Joint Commission Standards

Aalia Ameen

HCM612-1301A-01: Management of Healthcare Organizations  

January 23, 2013

Dr. Rockie McDaniel

Outline Objectives of the Presentation

Rush Oak Park Hospital History To Learn And Understand What Accreditation Is

And How To Obtain It Learn The History Of Joint Commission To Learn How JACO Operates. Discuss 2012 Standards And The Implications For

Hospitals Describe How Specific Standards Will Be

Implemented Make Recommendations For Improvement

Rush Oak Park Hospital

Rush Oak Park Hospital located in Oak Park, IL has been serving the community and its healthcare needs for over 100 years.

Rush Oak Park Hospital is a clinical partner with one of IL’s best academic healthcare facilities Rush University Medical center which enables them to provide more innovative care and services to patients.

Rush Oak Park Hospital is also affiliated with Wheaton Franciscan Healthcare which is a Catholic housing and healthcare agency.

Rush Oak Park Hospital is Joint Commission Certified.

What Is The Accreditation Of A Health Care

Organization?

“A process whereby a professional association or nongovernmental agency grants recognition to a school or health care institution

for demonstrated ability to meet predetermined criteria for established standards” (Joint Commission, 2012).

Healthcare organizations to become accredited, should meet specific quality standards. • These standards are broad and cover different aspects of the care services. • Not only the clinical services which is provided, but also the managerial

process, the outcomes of services, the qualification of providers and the patient’s satisfaction.

What is the Joint Commission?

• Joint Commission or JCAHO is a private not-for- profit USA organization.

• JCAHO operates accreditation programs for a fee to subscriber hospitals and healthcare organizations

• JCAHO accredits more than 17,000 organization and healthcare programs around the USA

• The majority of state governments recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement except in states of Oklahoma, Pennsylvania, and Wisconsin.

Why They Exist

Accreditation: Helps inform and protect consumers Support improvement in the quality of the health care system overall Required by private insurance companies

(Blue Cross, HMOs) Enhances community confidence.

Provides a report card for the public. Offers an objective evaluation of the organization's performance.

Stimulates the organization's quality improvement efforts. Aids in professional staff recruitment.

Provides a staff education tool. May be used to meet certain Medicare certification requirements.

Joint Commission Standards

Address the hospital's level of performance --not just their capacity to perform.

Set forth performance expectations for activities that affect the quality and safety of patient care.

Ask two kinds of questions: "Is the hospital doing the right things?“ "Is it doing them well?“

Also specify requirements to ensure that patient care is provided in a safe manner as well as in a safe and secure environment.

Leadership Standard LD.03.01.01

Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital.

Effective Jan. 1, 2009 the new Joint Commission Leadership Standard (LD.03.01.01), Elements of Performance 4 and 5 require that hospitals have a code of conduct that defines acceptable, inappropriate and disruptive behavior (American Medical Association 2012).

Leaders create and implement a process for managing disruptive and inappropriate behaviors (American Medical Association 2012) . .

In response to these actions by The Joint Commission, the American Medical Association adopted policy H-225.956, “Behaviors That Undermine Safety,” which calls for medical staffs to develop and implement their own code of conduct in

the medical staff bylaws, and that hospitals also have a code of conduct applicable to members of the board, management and all employees (American Medical Association 2012) .

License, Certification & Registration Verification – Standard HR .01.02.05

IT IS HR’S RESPONSIBILITY TO VERIFY LICENSE & CERTIFICATION AUTHENTICITY

Primary Source verification is required for all licenses, certifications and registrations upon hire and prior to expiration or at renewal time.

Copies of a licenses or certifications are no longer acceptable A copy of the primary source verification from the Board’s website must be printed RENEWALS: On or prior to the expiration date of the

license/certification The copy is date stamped electronically / one day after the expiration date

it is considered late and hospital is cited NEW HIRES: Prior to start date or on the employee’s first day of

work. Employees cannot work with an expired license.

Please make sure that any excused delay, employee on leave, employee was suspended is documented in the file

A HOSPITAL CAN LOSE ITS OPERATING LICENSE IF STAFF ARE PRACTICING WITH EXPIRED CREDENTIALS REQUIRED FOR THE JOB.

Implementation of Standards

Assign oversight of each chapter of standards to a respected leader who will identify team members from throughout the hospital.

Involve those who may also be skeptical of the process.

Look for good people skills, time management skills, and consensus building skills.

