Heggblade Marguleas Analysis

JCAHO is an organization that accredits health care institutions for a fee and sets standards for them in the United States. Now known as the joint commission the organization has made great efforts to improve the overall national health care by evaluating and monitoring the institutions that are providing quality services to the patients. The joint commission has a division known as the joint commission international which has extended its mission worldwide by helping to improve the quality of care given to patients in the international health care organizations, public health agencies and others in more than 60 countries. The board of the commissioners is made up of different members from the private health care fields such as physicians, nurses and health plan leaders who have practiced in the field for a given period of time and they spend most or half of their time in the accreditation organization. The joint commission has put in place a number of standards to measure the performances of the medical practice. In addition, an online guide to the public has been provided to help the patients in seeking the best health care organization that is available in the nation.

The process of redesigning the accreditation has been involving the improvement of the systems. The recommended systems have helped in promoting an approach which reduces errors and are aimed at taking the patient care processes with safety in mind. The joint commission has put in effect new standards that require organizations to form a culture of safety and to put into practice a safety program with a specific administrative leader who is assigned the responsibility of the patients’ safety. The administrative leader has a duty of disclosing the outcome of their care to the patients. The joint commission recommends the use of flow charts, Pareto charts, run charts or line graphs, control charts and histograms to represent data. The data collected is later analyzed to give results of the performance improvement. For simplicity the data should be readily completed and understood by most nurses. The method for analyzing these events is referred to as the root cause analysis. The reason for the root cause analysis review was to help hospitals in developing an action plan that ensures that the factors leading to the sentinel event was determined and dealt with. The joint commission had a publication which showed the cases reported and was intended to educate the hospitals concerning the errors that were occurring and how to prevent them. The publication also anticipated to stimulate a hands-on attitude so that the organizations would scrutinize their work processes carefully and make the changes required.

A thorough assessment of the sentinel events by the organization led to the endorsement of its first set of goals that were meant to standardize the risk reduction strategies used by the health care organizations all over the nation. By taking the patient safety in a uniform way, the commission would be able to rate the effectiveness of its key strategies set. Failure to put into practice one or more of the recommendations or the suitable alternative would result in a single special Type 1 recommendation (Goddard, et al., 2000). For compliance, the key issues determined include correct identification of the patient especially when giving medications or taking blood samples for clinical testing or providing any other treatments or procedures. Communication among the caregivers and the patients should be effective and an opportunity to ask and respond to the questions should be given. The caregivers should give the report of the patients on a timely basis. Lack of documentation reflects negligence in adhering to the medical practice as the patients records can be used another doctor and the documents can also be produced in a court of law as evidence. The other goals include the use of the medications safely, avoidance of surgery that is on the wrong site, and the use of infusion pumps and clinical alarms in a safe way. The goals and the recommendations put are re-evaluated each year. The organization has well-known units that are specific to quality indicators and came about as a result of problems in the nursing practice.

The quality indicators department facilitates improvement in the organization and it receives data, analyzes the trend and recommends actions that are necessary to be taken for improvements. There should also be a council who are the primary decision makers in addition to the quality circles who work with the service lines like surgical units, medical units, neurological units, rehabilitation units and outpatient units to improve care for patients. The team determines whether quality cares are missed by auditing the quality indicators each month. The quality circles use various methods to put their reviews as a priority whereas the service lines sets out a quality plan each year that is based on the areas that had problems recently. To determine compliance a quality indicator nurse is assigned the duty to audit charts or verify procedures by direct observation and send the results compiled to the quality indicator department. The results are analyzed and trended with graphic displays. There are also written committees reports produced on a monthly or quarterly basis (Zerwekh & Claborn, 2006).

The joint commission key indicators must be tracked regularly irregardless of whether there is an improvement in the medical services or not. Examples of the areas monitored closely include the rate of complications when sedation is given, the rate of reactions on blood- transfusion, the rate of effectiveness when pain is managed, and the rate of infections on surgical sites. The joint commission has toughened its commands by requiring documented evidence of patient and/or family education in the patient records. The relevance of this is in the doctrine of master servant rule which provides that the employer may be held liable for negligence or any other tort committed by an employee. Additionally, documentation is a medium of communication to other healthcare professions who will be involved with the care of the patient. Failure to document makes the staff and the facility liable and in risk of losing its Joint Commission accreditation and its Medicare and Medicaid reimbursement appropriations.

A three year accreditation cycle is given to a health care institution. A hospital need to apply for the accreditation process first. A postponement of the survey may be requested if the hospital is faced with a natural disaster, a strike or if there is movement of patients to a new building. A notice of inspection is given in advance to the hospital by the accreditation organization. The hospital must be familiar with the standards and must have conformed to them before the survey. The hospital should be prepared to improve its operation systems incase of any non-compliance noted by the surveyors. The hospital should list the performance measures in use and they should be the same as the ones submitted to the joint commission earlier when applying. The data presented should be in the form of comparison charts and control charts. The joint commission has the ability to identify any missing data and predict any unusual data patterns the institution has. During the entire three period of accreditation the surveyors will travel to the health care organizations to evaluate their practices and facilities and look for the implementation of the recommended standards.

After the survey accreditation is awarded if there is compliance with most of the standards applicable by the institution. The organization provides any standards that are to be improved incase the institution is not awarded the accreditation. The joint commission has improved health care for the public and its standards that expand patient safety are updated yearly. The standards are posted on the website for review by all interested persons and this makes the information and processes transparent to all the stakeholders in the nation. The commission has provided education and consultation services to the international community and continued improvement to their operations systems. There has been improved professional accountability since the consumer is able to access information easily. There has been a rapid advance in health care technology and quality has improved as the patient’s problems become advanced. To comply with the joint commission requirements all the health care institutions seeking to renew or seek for accreditation must sign a business associate agreement. The agreement must be in place by the time the institution is applying for accreditation (Goddard, et al., 2000).

Reference List

Goddard, M., Mannion, R., & Smith, P. (2000). Enhancing performance in health care: a theoretical perspective on agency and the role of information, 9(2), 95-107.

Zerwekh, J., & Claborn, J. (2006) Nursing today: transition and trends. New York. Elsevier Health Sciences.

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