BHA 4006 Voluntary Accreditation Paper

BHA 4006 Voluntary Accreditation Paper

Introduction to Accreditation

Accreditation is a process that allows healthcare organizations to demonstrate their ability to meet regulatory requirements and standards established by an accreditation organization. Hospitals and other healthcare organizations are mandated to provide safe and high-quality care to patients at all times. Specific accreditation resources are used to ensure healthcare organizations achieve these overarching goals effectively. Accreditation and regulatory compliance and Joint Commission Standards are some of the accreditation criteria involved in healthcare, and whose objectives is to enhance patient safety and increase the quality of healthcare (World Health Organization, 2017). Accreditation requires an organization to meet several requirements outlined by these organizations. Given this background, this paper discusses how accreditation works in healthcare, and how it affects the quality of healthcare, and its role in enhancing patient safety.

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Concepts of Accreditation in Healthcare

In healthcare settings, standards highlighting the expected conduct exist. These standards are set to ensure high-quality care is provided to the patients. They also ensure the organizations meet the guidelines and requirements like professional resources. The standards also ensure staff safety besides patients’ safety. Once organizations have achieved specific requirements, they are accredited which means that they can provide the best quality and safe care as per required standards. Accreditation creates an impression of improved healthcare, patient and staff safety, high levels of care delivery, staff commitment, interprofessional collaboration, and good leadership in such healthcare organizations.

Accreditation Analysis and Benefits of Accreditation

Characterizing the U.S. healthcare sector are high costs of operation and competition both in the public and private sectors. Healthcare organizations must provide quality care to win the community’s trust and to compete fairly with other healthcare organizations. The ability to provide quality care also ensure the organization has sufficient revenue that is integral to continued service delivery and sustainability. Accreditation serves to create a distinction between accredited and non-accredited healthcare organizations by showcasing a commitment to the provision of high-quality and safe care (Bracewell & Winchester, 2020). In addition, it enhances the continuous improvement of an organization. Commitment to the provision of quality care is the Hallmark of accreditation and hence accreditation is very integral. Accreditation also serves to showcase the diversity existing among healthcare organizations. It is integral in stimulating organizations to step up their care provision by instituting best evidence-based practices, optimizing healthcare costs, and continuous organizational improvement.

Accreditation is a voluntary process that individual healthcare organizations strive to achieve.  In addition, healthcare workers need regular motivation and for maximum productivity, they must feel comfortable and respect their workplaces. Accreditation aims at ensuring the best quality care, better health facilities, and better patient and staff experiences. It has several merits and demerits, most of which are covered by the Accountable Care Act (ACA). Healthcare accreditation is key in influencing staff training, creating control and evaluation tools, improving staff and patient safety, improving professionalism, and boosting staff morale (World Health Organization, 2020 BHA 4006 Voluntary Accreditation Paper). Synchrony of these aspects of healthcare enhances the smooth running of any organization. As Bracewell and Winchester (2020) observe, they are an indicator of an optimally functioning healthcare organization and are showcase excellent quality healthcare, care accountability, and patient safety.

Accreditation Requirements

As discussed above, accreditation is a vigorous exercise that requires a lot of hard work and commitment for the organization. Accreditation requirements serve as the roadmap to achieving high-quality holistic care. Achieving accreditation means a lot to any healthcare organization. The process begins with an application by the healthcare organization for the accreditation certificate. The whole process of issuance of the certificate takes an average of twelve months. The process is accompanied by huge costs that the organization must cater for to obtain approval. The accreditation agencies pay attention to a specific area that is of interest to the state and employers. Goals of healthcare are developed to facilitate care improvement through analysis and planning of improvement activities in these specific areas. These areas include Medicaid benefits and services, quality of leadership and management, population health management protocols, care collaboration strength, and members’ rights and responsibilities (NCQA, 2019).