Be prepared to change as new leaders emerge, and some leaders drop out.

Implementation of Standards

In addition to overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision

These may take some time to get revised or developed, undergo organizational review, and obtain final approval

Be certain that our policy reflects our actual practice, as this is what the surveyors will evaluate our organization against the standards.

Recommendations

Leadership Leaders must regularly

evaluate the culture of safety and quality using valid and reliable tools.

Leaders prioritize and implement changes identified by the evaluation.

Leaders must create and implement a process for managing disruptive and inappropriate behaviors.

License, Certification & Registration Verification

Leaders must define a process to verify any license, registration, or certification required by the organization.

The organization must identify, by job title, all licensure, certification, or registrations it requires of staff members in certain job groups/job titles and to determine the process for verifying that the individual possesses the required certificate, license, or registration.

SWOT Analysis Stregnths

Rush Oak Park Hospital have strength derived from its parental company’s perceptive and transparent policies and visionary leadership, as well as financial stability for future development (Rush 2012).

Rush Oak Park hospital has directly benefited from being a part of the Rush and Wheaton network by delivering same level of quality services as its sister companies does, this has become one of the strength in marketing our products and services.

The hospital is situated in the thriving community of Oak Park a western suburb of Chicago. The area provides accessibility and proximity to all modes of transports from all corners of Oak Park.

SWOT Analysis Weaknesses

A high nurse turnover has continued to affect nursing services at the institution.

Due to inadequate funds some planned activities especially in the Primary Health Care department have not been undertaken, for example creating a larger primary care group as well as a group of specialist.

Despite being a leading community hospital in terms of technological development, some surgeries and procedures are still too complex to perform at Rush Oak Park (for example complex neuro surgeries) which means that patients have to be referred to a more advanced hospital for treatment.

SWOT AnalysisOpportunities

Expansion of hospital services especially in Primary Health Care department.

Oak Park hospital may benefit from trends of patients with high blood pressure, heart diabetes , diabetes, at the same time, our hospital may have more people looking for preventive healthcare services due to awareness in health prevention.

A Joint Commission Certified Stroke Care Hospital in the Oak Park Area.

SWOT AnalysisThreats

Competition At lease 2 hospitals within close proximity to our facility.

Financial position of the hospital has not been well during the past few years. There is a real need for the hospital to explore other means of

sustaining the running of their institutions through income generating activities and other donors especially for community based activities.

CONCLUSION

Joint Commission is doing a very good job specially in making a national and

international health care standard, and it plays an important role in improving

the quality of the health care. However, as everything in the world, standards

for Joint Commission should be evaluated from time to time for efficiency.

References

CTU Online (2011). HCM387-1104B-02: Management Principles in Healthcare Retrieved

from website

https://campus.ctuonline.edu/pages/MainFrame.aspx?ContentFrame=/Default.aspx

Joint commission, (2012). Facts about the Joint Commission. Retrieved from

http://www.jointcommission.org/facts_about_the_joint_commission/ Allan Tobias, MD JD. (n.d). Need JCAHO, Retrieved from

http://www.medicalaw.net/new_page_11.htm

Kate Jackson, (2004), Beyond JCAHO: There’s More Than One Path to Accreditation, For the Record, Retrieved from http://www.fortherecordmag.com/archives/ftr_053104p30.shtml

Joint Commission International, (n.d), Costs of Accreditation. Retrieved from http://www.jointcommissioninternational.org/Cost-of-Accreditation/

References

Michael Wolfe, (2010), Benefits & Disadvantages of the Joint Commission, eHow, Retrieved from http://www.ehow.com/list_6900079_benefits-disadvantages-joint-commission.html

Liz Kowalczyk, (2007), Surprise check faults MGH quality of care, Boston Globe, Retrieved from http://www.allbusiness.com/health-care/health-care-facilities-nursing/11897140-1.html

Quality Check (2012) Facts about Quality Check and Quality Reports, Retrieved from www.qualitycheck.org/help_qc_facts.aspx

Health care quality news (2009) The Joint Commission updates sentinel event statistics, Retrieved from http://www.hcqualitynews.com/home/2009/10/25/the-joint-commission-updates-sentinel-event-statistics.html

The Washington Post (2005) Accreditors Blamed for Overlooking Problems, Retrieved from http://www.washingtonpost.com/wp-dyn/content/article/2005/07/24/AR2005072401023.htm