Capella University Accreditation in Healthcare Summary

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Description

Instructions

To meet your senior leaders' request, you will prepare a 10- to 12-page summary brief. A summary brief is a

common document in management that is used to summarize concepts, issues, products, or projects. Summary

briefs often vary in format. For academic purposes, the required format for this summary brief is current APA format,

a common format for health care research and academics. Consult these resources for additional guidance on

appropriate use of APA guidelines:

APA Guide—This is a tutorial on current APA style.

SONHS APA Template—This is an example to help you make sure your summary brief conforms to APA

formatting guidelines.

Use the following headings to organize your summary brief for leadership:

Accreditation in Health Care (3–4 paragraphs)

Provide a short overview of accreditation in health care.

Accreditation Requirements (3–4 paragraphs)

Include an overview of the most common accreditation requirements.

Accreditation and Regulatory Compliance (1–2 pages)

Compare and contrast accreditation and regulation requirements.

Detail how accreditation helps health care organizations meet regulatory requirements.

Joint Commission Standards (1–2 pages)

Analyze the key Joint Commission standards that apply to this organization.

Accreditation Best Practices (2–3 pages)

Describe industry best practices for meeting accreditation requirements.

Other Accrediting Organizations (2–3 pages)

Select one accrediting body other than the Joint Commission and analyze the benefits of its accreditation for

the organization.

Conclusion (3–5 paragraphs)

Share your informed opinion about whether the cost and required effort for meeting accreditation

requirements have value to the organization. Note: You do not need to perform a full financial analysis here.

You only need to share considered insights about the benefits and costs of voluntary accreditation.

Additional Requirements

Written communication: Ensure that your summary brief is clear, well-organized, and generally free of errors

in grammar, punctuation, and spelling.

APA format: Use current APA style and formatting. Indent the first sentence of all new paragraphs.

Length: A minimum of 10–12 double-spaced pages, not including abstract, title, and reference pages.

Font: Times New Roman, 12-point.

References: Cite a minimum of three references from peer-reviewed journals. Also include two webpages or

websites from health care accrediting organizations.

Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty

member will evaluate your work.