Medicaid adjustments instruct through Accountability Care Organizations that hospitals should be paid according to the quality of services they offer. Availability of Medicaid benefits in a hospital enhances population health management because no group of people is shut out due to lack of funds. Thus, availing of Medicaid benefits is very integral in the accreditation process (World Health Organization, 2017). Equally, population health management is an integral accreditation requirement. Hospitals should ensure they can serve all populations without shutting any population out, especially the vulnerable groups. Care collaboration and interprofessional collaboration are very integral for the performance of any healthcare organization. According to the WHO (2017), care collaboration improves patient safety and improved the quality of care due to reduced medical errors. Some institutions also qualify for Accreditation such as those that operate under an insurance license, are actively involved in improvement, provides care to self-insured patients, provide ambulatory and inpatient health services, and have an organized system of providing quality services. When an organization adequately achieves excellence in the listed areas, it can initiate the accreditation process.

Different accreditation organizations use different protocols and procedures for the application of accreditation. However, the process is largely similar with minor differences. When choosing an accreditation company, it is advisable to go for a respectable and recognized company. The goals of the company should also line with the healthcare organization’s goals and one that initiates and finishes the accreditation process. Quick surveys, consulting, and going through a company’s reviews could provide baseline data on the credibility of the accreditation company. The NCQA states that the first step in the accreditation process is consulting with the accreditation company (NCQA, 2019). At this stage, the healthcare organizations and the accreditation company hold an overview discussion on the goals for accreditation and reviews the whole process. They also perform a gap analysis and avails recommended survey and then submit a pre-application form. From this step, the healthcare organization fills and submits an online application form.

After the application process is done, the organization aligns itself with the requirements of the accreditation company. The organization submits the survey tool and if it meets the requirements of the accreditation company, the accreditation is issued. Accreditation is not absolute; it is redone after every three years to continuously evaluate the alignment of the healthcare organization and to ensure continuity of high-quality care (ACHC, 2020). Healthcare organizations that are accredited are required to maintain the highest quality of healthcare, availability of healthcare resources, ensure patient safety, and also ensure staff safety and care collaboration.

As discussed earlier, the accreditation process is tough and not all institutions get accredited. Failure is associated with minor mistakes either due to negligence or lack of information. Some of these simple mistakes include lack of adequate and appropriate fire equipment, and failure to manage risks arising from the hospital utility systems. Further, lack of building features that protect individuals from the effects of smoke and fires is another mistake organizations make during the accreditation process. Failure to meet requirements for infection prevention and control effectively and failure to maintain a safe and functional environment that is conducive for the patients and healthcare providers can also result in rejection of accreditation application.

Accreditation And Regulatory Compliances

Regulations are orders by the government or responsible bodies regarding a specific issue. Regulatory compliance is simply adherence to set rules and regulations by a responsible body. Regulatory compliance to the state and the company’s specific rules is integral in the accreditation process. The main goals of both accreditation and regulatory compliance standards are to achieve the best quality care to the patients and also enhance their safety. They also require employees to be adequately educated about them, in addition to requiring close monitoring by the management to enhance adherence.

Regulatory compliance demands written standards that must apply to specific organizations, and to which such organizations must comply at all times. Accreditation supports regulatory compliance primarily because healthcare organizations must be committed to adhering to regulations to efficiently attain accreditation. Accreditation ensures that an organization is always continuously improving which promotes compliance. Healthcare compliance regulations expect healthcare institutions to be willing to improve every time and maintain a high level of quality healthcare. As seen earlier, accreditation is not static but can change anytime. A healthcare organization that loosens its agility to provide quality and safe care and regulatory compliance loses its accreditation. Therefore, healthcare accreditation and regulatory compliance work hand in hand to ensure that organizations are continuously working hard to maintain the highest standard of quality care and are continuously improving.

Joint Commission Standards

The joint commission is a healthcare agency that works as an accreditation organization and whose rules and regulations are widely used. The Joint Commission is a non-profit organization involved in accrediting over 200,000 healthcare organizations in the United States and other nations (Mohamud & Rahman, 2017). The commission has several goals that align with accreditation goals. To begin with, they advocate for quality and safe patient care in all healthcare organizations as a top priority. They also place the patient at the center of healthcare. By doing so, they focus on actual healthcare problems and therefore develop effective ways to effectively handle them.

