Health Law

Health Law

Part I: The Role of the Joint Commission in Accreditation

Facilities to be accredited

The Joint Commission (JC) can accredit many kinds of health care organizations (HCOs) through on-site evaluation to assess compliance with the standards and verify improvement activities. The HCOs include hospitals, nursing homes, behavioral health treatment facilities, doctor’s offices, office-based surgery centers, and home care service providers (The Joint Commission, 2020). Ambulatory care and laboratory services also fall within the programs that the Joint Commission accredits. The accreditation standards seek to address crucial operation elements in the medical facilities, including medication safety, patients’ rights, infection control, and patient care.

Goals of the Commission

The Commission’s National Patient Safety Goals (NPSGs) program, established in 2002, were meant to help the JC-accredited organizations to focus on specific patient safety areas of high priority (The Joint Commission, 2020). For example, the NPSG intended to avoid the use of confusing and potentially confusing abbreviations. The JC recognizes that many hospitals post a list of unapproved abbreviations that providers might use as shortcuts that cause medical errors (The Joint Commission, 2020). Therefore, there is a need for health care organizations to use accurate labels that ensure the proper identification and recording of patient details to avoid endangering their lives. The shortcuts might also hamper staff communication about the clients’ issues.

The Commission gathers information every year on emerging patient safety issues. The diverse experts and stakeholders are an essential source of the crucial data because they interact a lot with the patients and understand their needs and worries. The Commission collects information that forms the basis for the NPSGs and tailors the goals for each specific program. The data gathered also informs the Commission’s event alerts, performance measures, standards, and survey procedures, educational resources, and the JC’s Center for Transforming Healthcare Projects (Joint Commission, 2020). For example, in ambulatory health care, the Commission recommends the use of at least two ways for identifying the patient. The Joint Commission (2020) recommends using the name and date of birth to ensure each client gets the correct prescription and treatment. The basis for all of JC’s goals is the minimization of the likelihood of harm to the patients.

Impact of Guidelines on Non-credited Facilities

Since hospitals can use the Commission accreditation for marketing, the JC’s guidelines will deprive the non-credited facilities of the publicity required to highlight compliance with safety and quality standards. Therefore, there is the likelihood that the absence of the JC certificate will cause patients to avoid the hospital and choose other organizations that comply. The facility will lose clients and the revenues they will have earned by complying with the JC standards. In other words, accreditation is a factor in building the reputation of the health care organization. Patients prefer the organizations that consider their safety and the quality of the care they offer, with the standard being accreditation. The media plays a significant role in giving exposure to the facilities that comply, a benefit the non-accredited hospitals do not enjoy.

Moreover, the non-accredited hospitals are at a higher risk of losing out on the Medicare program compared to the compliant organizations. The federal government relies on the Commission’s surveys to determine the facilities that comply with the standards of safety and quality. According to Lutfiyya et al. (2009), the objective measures of clinical ethics, patients’ rights, organizational leadership, and information management are essential in the pursuit of the corporate mission. Therefore, the failure to comply with these requirements will cause the federal government to fail to reimburse the health care organization because of failing to observe patient safety and care quality.

Meaning of Accreditation to the Organization

The JC accreditation of a facility means the facility is in compliance with the highest national safety and quality of care standards and is dedicated to the continuous improvement of patient care (The Joint Commission, 2020). Hence, the health care organization can use the Gold Seal of Approval for advertising on the television, print, billboard, and online. The facility’s public display of the accreditation status intends to communicate to the patients and stakeholders the commitment to the performance standards in the delivery of quality and safe care (The Joint Commission, 2020). An accredited HCO can also invite the media to publicize the essence of staff involvement in the maintenance of continuous compliance with standards and the demonstration of conformity during the impromptu on-site survey. Besides, the organization complying with the rules is confident explaining to the news agencies how the tracer methodology and observation of care facilitates the focus on the patient, client, or resident care (The Joint Commission, 2020). Therefore, an accredited facility benefits from additional positive publicity, both from the invited news media and the notified state or metropolitan provider association that publishes accreditation details in their newsletters.

Moreover, since the Centers for Medicare and Medicaid Services (CMS) recognizes the JC’s survey results, the health organizations that receive accreditation can participate in the federal Medicare program. Hence, the facility meets the federal requirements for reimbursement through participation in the survey. Importantly, the insurers and managed-care organizations consider accreditation as a crucial indicator for a facility that provides high-quality care for the enrollees. The CMS is responsible for hospital certification, which makes it a requirement for the facilities to meet the established standards, such as those of the JC (Jha, 2018). The elements of performance must meet the federal conditions to be considered eligible for Medicare and Medicaid reimbursement because the hospitals pay a fee to the Commission to be a part of the survey process. The HCOs depend significantly on revenue, with hospital funding a complicated endeavor that requires numerous plans that include federal contributions. Consequently, the facilities must comply with the safety requirements to participate.