Unformatted Attachment Preview

Running head: ABBREVIATED TITLE OF YOUR PAPER 1 The blue and red information in this paper is informational. After reading the information, please delete it, and use the paper as a template for your own paper. Edit the black writing with your own information for your paper to keep the correct format. Save this Template in a file for future use and information Note: The running head is an abbreviated title of the paper. The running head is located at the top of pages of a manuscript or published article to identify the article for readers. The running head should be a maximum of 50 characters, counting letters, punctuation, and spaces between words. The words "Running head" is on the cover page but not on the rest of the document. The running head title is all CAPS. Page 1 begins on the cover page. The entire document should be doublespaced, have 1" margins on all sides, and use 12 pt. Times New Roman font. Your Full Title of Your Paper Learner's Full Name Course Title Assignment Title Capella University Month, Year APA STYLE PAPER TEMPLATE 2 Abstract (Optional, check with your instructor) An abstract is a brief, comprehensive summary of the contents of a paper. It allows readers to quickly review the key elements of a paper without having to read the entire document. This can be helpful for readers who are searching for specific information and may be reviewing many documents. The abstract may be one of the most important paragraphs in a paper because readers often decide if they will read the document based on information in the abstract. An abstract may not be required in some academic papers; however, it can still be an effective method of gaining the reader's attention. For example, an abstract will not be required for NHS-FP5004. The following sentences serve as an example of what could be composed as an abstract for this paper. The basic elements of APA Style will be reviewed including formatting of an APA Style paper, in-text citations, and a reference list. Additional information will address the components of an introduction, how to write effective paragraphs using the MEAL plan, and elements of a summary and conclusion section of a paper. Key words should be included. APA STYLE PAPER TEMPLATE 3 APA Style Paper Template: A Resource for Academic Writing Note that this is not in bold. Please change the titles in this document to fit your paper. APA (American Psychological Association) Style is most commonly used to cite sources within the social sciences. APA Style is used when writing papers in the psychology programs offered at Capella University. This document serves as an APA Style template for learners to use when writing their own papers, as well as a resource containing valuable information that can be used when writing academic papers. For more information on APA Style, learners can refer to the Publication Manual of the American Psychological Association (American Psychological Association, 2010a). The author demonstrates in the first section of this paper, how an introduction effectively introduces the reader to the topic of the paper. In APA Style, an introduction never gets a heading. For example, this section did not begin with a heading titled "introduction", similar to the following section, which is titled "writing an effective introduction". The following section will explain in greater detail a model that can be used to effectively write an introduction in an academic paper. The remaining sections of the paper will continue to address APA Style and effective writing concepts including section headings, organizing information, the conclusion, and the reference list. Writing an Effective Introduction An effective introduction often consists of four main components including: (a) the position statement, thesis, or hypothesis, which describes the author's main position; (b) the purpose, which outlines the objective of the paper; (c) the background, which is general information that is needed to understand the content of the paper; and (d) the approach, which is APA STYLE PAPER TEMPLATE 4 the process or methodology the author uses to achieve the purpose of the paper. This information will help readers understand what will be discussed in the paper. It can also serve as a tool to grab the reader's attention. Authors may choose to briefly reference sources that will be identified later on in the paper as in this example (American Psychological Association, 2010a; American Psychological Association, 2010b; Walker, 2008). In an introduction, the writer will often present something of interest to capture the reader's attention and introduce the issue. Adding an obvious statement of purpose helps the reader know what to expect, while helping the writer to focus and stay on task. For example, this paper will address several components necessary to effectively write an academic paper including (a) how to write an introduction, (b) how to write effective paragraphs, and (c) how to properly use APA style. Level One Section Heading is Centered, Bold, Upper and Lowercase Using section headings can be an effective method of organizing an academic paper. The section headings should not be confused with the "running head", which is a different concept described in the cover page of this document. Section headings are not required according to APA style; however, they can significantly improve the quality of a paper. This is accomplished because section headings help both the reader and the author as will soon be discussed. Level Two Section Heading is Flush Left, Bold, Upper and Lowercase The heading style recommended by APA consists of five levels (American Psychological Association, 2010a, p. 62). This document contains two levels to demonstrate how headings are structured according to APA style. Immediately before the previous paragraph, a Level 1 Section