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BHA FPX 4006 Assessment 4
Voluntary Accreditation
The paper aims to analyze the importance of accreditation in healthcare organizations with an emphasis on its necessity, principles, and consequences for the fulfillment of the established legal demands. In healthcare, accreditation is usually a process through which the organization makes its own decision to seek recognition from outside agencies like TJC, HFAP, or AAC.
Even though the process of accreditation is voluntary, there are positive outcomes for healthcare organizations if they go through with it (Hussein et al., 2021). The first is the creation of a structured system and methodology for the organization’s constant quality enhancement.
VBM forces organizations to systematically evaluate and improve the processes with the purpose of achieving and surpassing the set benchmarks for quality, safety, and performance (Frank et al., 2020). The document also reviews the relationship between accreditation and compliance, which includes quality management systems, staff training, patient involvement, and a culture of improvement.
This is because certification entails advantages for the user, which include The benefit of having the standards of the organization developed uniquely In addition to the recognition by other agencies that undertake accreditation. It also accords paramountcy to certification in as much as it affirms quality, safety, and effectiveness in healthcare organizations.
Accreditation in Healthcare
Healthcare accreditation is defined as a procedure of an external inspection of the organization for compliance with stated standards and quality indicators related to healthcare quality and safety and organizational performance. The purpose of accreditation is to show to the patients, the stakeholders, and even the regulatory agencies that the specific organization provides care that is at least in line with the standard values for the delivery of healthcare.
This is the systematic evaluation of an organization’s policies, procedures, practices, and outcomes by an external and independent organization such as a governmental or private agency. Also, there is The Joint Commission is the most popular independent, nonprofit organization that focuses on the accreditation and certification of approximately 21,000 healthcare organizations and programs in the USA (The Joint Commission, 2024).
The Joint Commission lays down specifications that pertain to the management of patients, safety measures, averting infection, leadership, and performance enhancement.
Another type of accreditation in healthcare is the Healthcare Facilities Accreditation Program, which the CMS authorizes as an accrediting agency of acute care hospitals.
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Hence, while HFAP concentrates on assessing the quality and safety of customer service facilities such as hospitals, surgery centers, and laboratories, another body similar to the JC is HFAP. HFAP conducts surveys to determine a facility’s level of compliance with set standards and thus offers quality services to patients.
It must be noted that accreditation is not only for hospitals and healthcare centers but also for other elements of the healthcare sector, like managed care organizations, medical transportation services, and clinical laboratories.
For example, the national AAAHC accrediting body oversees ambulatory healthcare organizations such as ambulatory surgery centers, primary care clinics, and diagnostic imaging centers (Accreditation & Quality Compliance Center, 2024). The other key finding is that accreditation approved by AAAHC shows that these organizations comply with the highest set of patient care, safety, and quality management standards.
Accreditation Requirements
The requirements for accreditation in the healthcare industry include a large number of standards and criteria related to the quality of care, the protection of the patient, and the efficiency of the organization. These necessities are set by the identifying bodies, which include The Joint Commission, the Healthcare Facilities Accreditation Program (HFAP), and AAC, amongst others.
It is recognized that one primary accreditation standard often considered has to do with the care of the patients as well as clinical outcomes. Surveying agencies may evaluate healthcare delivery’s infection control practices, medication administration, and patients’ experiences (Alhawajreh et al., 2023).
For example, The Joint Commission’s accreditation standards embrace the elements that pertain to infection prevention, medication safety, and evidenced-based interventions in patient-community care.
Regarding the structure of the Patient Protection and Accreditation Connection, two more accreditation requirements are prescribed – the patient safety requirement and the risk management requirement.
Accrediting bodies assess the healthcare organizations’ initiatives in risk management for patient harm, including falls, medication errors, and surgical complications (Al-always et al., 2021). It may incorporate such practices as establishing safety measures to be followed, safety audits, and ensuring the staff adheres to safety standards.