An area of major concern to the commission is nosocomial infections, especially surgical wound infections, why and how they occur (Healthcare Management Degree Guide, 2020). A multidisciplinary team of professionals, providers, consumers, and government agencies are involved in setting standards of the joint commission which makes them all-inclusive. Healthcare organizations must meet all these standards for them to be accredited. The standards are all propelled towards achieving quality healthcare and improving healthcare experiences among the patients and healthcare providers. One of the practices they prioritize is cleanliness in all areas of the healthcare facility. They also prioritize the use of the evidence-based practice to provide holistic care (World Health Organization, 2017).

The commission advocates for the right education through seminars and training to ensure participating healthcare providers are up to date with what is required of their different professions. The joint commission serves as an evaluation tool for both the institutions and individual professionals. The commission’s accreditation process requires one to complete several specific steps. For a successful application, an organization building plan and healthcare day must be complete without losing any data. In addition, the healthcare organization should complete and submit a written base inspection process to show the accreditation agency how serious they are taking the accreditation affair (What is JCAHO, 2020). Once these steps are complete, the organization can then proceed with the accreditation application process with the joint commission.

Accreditation Best Practices

Healthcare accreditation differs in the accreditation company they chose and the kind of services they offer. However, they share the overall goals of accreditation. Healthcare accreditation agencies share the overarching goal of providing safe and high-quality healthcare and improving patient and providers healthcare experiences. Five top practices have been identified through the accreditation process, namely, deficiencies, sources of information, infection control, patient consent and specimen monitoring (Frank et al., 2020). The first practice is determining survey deficiencies. By doing so, an organization can detect and fix its flaws beforehand. Most flaws not detected during surveys include improper cleaning of products and poor documentation of training and education of infection prevention and control.

The second practice is selecting a standard source for specific information in the medical charts (Frank et al., 2020). By doing so, healthcare provides can eliminate inconsistencies found in these charts. For example, drug and food allergies should be charged alongside medications all along to avoid confusion and errors involving medication problems. The third practice is initiating infection control quality compliance. Organizations can detect flaws in infection prevention practices, and therefore take action to reduce the rates of spread of infection. Hand washing, body hygiene, following aseptic procedure techniques, proper waste segregation, and waste disposal are some of the practices that lead from the front in infection prevention.  Creating daily checklists for efficient monitoring of specimen pathology test results is another practice. By doing so, an organization can keep track of specimen and lab work results integral in the diagnosis process siding in better healthcare quality.

Lastly, providing a separate propofol registry on patient consent forms. The sim of this practice is to identify the effects that arose from the use of propofol. Propofol differs from other anesthetic drugs in its ability to cause patient confusion. Patients should be allowed to exercise autonomy fully, and the use of propofol impinges on this right. Patients require to be fully aware of what they are doing when signing consent forms for procedures within the healthcare organizations.

Other Accreditation Agencies

As discussed earlier, many accreditation agencies exist in the healthcare industry. When choosing the right agency, an organization should do a good survey of the company’s reputation as discussed earlier. The ethics and morals of a company are integral and they determine the credibility of the accrediting agency. Existing accreditation agencies include Utilization Review Accreditation Commission (URAC), National Committee for Quality Assurance (NCQA), Commission on Accreditation of Rehabilitation Facilities (CARF), and Council on Accreditation (COA) (BHM Healthcare Solutions, 2019). The benefits arising from accreditation include recognition and prioritization by insurance companies, opening up opportunities for further education and training, improving patient healthcare experiences and satisfaction, competitive advantage, and commitment to quality, safe, accountable, and reliable healthcare (BHM Healthcare Solutions, 2019).

For the URAC accreditation company, the application process takes around 4-6 months. This independent non-profit organization aims to promote health and sustain high-quality healthcare through accreditation and education activities. The NCQA shares its goals with URAC in promoting quality healthcare. The agency has been involved in the accreditation of over 40,000 healthcare organizations. The costs of the application process are determined based on the type of services offered and the extent of certification required (The Joint Commission, 2020). CARF is another non-profit accreditation agency, that has accredited more than 6000 healthcare organizations. It focuses on health and human services. The agency’s accreditation can be as high as $995 for a site visit.

