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.
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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.
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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
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(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
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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
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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
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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...