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Hospital Accreditation

By Darcy Brunick, Kristin Bumpass, Sierra Caudle
by

Darcy Brunick

on 18 July 2013

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Transcript of Hospital Accreditation

Hospital Accreditation
Darcy Brunick
Kristin Bumpass
Sierra Caudle

Hospital Accreditation Process
Joint Commission Requirements:
Fulfill state requirements
Inpatient eligibility; new hospital must have one active inpatient case and 10 inpatient records at the time of survey
If seeking medicare certification they must also have an Average Daily Census of 21 or more
If it's a specialty facility they must provide patient records for 10% ADC but not less than 30 ~ if the ADC is less than 30 they must provide 20 inpatient records

Eligibility for Hospital and Critical Access
Must be in US or US territories
Organization assesses and improve quality of care, treatment, services and review of clinicians
Identifies the services it provides, indicating which care, treatment and/or services it provides
provides services addressed by The Joint Commission Standards
Benefits of Becoming Accredited
Helps organize and strengthen patient safety efforts
Strengthens community confidence in the quality and safety of care, treatment and services
Provides a competitive edge in the market place
Improves risk management and risk reduction
May reduce liability insurance costs
Provides education on good practices to improve business operations
Provides professional advice and counsel, enhancing staff education
Provides a customized, intensive review
Objectives
Conclusion
The impact that hospital accreditation has on patient care and safety
The integral role that nurses play in hospital accreditation
How accreditation shapes the nursing process and role in the hospital setting
The process of hospital accreditation
How to make a positive impact on the accreditation process in a hospital setting
Discuss the process of Hospital Accreditation
Discuss the benefits of becoming a Joint Commission Accredited Hospital
Discuss the nurses role in Hospital Accrediation
Benefits of Becoming Accredited continued...
Enhances staff recruitment and development
Provides deeming authority for Medicare certification
Recognized by insurers and other third parties
Provides a framework for organizational structure and management
may fulfill regulatory requirements in select states
Survey Process
On site team survey consisting of one or more Health Care Professionals, including a physician, nurse, life safety code specialist, or hospital administrator
Tracing the care delivered to patients
Verbal and written information provided to the Joint Commission
On-site observations and interviews by the Joint Commission surveyors
Documents provided by the organization

Research ~ strong scientific evidence demonstrates that preforming the evidence-based care process improves health care outcomes, either directly of by reducing risks of adverse outcomes
Proximity ~ preforming the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs

Core Measures
Venous Thromboembolism
Heart Failure
Emergency Department
Surgical Care Improvement Project
Substance Use
Tobacco Treatment
Pneumonia Measures
Immunization
Acute Myocardial Infarction
Children’s Asthma Care
Hospital-Based Inpatient Psychiatric Services
Perinatal Care
Stroke
Hospital Outpatient Department
Steps to Improving Practices
In addition to the core measures hospitals use:
Accreditation Standards – TJC uses a multi-phase process involving health care experts and other stakeholders to develop standards
National Patient Safety Goals – focus on specific aspects of care that have proved problematic and often do harm and recommends steps to prevent or correct the issues.
Steps to Improving Practices
Joint Commission Standards
Addresses the Hospital’s performance in these specific areas:
Environment of Care
Emergency Medicine
Human Resources
Infection Control and Prevention
Information Management
Leadership
Life Safety
Medication Management
Medical Staff
National Patient Safety Goals
Nursing
Performance Improvement
Provision of Care, Treatment, and Services
Record of Care, Treatment, and Services
Rights and Responsibilities of the Individual
Transplant Safety
Waived Testing

Improving Practices, continued
National Patient Safety Goal for Medication Reconciliation







Taken from: The Joint Commission, National Patient Safety Goals,
www.jointcommission.org/patientsafety/nationalpatientsafetygoals/08_npsg_htm.
How JCAHO Improves Patient Outcomes
Table 5: Pneumonia Care Measure Results
Taken from Improving America’s Hospitals: The Joint Commission’s Annual Report on Quality and Safety 2012 Page 28

Role of the Nursing Team During
the Accreditation Process
The Nursing Team:
Performs all Standard Operating Procedures (SOP) and these are reviewed continuously
Cares for the human being, individually, within the family an the community,
Develops important actions, through care, are responsible for the comfort, care and well-being of the patients
Provides conditions for this care to occur in a safe way with quality
Trains the professionals as a strategy for reorganizing the work processes in pursuit of continuous improvement
Conducts training to try to be up to date
Passes the information to the team, including the medical team

Implications of Accreditation for the Nursing Team
Positive aspects include;
A feeling of pride, satisfaction, and achievement for helping the hospital pass the audit
Nurses feel that accreditation better prepared to meet the needs of the client
Providing a favorable organizational climate conducive to strengthening the relationships
Negative aspects include;
Feeling undervalued
Feeling that error are being sought out
Feeling their mistakes are criticized and victories are not praised or rewarded
Stress during the accreditation survey process