The COA is an independent agency, and just like the others, it is a non-profit organization. Unlike other agencies, COA focuses on family and behavioral accreditation services. Their costs are $750 to complete the application process and also require a fee of 400$annually for sustained accreditation (BHM Healthcare Solutions, 2019). The agencies have figured their accreditation process according to the type of services they accredit for but the process is relatively similar (ACHC, 2020).

Summary and Conclusion

Patient safety, healthcare satisfaction/ experiences, and quality healthcare are themes that cannot be discussed exclusively. The themes have appeared all through the discussion highlighting their great importance. Evaluation of performance for achievement of patient safety and delivery of quality healthcare through accreditation is this imperative (Kittle and Liss, 2018). As seen above, accreditation is voluntary, and healthcare organizations individually strife to adhere to set standards but the accreditation companies. As also seen, the accreditation process is demanding but beneficial to healthcare organizations. When choosing an accreditation agency, the cost, morals, ethics, and type of services the organization offers are huge considerations. Multiple options exist in healthcare accreditation. Smaller organizations may find it difficult to pay for the accreditation process and at that, they should seek smaller companies with lower costs for accreditation.

Healthcare organizations should seek accreditation services despite the fact that accreditation might be costly. Often, patients and other health service providers such as Medicare tend to opt for accredited institutions for convenience and reliability. Medicaid is known to pay hospitals according to the perceived quality of healthcare they offer. Accreditation serves to show that the organizations offer high-quality care, and thus the organization receives better pay for healthcare services availing more resources for continuous improvement.

Healthcare is a dynamic field and standards of care change daily. For this reason, healthcare organizations should strive to update the accreditation status frequently, and by seeking the same from recognized and respectable accreditation companies to maintain a high level of functioning. Accreditation also offers educational and training tools that ensure staff’s skills are up to date because healthcare is a very dynamic field. This also serves to enhance the quality of care delivered. Thus, any healthcare facility should initiate voluntary accreditation to enhance the quality of care they provide, to build client trust and to remain compliant with existing industry practice rules and regulations.

References for BHA 4006 Voluntary Accreditation Paper

ACHC. (2020). About Accreditation. Retrieved October 18, 2020, from https://www.achc.org/about-accreditation/

The Joint Commission. (2020). Accreditation and Certification. Retrieved October 21, 2020, from https://www.jointcommission.org/accreditation-and-certification/

Frank, J. R., Taber, S., van Zanten, M., Scheele, F., & Blouin, D. (2020). The role of accreditation in 21st-century health professions education: report of an International Consensus Group. BMC Medical Education20(1), 1-9. https://link.springer.com/article/10.1186/s12909-020-02121-5

Kittle, A., & Liss-Levinson, R. (2018). State health agencies’ perceptions of the benefits of accreditation. Journal of Public Health Management and Practice24, S98-S101. https://journals.lww.com/jphmp/fulltext/2018/05001/state_health_agencies__perceptions_of_the_benefits.23.aspx

NCQA. (2019). Health Plan Accreditation FAQs. Retrieved October 20, 2020, from https://www.ncqa.org/programs/health-plans/health-planaccreditationhpa/faqs/#:~:text=How%20long%20does%20it%20take,depending%20on%20an%20organization%27s%20readiness .

Mahmoud Salim, F., & Rahman, M. (2017). The impact of joint commission international healthcare accreditation on infection control performance: a study in Dubai hospital. Global Journal of Business & Social Science Review5(1), 37-45. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3002396

BHM Healthcare Solutions. (2019). The Big Five Healthcare Accreditation Organizations – Side by Side Comparison. (2019). Retrieved October 23, 2020, from https://bhmpc.com/calltoaction/accreditation-comparison-cta/Accreditation-ComparisonTool.pdf

Healthcare Management Degree Guide. (2020). What is JCAHO? Retrieved October 22, 2020, from https://www.healthcare-management-degree.net/faq/what-is-jcaho/

World Health Organization. (2017). Patient safety: making health care safer (No. WHO/HIS/SDS/2017.11). World Health Organization. https://apps.who.int/iris/bitstream/handle/10665/255507/WHO-HIS-SDS-2017.11-eng.pdf