BHA-FPX4006_Assessment 4-1

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Capella University *

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4006

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Health Science

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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.).

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

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