On the same note, accreditation requirements also cover issues pertaining to the governance and leadership of the organization. Of interest to this study are the leadership of healthcare organizations, their governance structures, and their strategic planning.
These are such things as having competent professional people in organization leadership, proper designation of authority and responsibility, and employing the systems of total quality management. Moreover, other rules may concern personnel and business capacity, staff and director qualifications, essential personnel, nursing care standards, infection control measures, disaster management protocols, and patients’ rights and privileges (Sperling & Pikkel, 2020).
However, accreditation standards pay special attention to the staff’s education and professional growth. Standard-setting organizations require continuing education and competency checks to ensure that healthcare staff members remain informed of new methodologies and practices in medical care delivery.
This continuous learning is paramount in guaranteeing elevated patient care and safety since the workforce will have adequate skills and knowledge to deal with new healthcare complexity.
Accreditation and Regulatory Compliance
Thus, although both accreditation and regulation are introduced to protect customers from receiving low-quality services and to guarantee their safety, there are differences between them concerning the range of activities, means of implementing such concepts, and the degree of freedom. Conventional authorities generally set up federal, state, or local specifications that become legal.
These are requirements that define the minimum level of compliance with the sanctions and penalties of healthcare organizations. Some of the regulations are the CoPs for Medicare and Medicaid certification that outline necessities of patient relations, infection control, and QAPI, among others set by the Centers for Medicare & Medicaid Services (Dunbar et al., 2021).
On the other hand, the accreditation standards are developed by independent, non-governmental organizations and described as voluntary but can become obligatory for licensure or reimbursement purposes. It is crucial to understand that accrediting bodies use the standard practices adopted by the organizations; these may be above the standards provided by the regulating authorities.
Although there are no legal requirements to accredit a healthcare organization, healthcare organizations seek accreditation so as to show their commitment … Healthcare organizations benefit by achieving a positive image and recognition in society.
For example, one specific focal area is the patient care domain, which includes elements of assessment and treatment, the evaluation of the educational needs of patients, and how patient care is coordinated. Some of the examples of the specific standards in this domain are to accurately and timely identify a patient’s needs, apply evidence-based treatment interventions, and involve the patient in the decision-making process regarding their care (Mossel et al., 2021).
BHA FPX 4006 Assessment 4 Voluntary Accreditation
Adherence to these standards assists healthcare facilities in providing safe, efficient, patient-centered care and enhances patients’ outcomes. For instance, during the admission process and other points in the healing cycle, formal evaluations of patients’ needs are necessary, and there must be adequate documentation of the designed treatment regimen and the sharing of this information among the care team.
Joint Commission Standards
Joint commission practices high minimum standards on a healthcare organization across different domains to improve the quality of patient care, safety, and pathological organizational performance. Surveying the seven essential Joint Commission standards of Mercy Medical Center entails determining highlights and requirements that should be fulfilled to gain accreditation.
For example, patient care is one of the domains of focus that involve aspects such as assessment and treatment, patients’ education, and coordination of care. Some examples of the specific standards within this domain are – timely and accurate identification and assessment of the patient’s needs, using the best evidence to plan and identify the required treatment interventions, and collaborating with patients in making decisions regarding their care (Levitan & Schoenbaum, 2021).
Adherence to these standards enables this health facility to deliver quality patient-centered care and enhance optimal results. Another domain is patient safety; this component comprises infection control, medication administration, and the number of falls synonymous with the healthcare institution’s standards.
At Mercy Medical Center, protocols have been developed to address strategies that concern healthcare-acquired infections, adverse drug events, and patient falls. Thus, the satisfying of these standards makes the center improve patient surroundings and decrease the risk of adverse outcomes.
Leadership and governance are also vital components of accreditation standards because committed leaders must be engaged to champion and promote quality improvement plans and a safety culture.
Some of these standards include leadership involvement in quality improvement initiatives, more explicit forms of accountability, and, lastly, the promotion of accountability and transparency. Successful accreditation is thus attained by healthcare organizations that embrace efficient leadership and have sound governance frameworks.
