BHA-FPX4006_Assessment 4-1
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Jun 27, 2024
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Overview of Voluntary Accreditation in Healthcare
Capella University
BHA-FPA4006: Healthcare Regulation and Compliance
Accreditation in Healthcare
Accreditation in healthcare is a voluntary process in which healthcare organizations may undergo evaluations to ensure they meet predetermined quality and safety standards in patient care. Healthcare accreditation also aims to promote continuous quality improvement. It is typically conducted by accrediting bodies or agencies like the Joint Commission, Utilization Review Accreditation Commission, the Healthcare Facilities Accreditation Program, or the Centers for Medicare and Medicaid Services. These accrediting agencies set standards for healthcare delivery, including patient care, safety, quality improvement, governance, and management.
The Centers for Medicare and Medicaid Services provides a "deemed status" to healthcare facilities that meet government requirements to participate in and receive payments from Medicare and Medicaid (LaPelusa et al., 2023). The Joint Commission states that a deemed
status demonstrates that the organization exceeds expectations for a particular area of expertise. The voluntary accreditation reflects a commitment to continuous improvement and excellence in patient care. The organization must implement policies and procedures to ensure staff competency and training. Accreditation enhances the organization's reputation, ensures regulatory compliance, and provides a framework for quality improvement. For patients, accreditation assures that the healthcare facility meets high standards of care, safety, and professionalism. Therefore, accreditation benefits healthcare organizations and patients by promoting quality, safety, continuous healthcare delivery, and compliance improvement.
Accreditation Requirements
Accreditation is a voluntary program in which organizations choose to participate instead of being mandated by laws and regulations (World Health Organization, p.20, 2022). However, if
Vila Health obtains accreditation with the Joint Commission, the organization must undergo a rigorous evaluation process. The Joint Commission suggests the following steps to achieve accreditation: First, we must familiarize ourselves with the accreditation standards by assessing the current policies and procedures to identify areas that require improvement. Once the self-
assessment is complete, performing a gap analysis allows Vila Health to determine discrepancies between the Joint Commission's standards and our current practices. Reviewing this information enables the organization to prioritize areas for improvement and develop a plan to address deficiencies. Finally, documentation of updated policies, procedures, training, and quality improvement initiatives are provided to demonstrate compliance with accreditation standards and
apply for accreditation (The Joint Commission, n.d.). Within the next 12 months, the organization will undergo an on-site survey by a Joint Commission representative. The surveyor assesses the facility's compliance with accreditation standards by conducting interviews, reviewing documentation, observing current processes, and the quality of patient care. After the on-site survey, the facility will receive a report containing any areas of non-compliance and opportunities for improvement (The Joint Commission, n.d.). Vila Health must implement recommended corrective measures to address deficiencies and ensure compliance with the accreditation standards. Conclusively, based on the survey and the facility's corrective actions, the Joint Commission will decide on accreditation and whether a "Gold Seal of Approval" has been attained. The accreditation survey is updated every three years
to stay compliant (Joint Commission Checklist, n.d.).
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Accreditation and Regulatory Compliance
Accreditation and regulatory compliance are essential for ensuring high-quality, safe, and
efficient healthcare, but they differ in scope, purpose, and enforcement. Accreditation is voluntary but pursued by healthcare organizations to enhance their reputation and demonstrate their commitment to high-quality care. Its standards cover various aspects of healthcare delivery, including patient care, safety, quality improvement, leadership, and facility management. The accreditation awarded promotes continuous quality improvement within the organization and ensures they meet predetermined quality and safety standards in patient care. Accreditation is managed by accrediting bodies such as the Joint Commission, the Healthcare Facilities Accreditation Program, and the Centers for Medicare and Medicaid Services.