Heading was used. That section heading describes how a Level 1 Heading should be written, which is centered, bold, and using upper and lowercase letters. For another example, see the APA STYLE PAPER TEMPLATE 5 section heading "Writing an Effective Introduction" on page 3 of this document. The heading is centered, bold, and uses upper and lowercase letters (compared to all uppercase in the running head at the top of each page). If used properly, section headings can significantly contribute to the quality of a paper by helping the reader who wants to understand the information in the document, and the author who desires to effectively describe the information in the document. Section Headings Help the Reader Section headings serve multiple purposes including (a) helping the reader understand what is being addressed in each section, (b) readers may be more likely to maintain an interest in the paper, and (c) they can help readers choose what they want to read. For example, if the reader of this document wants to learn more about writing an effective introduction, the previous section heading clearly states that is where information can be found. When subtopics are needed to explain concepts in greater detail, different levels of headings are used according to APA Style. Section Headings Help the Author Section headings do not only help the reader, they help the author organize the document during the writing process. Section headings can be used to arrange topics in a logical order, and they can help an author manage the length of the paper. In addition to an effective introduction and the use of section headings, each paragraph of an academic paper can be written in a manner that helps the reader stay engaged. How to Write Effective Paragraphs Using the MEAL Plan The MEAL plan is a model used by Capella University to help learners effectively compose academic discussions and papers. Each component of the MEAL plan is critical to writing an effective paragraph. The acronym "MEAL" is based on four components of a APA STYLE PAPER TEMPLATE 6 paragraph (M = Main point, E = Evidence or Example, A = Analysis, and L = Link). The following section includes a detailed description and examples of each component of the MEAL plan. When writing the content sections of an academic paper (as opposed to the introduction or conclusion sections), the MEAL plan can be an effective model for designing each paragraph. A paragraph begins with a description of the main point, which is represented by the letter "M" of the MEAL plan. For example, the first sentence of this paragraph clearly states the main point is a discussion of the MEAL plan. Once the main point has been made, evidence and examples can be provided. The second component of a paragraph contains evidence or examples, which is represented by the letter "E" in the MEAL plan. An example of this component of the MEAL plan is actually (and ironically) this sentence, which provides an example of an example. Evidence can be in the form of expert opinion examples from research. For example, evidence shows that plagiarism can occur even when it is not intended if sources are not properly cited (Marsh, Landau, & Hicks, 1997; Walker, 2008). The previous sentence provided evidence supported why evidence is used in a paragraph. Analysis, which is represented by the letter "A" of the MEAL plan, should be based on the author's interpretation of the evidence. An effective analysis might include a discussion of the strengths and weaknesses of the arguments, as well as the author's interpretations of the evidence and examples. If a quote is used, the author will likely provide an analysis of the quote and the specific point it makes for the author's position. Without an analysis, the reader might not understand why the author discussed the information that the reader just read. For example, the previous sentence was an analysis by the author of why an analysis is performed when writing APA STYLE PAPER TEMPLATE 7 paragraphs in academic papers. Even with the first three elements of the MEAL plan, it would not be complete without the final component. The letter "L" of the MEAL plan refers to information that "links" the current and the subsequent paragraphs. The link helps the reader understand what will be discussed in the next paragraph. It summarizes the author's reasoning and shows how the paragraph fits together and leads (i.e., links) into the next section of the paper. For example, this sentence might explain that once the MEAL plan has been effectively used when writing the body of an academic paper, the final section is the summary and conclusion section. How to Format Quotations While you want to avoid direct quotes whenever possible (we want to know what you think supported by the evidence, not what the author of the evidence thinks). Please paraphrase whenever possible and synthesize the findings. Here are some examples of quotes: 1. According to Palladino and Wade (2010), “a flexible mind is a healthy mind” (p. 147). 2. In 2010, Palladino and Wade noted that “a flexible mind is a healthy mind” (p. 147). 3. In fact, “a flexible mind is a healthy mind” (Palladino & Wade, 2010, p. 147). 4. “A flexible mind is a healthy mind,” according to Palladino and Wade’s (2010, p. 147) longitudinal study. 