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Accreditation Helps Mercy Medical Center Meet Regulatory Standards
Regulatory requirements are essential in any healthcare facility, and this is why accreditation from organizations like The Joint Commission is necessary. It gives Mercy Medical Center a framework to follow in order to meet those requirements and improve the center’s quality. Standards for accreditation are frequently the same as guidelines set by governments and their agencies, such as CMS or state health departments (Dunbar et al., 2021).
For instance, the infection prevention and control standards set by the Joint Commission in care are closer to the regulatory mechanisms as outlined in the CoPs for Medicare and medically needed services. Healthcare organizations that participate and gain accreditation show their affirmatively in that every organization is obligated to adhere to regulations and mandates set by the regulatory bodies, as well as show the practice of instituting infection control measures that remain relevant and vital in the fight against the increasing cases of healthcare-associated infections (Garcia et al., 2022).
In the same way, the standards for medication management and safety accreditation reflect regulatory points concerning medication administration, storage, and recording. With regards to certification, this center addresses the standards that aim at regulating medication in a bid to, amongst other things, minimize the occurrences of medication errors and adverse drug event risks, as stated by the CMS and the FDA.
Also, the process of accreditation contributes to the advancement and enhancement of quality performance, which is essential when evaluating the organization against specified standards. Thus, Mercy Medical Center does self-assessments, performance checks, and quality enhancement activities to reveal deficiencies and take necessary actions.
Through implementing and adhering to the provisions of quality management systems and getting accredited, healthcare organizations show their willingness and ability to meet set requirements of quality in patient care.
Accreditation Best Practice
Meeting accreditation requirements entails the adoption of various standard operating procedures in the provision of healthcare, management of healthcare quality, and healthcare organization system. These best practices help relevant healthcare organizations to attain accreditation and also foster the delivery of safe high, high-quality care to patients. Through a quality management system QMS, it is possible to ensure that the accreditation requirements are met.
It should include procedures for assessing, controlling, and enhancing the quality of the care and services offered to the patients. Quality management practices include Performance Appraisals’ conducting, data gathering and analysis on clinical results and patient satisfaction, and recognition of other lapses in line with evidence-based practices (Friedel et al., 2023). The application of these metrics allows organizations to use the systematic identification of areas for improvement and focus on the improvement of care delivery processes.
Policies and procedures that meet accreditation standards must also be written and implemented as is another best practice. Policies and procedures relating to accreditation must be reviewed and updated occasionally to conform to changes in accreditation requirements, organizational standards/procedures, and other improvements that could help improve the quality of services being delivered to the public.
For instance, policies for infection control, medication, and safety of patients and nursing must be designed and implemented very carefully and uniformly in the organization (Braun et al., 2020). Policies within human resources must be precise and current so that all employees realize the company’s expectations.
Offering ongoing professional development for qualified employees is the primary precondition for their competence and compliance with the standards of accreditation. It is recommended that these organizations formulate strict training programs that address topics that include but are not limited to infection control measures, patient safety measures, emergency measures, and ethical practices.
Daily new updates and the procedure of continuing education make sure that the staff is up-to-date with the existing best practices and any changes in the regulations (Mlambo et al., 2021).
These assessments and audits are essential since they help establish where some practices excel and where there is potential for enhancement. These phases involve internal audits and self-assessment surveys that an organization undertakes to identify compliance issues and is capable of correcting before accreditation surveys are conducted (Mossel et al., 2021).
Other Accreditation Organization
For any healthcare organization that needs accreditation beyond The Joint Commission, the Healthcare Facilities Accreditation Program (HFAP) can be very useful to the organization. HFAP provides various accreditation standards that the client organizations may require, depending on the needs of the facility; the organization’s services include accreditation in hospitals, ambulatory surgical centers, and clinical laboratories (Accreditation Quality Compliance Center, 2020).