In comparison, regulatory compliance is mandatory and promotes adherence to federal and state laws on fraud abuse and federal, state, and private health plan program requirements (III, G.B. M., 2013). The regulatory requirements cover patient care, safety, privacy, security, and
billing practices. These requirements are designed to protect patient rights, ensure patient safety, prevent fraud and abuse, and maintain the integrity of the healthcare organization. Regulatory compliance is enforced by government agencies such as The Centers for Medicare and Medicaid Services and The Department of Health and Human Services. Failure to comply with regulations may result in a loss of license, denial of reimbursement opportunities, monetary penalties, and criminal charges. In summary, accreditation and regulatory compliance have similar goals to ensure high-
quality, safe, and effective healthcare delivery. Vila Health must meet the legal requirements and government regulations; however, working with accrediting bodies assists the organization in
implementing policies, procedures, and processes to ensure regulatory compliance while focusing on quality improvements and patient-centered care. Joint Commission Standards
The Joint Commission maintains over 250 standards and may update them at various times. (Ibrahaim et al., 2022). The standards cover several aspects of patient care, safety, quality improvement, governance, leadership, and facility management. Those standards include patient rights and responsibilities, infection prevention and control, medication management, and performance management (Barlow, 2023). The standard Patient Rights and Responsibilities have the right to respectful care that protects their rights, ensures their safety, and meets their medical needs without discrimination. Patients can access their medical records and keep their information confidential. Compliance with TJC ensures patients' trust and that they receive high-quality care. Infection Prevention and Control requires hospitals to implement procedures to prevent and control the spread of healthcare-associated infections (HAIs). TJC requires hospitals to have a system to identify and respond to outbreaks and infectious diseases (Barlow, 2023). Additionally, continuing education is necessary to stay current with the latest industry standards and policies. Medication Management is a standard that requires healthcare providers to establish a system to ensure the safe and effective use of medications, including prescribing, dispensing, and
monitoring. This standard ensures that medications are prescribed and administered to reduce the
risk of medication errors and ensure patient safety. Healthcare providers must establish a process for medication reconciliation and monitor patients for adverse drug reactions and interactions.
Finally, providers must educate patients about their medications and proper storage (Barlow, 2023). The Quality and Process Improvement standard implements initiatives that continuously improve patient outcomes and healthcare delivery. Healthcare providers must create a process improvement program that monitors, analyzes, and coordinates improvements of current processes and outcomes by addressing areas of concern and applying new evidence-based practices and industry standards. TJC states that this standard is critical to ensuring patients receive high-quality care. Although these are a few examples of standards set by The Joint Commission, Vila Health will demonstrate compliance and undergo regular reviews and audits to maintain the accreditation. Our organization will consistently apply these standards by allowing patients access to their information while maintaining confidentiality and informing them of their right to file complaints or grievances about their care or information breaches. The organization will provide regular training sessions to notify staff of up-to-date policies and procedures, identify improvement areas, and follow up by implementing new evidence-based practices. Accreditation Best Practices
Accreditation best practices for healthcare organizations involve implementing strategies to ensure compliance with accreditation standards, promote continuous quality improvement, and
enhance patient safety. The Continuous Joint Commission Readiness (CSR) Program recommends that the healthcare organization remain "survey ready." Some of these best practices
are:
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1.
Establish a culture of safety and quality by prioritizing quality, safety, and continuous improvement. Encourage open communication, collaboration, and accountability among staff members by involving them in initiatives and decision-making.
2.
Develop a team of leaders that can interpret standards and provide resources and support for accreditation and quality improvement initiatives. Ensure senior leadership is committed to accreditation and quality improvement efforts. Establish clear directives and accountability processes to oversee accreditation activities.
3.
Regular self-assessments will be conducted to evaluate compliance with accreditation standards and identify areas of strength and areas that need improvement. Develop audit and tracer reports and use the data and performance metrics to monitor progress and track
improvements. 4.
Implement evidence-based practices and guidelines to improve patient outcomes and safety. Ensure staff members are trained in the created practices and consistently followed. 5.
Promote patient-centered care by involving patients and families in their care and decision-making. Vila Health must respect patients' rights to ensure they are appropriately
informed and engaged in their care. Also, request and respond to patient feedback to improve the patient experience.
6.
Focus on continuous improvement by establishing a quality improvement program to monitor, evaluate, and improve performance. Use data and performance metrics to identify opportunities for improvement and track progress over time. Implement regular performance reviews, audits, and surveys to assess compliance with accreditation standards.
7.