Is Accreditation Mandatory?

JC accreditation is a voluntary program that HCOs choose to pursue, which means it is not a requirement. However, for organizations that require federal reimbursement, they might need to select a CMS survey to fulfill the conditions for Medicare qualification. Although accreditation is not compulsory, the hospitals should comply because it determines the crucial processes for mission success. The facility cannot identify the effectiveness of its operations if there is no objective assessor to scrutinize the weaknesses and suggest improvements. Since the Joint Commission accords the hospital time to correct the existing shortcomings, the organizations that do not seek accreditation will not benefit from the chance to correct their errors. Therefore, the HCO will suffer reputational injuries that might lead to criminal lawsuits and substantial financial losses. The patients need to be confident about visiting a medical facility, which makes it necessary for the organization to seek surveyors. Besides, the federal government does not commit its fiscal resources to entities that do not consider safety and quality.

Part II. Memorandum for the Health Information Department

To: Department Staff

From: Department Administrator

Date: 28 Apr. 2020

Subject: Preparation for the Joint Commission Accreditation

Please be notified that the Joint Commission will be visiting for an on-site survey within the next three weeks. For the benefit of the new staff who have not been around since the last three years, when the previous accreditation happened, the Commission will be assessing how the facility is complying with the patient safety standards and the quality of care. Hence, within the health information department, it will be crucial that all client records are accurate. The documentation must capture the patient’s name and date of birth as a way to match the correct diagnosis and treatment. Therefore, it will be essential to update the files and to crosscheck them against the physical documents about the progress of each client and the outcomes. Further, there should be a technical check of the electronic health records to ascertain their security because they store crucial patient data. The accuracy of the information translates to the provision of quality medical care.

While preparing for the survey, it is crucial to be familiar with the possible questions the Commission might ask. For example, there is the likelihood that the assessor will ask how the department traces the care delivered to the patients, to ascertain the facility’s compliance with the standards of safety. The appropriate response would be to demonstrate the role of the hospital’s electronic tracking system plays, using the real-time location of each patient by use of the barcode tag each wears on the wrist. Hence, the elimination of manual notification underlines the facility’s commitment to client safety and the quality of care because it records those who have exited the hospital and the new residents. Another likely question will be how the hospital prevents infections. The staff should be prepared to highlight how the installation of powerful lighting on each corner of the building eliminates the hidden infection risks. The administration is capable of identifying the improperly discarded waste by monitoring the floors with proper lighting. Besides, every department member should be aware of the routine daily cleaning of the hospital space with disinfectants, at least three times a day, and on-demand depending on potential spillages of materials and chemicals. Since the survey is mostly about quality and safety, the highlighted issues will be paramount and serve as a blueprint for any other likely related inquiries.

The accreditation survey might result in adverse findings that will require a response from the hospital administration. The Commission’s assessment usually entails random selection of patients and using their health records to assess compliance with the standards. The surveyors also talk to the staff who interact with the clients. They might observe them in the process of care provision. Consequently, some of the procedures might fall below the Commission’s requirements and will require an appropriate response. For example, one course to pursue will be to resolve the issues during the survey, by seeking a mutual understanding of the significant findings while the Commission is still on site. The involvement of experts on the specific matter is crucial, such as a technical specialist in case any electronic health files might be corrupted. Each member of the department is responsible for demonstrating the measures that have been taken to address possible inadequacies in the system.

Furthermore, the facility needs to avoid current noncompliance findings in the future. For instance, there will be a need to keep up-to-date with the general safety and quality standards from various agencies, not just the Joint Commission. The move will ensure that the hospital updates its processes, policies, and systems to match the prevailing requirements. Some of the efforts the hospital can engage in include the maintenance of a culture that acknowledges safety challenges and seeking system improvements rather than blaming any specific party for the shortcomings. The facility can also contract an expert surveyor to evaluate the organization and identify the potential risks and recommend appropriate solutions.

References

Jha, A. K. (2018). Accreditation, quality, and making hospital care better. Jama, 320(23), 2410-2411.

Lutfiyya, M. N., Sikka, A., Mehta, S., & Lipsky, M. S. (2009). Comparison of US accredited and non-accredited rural critical access hospitals. International Journal for Quality in Health Care, 21(2), 112-118.

The Joint Commission. (2020). Accreditation & Certification. https://www.jointcommission.org/.