They are general practices that professionals in that particular field review to meet the current changes in the health care system. For example, the ACUC Standards Statement deals with specific guidelines concerning patient safety, infection control, surgical service, and anesthesia service in ASCs to guarantee that HFAP members practice in compliance with superior quality and safety standards.
Furthermore, the HFAP accreditation is accepted by the CMS or the Centre for Medicare and Medication Part B so that the healthcare organization that receives the certification can be reimbursable under Medicare and can also reveal compliance with the CMS requirements.
Many hospitals in the United States are accredited by HFAP, which entails a rigorous examination of the hospital’s conformity to the CMS Conditions of Participation (CoPs), which are the federal requirements for quality and safety (Al-Sayedahmed et al., 2021).
This approval from regulatory bodies helps patients, stockholders, and the community have confidence in the organization’s ability to render quality service that complies with required standards.
The same can also be found in HFAP accreditation because it promotes a culture of continual enhancement in healthcare institutions. AHF’s aspiration is that accredited facilities engage in performance improvement initiatives and evidence-based practice and conduct self-assessments, using published data on clinical outcomes to determine areas for improvement (Goorts et al., 2021).
For example, the Standards for Clinical Laboratories set by HFAP are the aggregation of quality management systems, proficiency testing, competency, and tests to enhance laboratory testing reliability. Accredited laboratory gives constant checks and balances on their competency to perform testing that will further increase the quality of the patient’s care and safety.
Last but not least, accreditation by the HFAP always helps to build up the image and reputation of the healthcare organization. For the patient and client, accreditation proves the organization’s capacity to provide the best health care in full compliance with the necessary standards.
Conclusion
The process of accreditation in the healthcare industry is very procedural, which entails a lot of time, energy, and, more importantly, money. But again, while involving some costs, accreditation is paired with so many benefits that it’s a worthy investment for most of the facilities.
Accreditation is the process of verifying the quality, safety, and efficacy of patient care processes, which is comprised of The Joint Commission and the HFAP. This is entirely instrumental in improving patient health since high standards are embraced, and it creates confidence in the health institution from the patient’s side, families, and society in general.
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BHA FPX 4006 Assessment 2 Compliance Program Implementation and Ethical Decision-Making
References
Accreditation & Quality Compliance Center. (2024). Accreditation & quality compliance center.
https://www.accreditationqualitycenter.com/
Accreditation Quality Compliance Center. (2020). CMS approves merger of HFAP with Accreditation Commission for Health Care | Accreditation & Quality Compliance Center.
Al-alawy, K., Moonesar, I. A., Obaid, H. A. M., Gaafar, R., & Bawadi, E. I. A.-A. (2021). A mixed-methods study to explore the impact of hospital accreditation. Inquiry: The Journal of Health Care Organization, Provision, and Financing, 58.
https://doi.org/10.1177/0046958020981463
Al-Sayedahmed, H., Al-Tawfiq, J., Al-Dossary, B., & Al-Yami, S. (2021). Impact of accreditation certification on improving healthcare quality and patient safety at Johns Hopkins Aramco Healthcare. Global Journal on Quality and Safety in Healthcare, 4(3), 117–122.
https://doi.org/10.36401/jqsh-21-8
Alhawajreh, M. J., Paterson, A. S., & Jackson, W. J. (2023). Impact of hospital accreditation on quality improvement in healthcare: A systematic review. Public Library of Sciences One, 18(12).
https://doi.org/10.1371/journal.pone.0294180
Berger, S., Saut, A. M., & Berssaneti, F. T. (2020). Using patient feedback to drive quality improvement in hospitals: A qualitative study. British Medical Journal Open, 10(10).
https://doi.org/10.1136/bmjopen-2020-037641
Bracewell, N., & Winchester, D. E. (2021). Accreditation in health care: Does it make any difference to patient outcomes? British Medical Journal Quality & Safety, 1–3.
https://doi.org/10.1136/bmjqs-2020-012533
Braun, B. I., Chitavi, S. O., Suzuki, H., Soyemi, C. A., & Asensio, M. P. (2020). Culture of safety: Impact on improvement in infection prevention process and outcomes. Current Infectious Disease Reports, 22(12).