Provide ongoing training and education on accreditation standards, quality improvement principles, and safety. These additional opportunities allow staff to develop new skills, stay current with best practices, and contribute to quality improvement efforts.
8.
Utilize technology and data systems such as electronic health records (EHR) to support accreditation and quality improvement efforts. Working with a Joint Commission representative provides resources for valuable information
and tools to help Vila Health implement these best practices to maintain accreditation, quality, and safety (Joint Commission Resources, n.d.). Other Organizational Organizations
The Accreditation Commission for Healthcare (ACHC) is an accrediting organization that
offers accreditation services to various healthcare organizations, including hospitals, home health
agencies, hospices, and pharmacies. An ACHC accreditation demonstrates Vila Health's commitment to meeting accreditation standards at a higher level of performance and a greater focus on patient care (ACHC, 2024). The ACHC has a Centers for Medicare and Medicaid Services (CMS) deeming authority designation, which means the organization consistently exceeds CMS's expectations. Working with ACHC to obtain an accredited status helps enhance service quality and improves operational efficiencies. The ACHC accreditation process is like that of the Joint Commission, but it begins with an application and is followed by a self-assessment. An accredited advisor is assigned to guide the hospital through the accreditation process. An on-site survey is performed to assess compliance with accreditation standards. Finally, the hospital is provided with a detailed report of the survey findings and works with the ACHC advisor to address any areas of non-
compliance.
The benefits of obtaining an ACHC accreditation are comparable to other accreditations. An ACHC accreditation demonstrates a commitment to excellence, differentiates the organization from different healthcare organizations, and provides a partner in compliance. ACHC offers ongoing support and education through various training programs, educational resources, and best practices to help improve patient safety and care (ACHC, 2024.). With the ACHC accreditation, Vila Health would be better positioned to meet regulatory requirements, qualify for better reimbursement, and attract patients and healthcare professionals. Conclusion
The annual cost for accreditation with the Joint Commission is between $10,000 and $45,000, which includes a financial audit and the surveying process (BHM, 2017). The fees are paid over three years, which is the time for recertification. The survey fee is 60% of the cost in the first year and 40% in the following two years. These annual costs would double as Vila Health has locations in Minnesota and Wisconsin.
The organization would potentially have enhanced quality of care, improved patient outcomes, and compliance with regulatory requirements and standards set by government agencies. Vila Health's reputation and credibility would be enhanced, thus attracting more patients, physicians, and other health professionals. Nonetheless, the costs and effort required to achieve accreditation can add significant value to Vila Health. Although the processes may be demanding, time-consuming, and costly, the
benefits of accreditation far outweigh the challenges. References
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III, G.B. M. (2013). Managing Legal Compliance in the Health Care Industry. Jones & Bartlett Learning. https://capella.vitalsource.com/books/9781284075533
BHM Healthcare Solutions. A cost/benefit analysis of TJC accreditation
(2017, April 2). https://bhmpc.com/2015/03/a-costbenefit-analysis-of-tjc-accreditation/ Federal deemed status fact sheet. The Joint Commission. (n.d.).
https://www.jointcommission.org/resources/news-and-multimedia/fact-sheets/factsabout
federal-deemed-status/ Ibrahim, S. A., Reynolds, K. A., Poon, E., & Alam, M. (2022). The evidence base for US joint
commission hospital accreditation standards: cross sectional study. BMJ: British Medical
Journal (Online), 377 https://doi.org/10.1136/bmj-2020-063064
The Joint Commission. (n.d.). Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/accred-and-cert/hap/hap-
accreditation-checklist.pdf
Process for hospital accreditation. The Joint Commission. (n.d.). https://www.jointcommission.org/what-we-offer/accreditation/health-care-settings/
hospital/learn/process/
LaPelusa, A., & Bohlen, J. (2023, September 4). Medicare and Medicaid accreditation and
deemed status. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK597359/
World Health Organization. (2022). Health Care Accreditation and quality of care - Iris.
https://iris.who.int/bitstream/handle/10665/363528/9789240055230-eng.pdf?sequence=1
ACHC Home. ACHC. (2024, April 22). https://www.achc.org/