Nurses must be Prepared
Be familiar with JCAHO Standards, the accreditation manual and scoring guidelines
Mentally go over the policies and procedures of the hospital and unit
Learn as much as you can about the newest survey process
Attend hospital workshops on The Joint Commission standards and survey procedures
A Patient Safety Success Story
While caring for patients a nurse in the CCU at Brunick-Bumpass-Caudle Medical Center, Sara H. noticed that the Robin B.’s weight was recorded in pounds not kilograms. Since medication doses are calculated based on weight in kilograms, Sara knows that there would be serious medication errors if the dose was calculated based on RB’s weight in pounds.
Sara also knows that as a nurse leader at an accredited hospital medication error prevention is a main priority to improve patient outcomes so she fixes the chart to reflect her patients weight in kilograms, calls the Physician and double checks that all the medication orders reflect the correct dosage based on RB’ weight in kilograms. She sees that RB has morphine ordered at 10mg/70kg q4hrs. Under her weight in pounds, 154, that would be 20mg q 4hrs instead of the 10mg q 4hrs as the physician had intended.
She also contacted the IT department to inform them that the default setting for patient’s weight was set to pounds causing the error in the first place. After the IT department fixed the setting in the electronic records, she helped the hospital avoid future medication errors.
NCLEX Style Questions
When Sara caught this error, she was protecting herself, her patient and the hospital. Which areas of the Joint Commission’s standards was Sara complying with? Select all that apply:

A. Human resources
B. Leadership
C. Infection Prevention and Control
D. Medication Management
E. National Patient Safety Goals
NCLEX Style Questions
When Sara caught this error, she was protecting herself, her patient and the hospital. Which areas of the Joint Commission’s standards was Sara complying with? Select all that apply:

A. Human resources
B. Leadership
C. Infection Prevention and Control
D. Medication Management
E. National Patient Safety Goals
NCLEX Style Questions
Joint Commission Standards address the Organization’s level of performance in key functional areas in all of the following except?

A. Patient focused functions
B. Organization focused functions
C. Structures with functions
D. Community focused functions
NCLEX Style Questions
Joint Commission Standards address the Organization’s level of performance in key functional areas in all of the following except?

A. Patient focused functions
B. Organization focused functions
C. Structures with functions
D. Community focused functions
Goals for the Hospital of the Future
Technology Adoption:
Establish the business case and sustainable funding sources to support the widespread adoption of health information technology
Redesign business and care processes in tandem with health information technology to ensure benefit accrual
Use digital technology to support patient-centered hospital care and extend that care beyond the hospital walls
Establish reliable authorities to provide technology assessment and investment guidance for hospitals
Adopt technologies that are labor-saving and integrative across the hospital

Principles to Guide Achievement of Patient-Centered Care
Make adoption of patient-centered care values a priority for improving patient safety and patient and staff satisfaction
Incorporate patient-centered care principles into the activities of hospital oversight bodies and transparency initiatives
Address barriers to patient and family engagement, such as low health literacy and personal and cultural preferences
Eliminate disparities in the quality of care for minorities, the poor, the aged and the mentally ill
Improve the quality of care for the chronically ill through adoption of care models that encourage coordinated, multi-disciplinary care
Use robust process improvement tools to improve quality and safety, and support achievement of patient-centered care

JCAHO’s Five Year Plan
Refinement of the process for electronic receipt of high quality standardized performance measure data that cover all aspects of care delivery
Expansion of the scope of measure sets available for selection by health care organizations
Creation of sophisticated applications of measurement data use for accreditation, accountability and public reporting purposes
Coordination of data demands and prioritization of critical measurement areas by the various public and private sector entities to minimize data collection burden and eliminate redundancies for health care organizations, while maximizing the consistency and usefulness of the data.
Continued, proactive support for the leadership role of the National Quality Forum in the identification of national measurement objectives and the establishment of a long term collaborative relationship
Continued proactive support for and participation in, the work of the Hospital Quality Alliance, The AQA and their combined efforts to harmonize these activities.
Accountability Measures
Research ~ strong scientific evidence demonstrates that preforming the evidence-based care process improves health care outcomes, either directly of by reducing risks of adverse outcomes
Proximity ~ preforming the care process is closely connected to the patient outcome; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs
How Hospital Accreditation shapes the healthcare
Present
Governs rules and regulations related to patient care and safety
Sets a standard for how patient care should be delegated and implemented
Gives guidelines for how to implement nursing practice
Future
Sets future goals and guidelines for nursing practice
Helps to determine the best safety practice for future implementation
Helps nurses to better implement evidence based practice into future nursing care
AHA MOMENT....
Crestwood Hospital was named a
top performing hospital in
The Joint Commission 2012 Annual Report.
References:
Chassin, M. (2008). The Joint Commission: a new look at what it can do; improved patient safety and satisfaction, marketing strength, reduced liability premiums – to name a few. The Journal of Family Practice Current Clinical Practice.

Manzo, B. F., Ribeiro, H. C. T. C., Brito, M. J. M., & Alves, M. (2012). Nursing in the hospital accreditation process: practice and implications in the work quotidian. Rev. Latino-Am. Enfermagem vol.20 no.1 Ribeirão Preto Retrieved July 13, 2013 from http://dx.doi.org/10.1590/S0104-1169201200010002

Moore-Greenlaw, R.C. & Hurley, M.L. (1994). “Nurses are the key to hospital accreditation.” Health Source: Nursing/Academic Edition. RN 57.3, p 31-33, Retrieved June 28, 2013 from http://search.ebscohost.com.elib.uah.edu/login.aspx?direct+true&db+hch&AN=9407014960&site+ehost-live

Motacki, K., & Burke, K. (2011). Nursing Delegation and Management of Patient Care. St Louis, MO: Mosby Elsevier.

The Joint Commission. (2010) Evolution of performance measurement at the Joint Commission 1986-2010: a visioning document, Attachment B. Washington, DC: Government Printing Office.

The Joint Commission. (2012) Fact about accountability measures. Washington, DC: Government Printing Office.

The Joint Commission. (2013) Fact about hospital accreditation. Washington, DC: Government Printing Office.

The Joint Commission. (2013) Improving America’s hospitals, The Joint Commission annual report on quality and safety 2012. Washington, DC: Government Printing Office.
Nurses Must be Prepared
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