5. Palladino and Wade’s (2010) results indicate that “a flexible mind is a healthy mind” (p. 147). The exception is the long quote – one that is greater than 40 characters. These quotations belong in block formatting: APA STYLE PAPER TEMPLATE 8 • When do you use block formatting? According to the Publication Manual (p. 171), “If the quotation comprises 40 or more words, display it in a freestanding block of text and omit the quotation marks.” • Do you still use quotations marks around the block? No • How far should you indent? Indent “about a half inch from the left margin (in the same position as a new paragraph)” (p. 171). • Does the citation go before or after the period? The citation should include the page(s) or paragraph number and should appear after the end punctuation • I’ve already cited the author in the paragraph. Do I still need to include the author name and year? Yes. All quotations, both in-line and block quotations, must include the complete citation The author name(s) may appear in your introductory sentence or in the parentheses This example demonstrates a block quote. Because some introductory phrases will lead naturally into the block quote, you might choose to begin the block quote with a lowercase letter. In this and the later examples we use “Lorem ipsum” text to ensure that each block quotation contains 40 words or more. Lorem ipsum dolor sit amet, consectetur adipiscing elit. (Organa, 2013, p. 234) Summary and Conclusion A summary and conclusion section, which can also be the discussion section of an APA Style paper, is the final opportunity for the author to make a lasting impression on the reader. The author can begin by restating opinions or positions, and summarizing the most important points that have been presented in the paper. For example, this paper was written to demonstrate to readers how to effectively use APA Style when writing academic papers. Various components APA STYLE PAPER TEMPLATE of an APA Style paper that were discussed or displayed in the form of examples include a running head, title page, introduction section, levels of section headings and their use, in-text citations, the MEAL plan, a conclusion, and the reference list. 9 APA STYLE PAPER TEMPLATE 10 References American Psychological Association. (2010a). Publication manual of the American Psychological Association (6th ed.). Washington, DC: Author. American Psychological Association. (2010b). Ethical principles of psychologists and code of conduct. Washington, DC: Author. Retrieved from http://www.apa.org/ethics/code/index.aspx Marsh, R. L., Landau, J. D., & Hicks, J. L. (1997). Contributions of inadequate source monitoring to unconscious plagiarism during idea generation. Journal of Experimental Psychology: Learning, Memory, and Cognition, 23(4), 886-897. doi: 10.1037/02787393.23.4.886 Walker, A. L. (2008). Preventing unintentional plagiarism: A method for strengthening paraphrasing skills. Journal of Instructional Psychology, 35(4), 387-395. Retrieved from http://search.proquest.com/docview/213904438?accountid=27965 Please note that this link is not to be used as part of the reference, but as an indicator for Capella learners and faculty to locate sources in the library. You will not use it in your papers as a reference since if the reader is not linked to Capella, it will not locate the article. In the event that the article does not have a doi – use the home page of the journal url in your references. Always begin a reference list on a new page. Use a hanging indent after the first line of each reference. You can look under paragraph for formatting the hanging indent so that you will not have to tab the indent. It gives a smoother look and when you make edits, does not affect the spacing. The reference list is in alphabetical by first author’s last name. A reference list only contains sources that are cited in the body of the paper, and all sources cited in the body of the paper must be contained in the reference list. The reference list above contains an example of how to cite a source when two documents are written in the same year by the same author. The year is also displayed using this method for the corresponding in-text citations as in the next sentence. The author of the first citation (American APA STYLE PAPER TEMPLATE 11 Psychological Association, 2010a) is also the publisher, therefore, the word "Author" is used in place of the publisher's name. When a digital object identifier (DOI) is available for a journal article, it should be placed at the end of the citation. If a DOI is not available, a uniform resource locator (URL) should be used. The Marsh, Landau, and Hicks (1997) reference is an example of how to cite a source using a DOI. The Walker (2008) reference is an example of how to cite a source using a URL. Please REMINDER: Delete all blue and red notes from your paper, as well as any extra information in black that is not needed. 5/18/2020 Assessment 4 Instructions: Voluntary Accreditation – ... Course Navigation  Tutorials Andrea Support LogLowe Out FACULTY  Alyssa Seehafer Rachel Beltran Cardoso COACH 23  Assessment 4 Instructions: Voluntary Accreditation Prepare a summary brief (10-12 pages) for senior leaders on how Joint Commission accreditation helps the organization comply with regulatory requirements, improve quality, and meet stakeholder needs. Include a recommendation about other accrediting bodies that might benefit the organization. Introduction Health care leaders and managers need to know the best approaches to regulatory compliance. Often, the industry refers to these as best practices. Compliance best practices require health care organizations to meet specific standards. Common standards include: Quality of care. Privacy and patient protection. Patient satisfaction. Ability to meet stakeholder needs, including serving the community. How do health care organizations determine standards? How do they evaluate how well they are meeting those standards? Government agencies do set and enforce many standards; however, these standards stipulate the minimum requirement for compliance. Most government oversight organizations are not interested in providing a “score card” or a ranking system for health care organizations. They are more interested in whether or not health care organizations are meeting the regulatory standards. Most health care organizations, on the other hand, want to perform above the minimum standards. They want to pursue