation are a combination of outcome and process measures. The measures include; rates of medication/medical errors, length of stay, mortality rates, rates of healthcare-associated infections, rates of patient satisfaction, rates of employee satisfaction, 30-day readmission rates, and the percentage of people receiving the care that they require to address their health needs (Hussein et al., 2021). A quality improvement project should receive accreditation when it is performing well in the named measures.
The Effect of Quality Performance on the Financial Performance of the Organization
Quality performance is linked with financial impacts on the healthcare organization. Precisely, the organization will have improved financial performance when it is performing well in a number of quality measures. Conversely, poor performance in quality measures causes poor financial results (Penner, 2017). Published literature provides evidence that supports this notion. For example, in a study conducted by Akinleye et al. (2019) to examine the correlation between quality/safe care and hospital finances, the researchers discovered that poor quality performance such as high rates of 30-day readmission is negatively associated with the financial performance of healthcare organization. On the other hand, high-quality performances such as high patient safety scores are linked with positive financial outcomes in hospitals. Based on this evidence, healthcare organizations should strive to improve quality, not only to obtain and protect accreditation but also to improve financial performance.
Conclusion
Accreditation improves quality in healthcare delivery and encourages healthcare organizations to adhere to quality and safety standards set by the accrediting body. There are various accrediting agencies in the United States that healthcare organizations can consider for their accreditation needs. The accrediting body that would be the most appropriate for my healthcare organization is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), commonly known as the Joint Commission. The Joint Commission is an independent agency that will offer an unbiased evaluation of the healthcare organization to establish whether the services that it offers achieve the desired quality standards. Being, a Nursing Care Center, the facility will have to meet the requirements set for such organizations in order to receive accreditation from the Joint Commission. When presenting a quality improvement project to the Joint Commission for accreditation, the nurse must ensure that it meets the quality or performance metrics set by the agency. Since there is a direct correlation between quality performance and financial outcomes of a healthcare organization, contemporary medical facilities should strive to improve quality, not only to obtain and protect accreditation but also to improve financial performance.
References
Akinleye, D. D., McNutt, L. A., Lazariu, V., & McLaughlin, C. C. (2019). Correlation between hospital finances and quality and safety of patient care. PloS One, 14(8), e0219124. https://doi.org/10.1371/journal.pone.0219124
Clancy, C., Goodrich, K., Moody-Williams, J., Sheares, K. D., O’Kane, M. E., Cha, S., & Agrawal, S. (2021). Quality, safety, and standards organizations COVID-19 impact assessment: Lessons learned and compelling needs. NAM Perspectives, 2021, 10.31478/202107d. https://doi.org/10.31478/202107d
Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC Health Services Research, 21(1), 1057. https://doi.org/10.1186/s12913-021-07097-6
Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders (3rd ed.). New York, NY: Springer Publishing. ISBN-13: 9780826160010.
Stanhope, M. & Lancaster, J. (2021). Foundations for population health in community/public health nursing – e-book. 6th ed. Elsevier Health Sciences
The Joint Commission. (2022a). About the Joint Commission. https://www.jointcommission.org/about-us/
The Joint Commission. (2022b). Why choose the Joint Commission. https://www.jointcommission.org/accreditation-and-certification/why-the-joint-commission/#11f9ade9687443d090b3dd14b86483f9_0bf5ad80ee2c4bf99b741b6502fb1721
The Joint Commission. (2022c). Assess your eligibility. https://www.jointcommission.org/accreditation-and-certification/health-care-settings/nursing-care-center/learn/eligibility/
The Joint Commission. (2022d). Measures. https://www.jointcommission.org/measurement/measures/#:~:text=Accountability%20measures%20are%20quality%20measures,accountability%20and%20non%2Daccountability%20measures.