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 time-consuming 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.

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.

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.

Resources: Standards

• Shaw, C. D. (2015). How can healthcare standards be standardised? BMJ Quality & Safety, 24(10), 615–619.
• Resources: Voluntary Accreditation
• Wickersham, M. E., & Basey, S. (2016). Is accreditation sufficient? A case study and argument for transparency when government regulatory authority is delegated. Journal of Health and Human Services Administration, 39(2), 245.Resources: Joint Commission Standards
• CMS reg in limbo, but Joint Commission standard kicks in. (2018). Hospital Infection Control & Prevention, 45(1).
• Murray, K. (2016). Leadership Q&A.; The Joint Commission patient safety standards. Nursing Management, 47(1), 56.
• Murray, K. (2016). The Joint Commission patient safety standards. Nursing Management, 47(1), 56.
• Stern, G. (2017). Using a scientific approach to meet Joint Commission AEM standards. Biomedical Instrumentation & Technology, 51(2), 157–162.