excellence. This type of approach to compliance helps ensure the organization is meeting regulatory requirements and helps the organization deliver high quality to their stakeholders. To accomplish this, health care organizations often rely on standards set by accrediting organizations. Achieving accreditation from a third-party organization that sets high standards is often a vigorous and timeconsuming process. It does, however, help the organization ensure it is meeting standards well above the regulatory minimums. In most cases, accreditation is voluntary. Some states, however, require certain accreditation for licensure. Joint Commission accreditation is the most common and well-known voluntary accreditation in health care. The Joint Commission accredits a wide array of health care organizations. Many benefits to accreditation exist; however, helping to ensure compliance is the main one. Now that your hospital has a robust compliance program and an all-staff compliance training program in place, senior leaders want to take the next step. They want the organization to perform an in-depth analysis of the benefits of voluntary accreditation. Senior leaders know the Joint Commission accreditation it currently possesses is good for the organization’s reputation and standing in the community. However, they also want to know what additional benefits might exist for the organization that it has not capitalized on yet. They hope to better justify the costs associated with voluntary accreditation. Because of your involvement in developing and implementing the new compliance program, they have asked you to research and prepare a summary brief on how Joint Commission accreditation helps the organization comply with regulatory requirements, improve quality, and meet stakeholder needs. In your summary brief, they have also asked you to consider other accrediting organizations that could benefit the organization. https://courserooma.capella.edu/webapps/blackboard/content/listContent.jsp?course_id=_252372_1&content_id=_8831675_1 1/3 5/18/2020 Assessment 4 Instructions: Voluntary Accreditation – ... Demonstration of Proficiency By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria: Competency 2: Explain the concept of accreditation in health care. Compare and contrast accreditation and regulation requirements. Analyze how accreditation helps health care organizations meet regulatory standards. Describe best practices for meeting accreditation requirements. Summarize the benefits a specific health accrediting organization provides to a health care organization. Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with health care professionals. Write a scholarly, clear, well-organized, and generally error-free summary brief that conforms to current APA formatting requirements and is reflective of professional communication in a health care setting. Instructions To meet your senior leaders' request, you will prepare a 10- to 12-page summary brief. A summary brief is a common document in management that is used to summarize concepts, issues, products, or projects. Summary briefs often vary in format. For academic purposes, the required format for this summary brief is current APA format, a common format for health care research and academics. Consult these resources for additional guidance on appropriate use of APA guidelines: APA Guide—This is a tutorial on current APA style. SONHS APA Template—This is an example to help you make sure your summary brief conforms to APA formatting guidelines. Use the following headings to organize your summary brief for leadership: Accreditation in Health Care (3–4 paragraphs) Provide a short overview of accreditation in health care. Accreditation Requirements (3–4 paragraphs) Include an overview of the most common accreditation requirements. Accreditation and Regulatory Compliance (1–2 pages) Compare and contrast accreditation and regulation requirements. Detail how accreditation helps health care organizations meet regulatory requirements. Joint Commission Standards (1–2 pages) Analyze the key Joint Commission standards that apply to this organization. Accreditation Best Practices (2–3 pages) Describe industry best practices for meeting accreditation requirements. Other Accrediting Organizations (2–3 pages) Select one accrediting body other than the Joint Commission and analyze the benefits of its accreditation for the organization. https://courserooma.capella.edu/webapps/blackboard/content/listContent.jsp?course_id=_252372_1&content_id=_8831675_1 2/3 5/18/2020 Assessment 4 Instructions: Voluntary Accreditation – ... Conclusion (3–5 paragraphs) Share your informed opinion about whether the cost and required effort for meeting accreditation requirements have value to the organization. Note: You do not need to perform a full financial analysis here. You only need to share considered insights about the benefits and costs of voluntary accreditation. Additional Requirements Written communication: Ensure that your summary brief is clear, well-organized, and generally free of errors in grammar, punctuation, and spelling. APA format: Use current APA style and formatting. Indent the first sentence of all new paragraphs. Length: A minimum of 10–12 double-spaced pages, not including abstract, title, and reference pages. Font: Times New Roman, 12-point. References: Cite a minimum of three references from peer-reviewed journals. Also include two webpages or websites from health care accrediting organizations. Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty member will evaluate your work. SCORING GUIDE Use the scoring guide to understand how your assessment will be evaluated. VIEW SCORING GUIDE  https://courserooma.capella.edu/webapps/blackboard/content/listContent.jsp?course_id=_252372_1&content_id=_8831675_1 3/3
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Explanation & Answer

