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Unformatted text preview: The Joint Commission
Community Health 458 Pam Bigler/Julianna Sellett Leadership Chapter Joint Commission: Mission To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. Other Accrediting Agencies The Joint Commission Det Norske Veritas (DNV) Healthcare Facilities Accreditation Program (HFAP) Joint Commission Background Is an independent, notforprofit organization. Evaluates and accredits over 17,000 health care organizations in the US. Serves as the nation's predominant standardssetting and accrediting body in health care. Is recognized nationwide as a symbol of quality. Background continued
Conducts surveys every 1839 months. Starting in 2000, organizations no longer receive advanced notice for random surveys. Is governed by a diverse Board of 29members including physicians, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate and educators. Accredits approximately 88% of the nation's hospitals. History The Joint Commission has been accrediting hospitals for over 50 years. 1910 Ernest Codman, M.D., proposes the "end result system of hospital standardization." A hospital would track every patient long enough to determine whether the treatment was effective. Codman's efforts led to the founding of the American College of Surgeons (ACS) and its Hospital Standardization Program Program 1918 The ACS begins onsite inspections of hospitals. Only 89 of 692 hospitals surveyed meet the requirements of the Minimum Standard. History continued 1926 The first standards manual is printed consisting of 18 pages. 1950 the standard of care improves and by this time over 3,200 hospitals achieve approval. 1951 The ACP, AHA, AMA and CMA join with the ACS to create Joint Commission on Accreditation of Hospitals (JCAH). 1953 JCAH publishes Standards for Hospital Accreditation. 1965 Hospitals accredited by JCAH are "deemed" to be in compliance with most of the Medicare Conditions of Participation for Hospitals and able to participate in Medicare and Medicaid programs. Continuous Accreditation Hospitals that participate in continuous accreditation efforts monitor and improve their performance every day, not just in preparation for a survey. Continuous improvement efforts help hospitals maintain the highest quality of patient care and services. Avoids high cost of preparing later. Performance Measures ORYX (National Hospital Quality Measures) implemented in 1997 by JCAHO. Acts as JCAHO's performance measurement and improvement iniative. With ORYX hospitals are required to collect and transmit data to Joint Commission for a minimum of 4 core measure sets. Survey Process Designed to be customized to each organization and support its efforts to improve performance. This process includes: Tracing the care delivered to patients Verbal & Written information provided to JCAHO. Onsite observations & interviews by Joint Commission surveyors Documents provided by the organization Deemed Status with CMS The Joint Commission has "deemed" status with CMS. If The Joint Commission enforces CMS standards they may be granted "deeming" authority and CMS will "deem" each accredited health care organization as meeting the Medicare and Medicaid certification requirements. Organizations with "deemed" status would not be subject to the Medicare survey and certification process. Deemed status options are available for Joint Commission accredited ambulatory surgical centers, clinical laboratories, home health agencies, hospice organizations and hospitals. Accreditation & Certification Services The Joint Commission provides accreditation services for the following types of organizations: General, psychiatric, children's and rehabilitation hospitals Critical access hospitals Medical equipment services, hospice services and other home care organizations Nursing homes and other long term care facilities Behavioral health care organizations, addiction services Rehabilitation centers, group practices, officebased surgeries and other ambulatory care providers Independent or freestanding laboratories Benefits of Accreditation & Certification Strengthens community confidence in the quality and safety of care, treatment and services Provides a competitive edge in the marketplace Improves risk management and risk reduction Provides education on good practices to improve business operations Provides professional advice and counsel, enhancing staff education Enhances staff recruitment and development Recognized by select insurers and other third parties May fulfill regulatory requirements in select states Any organization can apply for accreditation if the following requirements are met: Eligibility The organization is in the United States or its territories or, if outside the United States, is operated by the U.S. government, under a charter of the U.S. Congress. The organization assesses and improves the quality of its services. This process includes a review of care by clinicians, when appropriate. The organization identifies the services it provides, indicating which services it provides directly, under contract, or through some other arrangement. The organization provides services addressed by the Joint Commission's standards. 2010 National Patient Safety Goals
Purpose is to promote specific improvements in patient safety. NPSG highlight problematic areas in health care and describe evidence and expertbased solutions to these problems. GOAL Improve the accuracy of patient identification. GOAL Improve the effectiveness of communication among caregivers. 2010 National Patient Safety Goals For Hospitals continued GOAL Improve the safety of using medications. GOAL Reduce the risk of health care associated infections. GOAL Accurately and completely reconcile patient medications across the continuum of care. GOAL The organization identifies safety risks inherent in its patient population GOAL Preventing wrong sites, wrong procedure, and wrong person surgery. Joint Commission standards are developed with input from health care professionals, providers, measurement experts, consumers, government agencies and employers. Joint Commission standards are the basis of an objective evaluation process for health care organizations that can help measure, assess and improve organization performance. The standards focus on important patient, client or resident care and organization functions that are essential to providing quality care in a safe environment. Standards The 2010 standardsbased performance areas for hospitals are: Standards continued Accreditation Participation Requirements Environment of Care Emergency Management Human Resources Infection Prevention and Control Information Management Leadership Life Safety Medication Management National Patient Safety Goals Provision of Care, Treatment, and Services Performance Improvement Record of Care, Treatment, and Services Rights and Responsibilities of the Individual Waived Testing ...
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This note was uploaded on 05/17/2010 for the course AVI 497 taught by Professor Morrow during the Spring '08 term at University of Illinois, Urbana Champaign.
- Spring '08