https://doi.org/10.1007/s11908-020-00741-y
Dunbar, P., Browne, J. P., & O’Connor, L. (2021). Determinants of regulatory compliance in health and social care services: A systematic review protocol. Health Research Board Open Research, 4(4).
https://doi.org/10.12688/hrbopenres.13214.3
Endalamaw, A., Khatri, R. B., Mengistu, T. S., Erku, D., Wolka, E., Zewdie, A., & Assefa, Y. (2024). A scoping review of continuous quality improvement in the healthcare system: Conceptualization, models and tools, barriers and facilitators, and impact. BioMed Central Health Services Research, 24(1).
https://doi.org/10.1186/s12913-024-10828-0
Frank, J. R., Taber, S., Zanten, M. van, Scheele, F., & Blouin, D. (2020). The role of accreditation in 21st century health professions education: Report of an international consensus group. BioMed Central Medical Education, 20(S1).
https://doi.org/10.1186/s12909-020-02121-5
Friedel, A. L., Siegel, S., Kirstein, C. F., Gerigk, M., Bingel, U., Diehl, A., Steidle, O., Haupeltshofer, S., Andermahr, B., Chmielewski, W., & Andermahr, I. K. (2023). Measuring patient experience and patient satisfaction—how are we doing it, and why does it matter? A comparison of European and U.S. American approaches. Healthcare, 11(6).
https://doi.org/10.3390/healthcare11060797
Garcia, R., Barnes, S., Boukidjian, R., Goss, L. K., Spencer, M., Septimus, E. J., Wright, M.-O., Munro, S., Reese, S. M., Fakih, M. G., Edmiston, C. E., & Levesque, M. (2022). Recommendations for change in infection prevention programs and practice. American Journal of Infection Control, 50(12), 1281-1295.
https://doi.org/10.1016/j.ajic.2022.04.007
Goorts, K., Dizon, J., & Milanese, S. (2021). The effectiveness of implementation strategies for promoting evidence-informed interventions in allied healthcare: A systematic review. BioMed Central Health Services Research, 21(1).
https://doi.org/10.1186/s12913-021-06190-0
Hunt, D. F., Dunn, M., Harrison, G., & Bailey, J. (2021). Ethical considerations in quality improvement: Key questions and a practical guide. British Medical Journal Open Quality, 10(3).
https://doi.org/10.1136/bmjoq-2021-001497
Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: A systematic literature review. BioMed Central Health Services Research, 21(1).
https://doi.org/10.1186/s12913-021-07097-6
Levitan, S. E., & Schoenbaum, S. C. (2021). Patient-centered care: Achieving higher quality by designing care through the patient’s eyes. Israel Journal of Health Policy Research, 10(1), 1–5.
https://doi.org/10.1186/s13584-021-00459-9
Mlambo, M., Silén, C., & McGrath, C. (2021). Lifelong learning and nurses’ continuing professional development, a meta-synthesis of the literature. BioMed Central Nursing, 20(62), 1–13.
https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-021-00579-2
Mossel, L. H., Ahaus, K., Welker, G., & Gans, R. (2021). Understanding how and why audits work in improving the quality of hospital care: A systematic realist review. Public Library of Sciences One, 16(3), 1–25.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8011742/
Samardzic, M., Doekhie, K. D., & Wijngaarden, J. D. H. (2020). Interventions to improve team effectiveness within health care: A systematic review of the past decade. Human Resources for Health, 18(2).
https://human-resources-health.biomedcentral.com/articles/10.1186/s12960-019-0411-3
Sperling, D., & Pikkel, R. B. (2020). Promoting patients’ rights through hospital accreditation. Israel Journal of Health Policy Research, 9(1).
https://doi.org/10.1186/s13584-020-00405-1
The Joint Commission. (2024). Joint commission accreditation | the joint commission.