Attached.

Voluntary Accreditation - Outline
I.

Accreditation in Healthcare

II.

Accreditation Requirements

III.

Accreditation and Regulatory Compliance

IV.

Joint Commission Standards

V.

Accreditation Best Practices

VI.
VII.

Other Accreditation Organization
Conclusion


Running head: VOLUNTARY ACCREDITATION

Voluntary Accreditation
Name
Institution

1

VOLUNTARY ACCREDITATION

2
Voluntary Accreditation

Accreditation in Healthcare
Accreditation in healthcare is a voluntary process where health organization seeks to e
recognized for meting standards and regulations that have been set by regulatory bodies. The
accreditation process shows that a healthcare facility is dedicated and committed to the set
standards that reflect a high level of patient care and performance (Tuck & Hough, 2017).
Initially, the accreditation was focused on acute care hospitals but has since been extended to
long term facilities, special hospitals, ambulatory care services, home care programs and even
public health departments (Griffith, 2018). The accreditation involves a multidisciplinary and
systematic inspection of the organizational and physical structure of the facility, including all the
functioning components. Measures such as available facilities, staff competencies, recordkeeping, organization, quality assurance and staff education are put into consideration.
Accreditation in healthcare is important as it reflects the commitment of the facility to
quality care. Once a facility is accredited, it means that it has demonstrated the provision of
quality care services after a thorough inspection of their records and methods of operation (Tuck
& Hough, 2017). Therefore, such an institution can be trusted by patients. Also, accreditation
sets the facility apart from other competing health care centres due to proven patient outcomes.
During an inspection, self-reports and patient reviews are also considered when determining the
standards of the hospital. When a facility achieves a certain accreditation, they can be distinct
from other organizations regarding safety and quality care (Tuck & Hough, 2017). Lastly,
accreditation is a reflection of the facility’s commitment to compliance with set industry rules
and best practices. It shows that the organization is determined to offer patient care services
while containing costs and improving their performance.

VOLUNTARY ACCREDITATION

3

When seeking accreditation, a healthcare organization sends a request to the accrediting
body indicating that they have met the standards set. The available commission bodies in the
healthcare industry have defined standards and regulatory requirements that an institution needs
to meet for accreditation to be awarded. A self-assessment, on-site survey and follow-up are
included during the process (Tuck & Hough, 2017). The commissioning body then conducts an
independent survey where the organization has to cover the associated costs while providing all
the needed data. In case the survey shows some deficiencies, the commission reports them and
offers the organization an opportunity to correct them. Follow-up inspections are then conducted
to note improvements before a certificate of accreditation can be awarded to the facility.
Accreditation Requirements
The accreditation process is long and tedious as it involves a whole look for the facility to
ensure it meets all the requirements needed. Since the aim is to demonstrate the care quality
offered in the institution, the Joint Commission has some eligibility criteria in seeking
accreditation. The hospital must be operating in the country and provides a range of services
such as curative, diagnostic and rehabilitative (Tuck & Hough, 2017). In the case of special
hospitals, a defined set of services must be provided such as eye, dental, pediatric or psychiatry,
among others. The services offered in the hospital should be accessible for 24 hours with
provision for emergency care services. These requirements should be defined in the
organizational structure of the hospital to ensure that its services are well established.
The hospital should also be addressing the standards of care specified by the commission
in providing quality care, patient safety and quality improvement (Mosadeghrad, Akbari Sari &
Yousefinezhadi, 2019). Also, the hospital, during its application, is expected to accept the
responsibility of improving the services and quality of care according to recommendations given

VOLUNTARY ACCREDITATION

4

(Tuck & Hough, 2017). The hospital also should be in full operation, meaning that patients
should be discarded and admitted to allow for a complete evaluation and demonstrated
compliance with standards. Since the process is voluntary, the board of governors can assess
whether all the requirements are met before applying for accreditation.
Part of the accreditation requirements is a self-assessment report by the hospital
management that shows and demonstrates what the hospital has been doing to meet
accreditation. The reports from patients, including reviews and surveys, can demonstrate
satisfaction levels (Tuck & Hough, 2017). Internal monitoring of operations can help with
providing all required data and tacking it if needed for accreditation. Therefore, since the process
takes some time, an institution must lay a strategy towards seeking accreditation. The
independent commission is then expected to conduct their survey and report appropriately before
accreditation.
Accreditation and Regulatory Compliance
Regulations in healthcare are authoritative rules that must be adhered to for a healthcare
organization to be allowed to offer services to patients. Such rules require that relevant laws,
guidelines and specifications are followed in the business process (Chassin, Braun & Benedicto,
2017). Any violations of the regulatory compliance regulations result in federal fines as a form of
legal punishment. For instance, reimbursement and OSHA regulations have to be followed in
healthcare meeting the set minimum standards (Tuck & Hough, 2017). Regulatory compliance
aims to promote patient care by setting standards expected when dealing with patients.
On the other hand, accreditation compliance is voluntary, where a healthcare centre
commits to exceeding the regulatory requirements in a bid to provide even better patient care. In
meeting accreditation compliance, an organization is recognized for its outstanding commitment

VOLUNTARY ACCREDITATION

5

to meeting certain aspects of care (Chassin, Braun & Benedicto, 2017). Nonetheless, meeting
regulatory requirements is one way in which healthcare facilities manage to meet accreditation
compliance. If a facility does not observe the set regulations in the industry, then accreditation
becomes complicated too. Therefore, both processes ensure that quality care is offered in safe
environments. In some instances, accreditation is part of regulatory compliance in
healthcare(Chassin, Braun & Benedicto, 2017). For instance, before a centre can be accredited
for Centre for Medicaid Services, it has to meet all the regulatory requirements for the same.
Unlike in accreditation, regulatory compliance is enforceable and could lead to the withdrawal of
licensure for a facility.
Accreditation allows organizations to work towards achieving quality patient care in the
healthcare environment. As a quality improvement initiative, accreditation pushes the
organization to meet regulatory requirements in patient care and safety, which in turn promote
patient outcomes (Chassin, Braun & Benedicto, 2017). The accreditation helps hospitals to
maintain consistent standards in the provision of care by reducing errors and using evidencebased practices as they offer health services. Further, accreditation sets another standard for a
facility which promotes high quality and safety procedures in the institution (Chassin, Braun &
Benedicto, 2017). An emphasis on patient safety in the hospital environment involves meeting
set regulations such as HIPAA that safeguard the data of patients. For an organization to be
accredited safety standards in patient care, the adaption of HIPAA is needed. Therefore, as an
organization looks to be accredited, it as to ensure it meets regulatory requirements which show
the minimum standards of care have been met and exceeded. Also, part of the accreditation
process is self-assessment which helps healthcare organization note any areas of deficiencies
before they can apply for accreditation (Tuck & Hough, 2017). In the process, any new

VOLUNTARY ACCREDITATION

6

regulatory requirements can be reviewed and implemented, leading to better ratings. In short,
accreditation and regulatory compliance are intertwined in healthcare with both leading to better
patient outcomes and improvement of service quality.
Joint Commission Standards
The Joint Commission standards are meant to help the organization make an objective
evaluation by measuring, assessing and improving their performance. In the hospital settings, the
standards focus on safety, quality of care and services offered. Since the hospital is concerned
with inpatient and outpatient care, the standards that apply include quality of care, patient
satisfaction, privacy protection and staff requirements.
The quality of care offered in the hospital should meet the national patient safety goals
that were developed by the commission. The standards define specific measures to be observed
when caring for patients (Kagan, Farkash-Fink & Fish, 2016). For instance, in the case of blood
transfusion, it is expected that patient identification is made correctly to avoid confusion. Also,
all measures to prevent infection are put in place following a standard procedure. Staff
communication is also enhanced before, during and after the transfusion process. Any patient
safety risks are identified and appropriate solutions put in place. These standards cover alarm
safety, medication use, mistakes in surgery and staff communication as important elements when
caring for a patient (Kagan, Farkash-Fink & Fish, 2016). Therefore, the facility has to
demonstrate that these standrads are followed and incorporated in a compliance program.
Another standard in hospitals is patient satisfaction, where the commission focuses on
superior customer experience, patient perception of care and employee satisfaction. The
commission notes that improving patient experience is essential in improving patient safety.
Patient communication, compassion and competence are requirements in meeting customer

VOLUNTARY ACCREDITATION

7

experience. When this is done, early warning signs during care can be identified, the treatment
regimens will be safer, and the care plans will be more effective. The perception of patients
regarding their care is critical as it influences clinical outcomes, patient safety and financial
performance (Mosadeghrad, Akbari-sari & Yousefinezhadi, 2017). Therefore, a hospital must be
committed to improving the customer experience in the care environment by promoting a culture
of communication and patient safety. In the same manner, transforming the patient experience
requires employee satisfaction which entails enhanced communication, ongoing staff learning
and culture of care. When employees are engaged in building a system of excellence, the patients
are more satisfied.
Confidentiality when handling patient data is an essential standard that is required by the
commission. The confiden...


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