Joint Commission on Accreditation of Healthcare Organizations - Case Study Example

Running Head: REGULATORY AGENCY Regulatory Agency Name Institution Date Introduction In the health care industry, various issues, may arise that may call for consultations from a legal body, a lawyer and a health ethicist. This body may consist of lawyers and risk managers. The significance of the two is for maintaining law and managing risks. Law defines the rules of conduct for which violation may result to crimes. Risk management involves setting up policies that guide in reduction of risks of liability. Medical ethics is a discipline that considers implications of technology in healthcare, the modes of treatments and how it is supposed to be. Law and ethics in healthcare addresses issues such as access to healthcare facilities, the concept of informed consent, confidentiality in patient matters, issues of abortion and doctor-assisted suicide (Fremgren, 2009). This essay looks at an example of an agency in the United States (JCAHO) that governs various legal issues in the healthcare. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Currently known as The Joint Commission (TJC), JCAHO is a private, nonprofit making organization in the United States that runs accreditation programs at a fee in its subscriber hospitals and other health care providers. This commission was formed in 1951 when it was referred to as the Joint Commission on Accreditation of Hospitals. This commission grew from the efforts Ernest Codman in promoting reform sin the hospitals by focusing on management of outcomes in patient care. His efforts led to formation of Hospital Standardization Program by the American College of Surgeons, which later grew into a new entity, the Joint Commission on Accreditation of Hospitals. This was formed through a merger of the hospital Standardization Program and other health care organizations such as American College of Physicians. The Joint Commission on Accreditation of Hospitals was then rebranded in 2007 to The Joint Commission. The mission of the JCOHA is to collaborate with the stakeholders in improving health care services for the members of the public by evaluating the services offered by the healthcare facilities and encouraging them to stand out in providing healthcare services that are safe and effective, and of the highest value. JCAHO -source and scope of its authority The Joint Commission on Accreditation of Hospitals was granted power over the hospitals by "Under 42 U.S.C. §§ 1395bb(a),(b),which states that a hospital that qualifies for joint hospital accreditation I supposed to meet the Medicare Conditions of Participation, a requirement for healthcare. The commission was also granted deeming authority by the Center for Medicare & Medicaid Services (CMS) after it announced its continued approval of the body as an accreditation agency. The commission has the right to ban a certain practice even if the practice is allowed in the standards given by other professional organizations. Since many hospital issues are not constitutional, some situations may arise that are not under the federal laws, JCAHO therefore requires that every hospital to have policies for addressing such issues. However, JCAHO is not a regulatory agency that is owned by the government, it therefore does not have authority to impose fines on the health care facilities that do not meet its standards or that do not respond to its look out alerts. However, the commission carries certain powers in that hospitals that fail to meet the standards evaluated by the commission survey may lose their accreditation and this may lead to loss of large amounts of dollars from the Medicare and Medicaid programs. The Center for Medicare & Medicaid Services (CMS) therefore recognizes hospitals and health care centers that has been accredited by JCAHO as having met the requirements for participation in the Medicare and Medicaid (JCOHA, & Joint Commission Resources, 2005). The Standards and Structure of JCOHA The standards of the JCAHO address the performance of the healthcare organizations in the main functional areas. Its standards are defined as Elements of Performance (EP) that explains the requirements that form the broad framework that the surveyors if JCAHO use in evaluating the performance of healthcare facilities. Some standards address the issues of the environment that fall under the Environment of Care (EC) standards. Other standards address the human resource issues and leadership. The surveying guide relates each of its elements of performance to the federal laws so that healthcare facilities can meet both of them. It also gives the healthcare facilities steps that they can take to streamline its activities. All these standards are updated on yearly basis as the commission expands its patient safety goals. They are then posted on their website so that all stake holders can be able to access the information (Fremgren, 2009). The Joint Commission is made up of several groups that deal with the above health care maters. These include the Nursing Advisory Council, the Surveyor Advisory Committee, The Hospital Advisory Group, The Technical Advisory Committee and the Patient and Family Advisory Council. Other members are its advisory groups that give feedback on effectiveness of its policies and standards in providing care to the members of the public. The Joint Commission is headed by a board of commissioners which has a chairman, the members of the board and an executive staff. All these people work jointly to maintain effective working relationships. It has an overall president who is currently known as Mark Chassim, who is also the managing director. The governing body of the Joint Commission is the board of Commissioners. This is dedicated to the mission of the Joint Commission in efforts to improve health care to the members of the public. The commission works in collaboration with other stakeholders in the health sector by evaluating the care given by the healthcare services to ensure that it is of the highest quality. The members of the board must be the experienced people in the healthcare sector, in the business sector and also public policy makers. Most of them must have experience on the fields served by The Joint Commission. Some of the medical fields served by The Joint Commission include the nurses, employers in healthcare, the ambulatory services, hospitals, home care services, and the hospital administrators and their physicians (JCOHA, & Joint Commission Resources, 2005). How JCAHO carries out its day-to-day responsibilities The main responsibilities of JCAHO are accreditation, evaluation, and management of information systems. In carrying out these responsibilities, the commission has employed various means ion each of its duties. In its accreditation functions, JCAHO acts upon voluntary needs of the healthcare providers by using certain established standards and indicators of quality care. These indicators are used to evaluate the quality of care offered in the healthcare facility. This information is then used in making decisions on whether to approve or deny accreditation of the facility. In this role, JCAHO functions as a third agent. The healthcare professionals are used as site surveys in evaluating how healthcare is given in a particular situation. In evaluation functions, JCAHO uses various standards set by use scientific research methods such as literature reviews, involvement of the field experts, public opinions, and development of consensus of how optimal care may be achieved. Guidelines are therefore developed from this consensus and are used in evaluating the type of care offered by the health care facilities. This process is represented in the Information management standards that were developed in 1994. Manuals for this were given to the healthcare facilities and home care providers. This also ensured that there is competency in provision of homecare (Astarita, Materna, & Blevins, 2000). The other role is management of information system where JCOHA has changed its perspective from Quality Assurance to Total Quality Assurance and Continuous Quality Improvement. The continuous quality assurance considers the healthcare organization as an incorporated unit, with ability to deliver cost effective, quality and patient centered healthcare services. The standards of the CQI focus on issues hindering proper care to the patient in various departments. Impacts of JCOHA on the health care industry Considering the financial impact that may be felt by hospitals that fail to comply to the standards of The Joint Commission, most of them have taken the accreditation and certification process of JCOHA seriously. The hospital managements have used creativity in encouraging and motivating their staff to in providing effective care to the patients. This is in the fear of the random audits and inspection done by JCOHA that catches hospitals by surprise. To keep the employees encouraged and motivated, hospitals and other health care facilities offer regular refresher courses to their employees especially on the various issues of importance to JCOHA. This helps in ensuring that the hospital staff if always familiar with the requirements of the Medicare Act. The accreditation process by JCOHA has also streamlined other healthcare factors thus ensuring that patients get optimum effective healthcare. This commission has streamlined the modes of payments of hospital bills, unethical practices in the hospitals and better treatment of the employees. Some hospitals have also been facing various problems whose solutions were provided by JCOHA for example, Miami Valley Hospital had been experiencing problems of dealing with hazardous materials and chemicals in the hospital. Solution to this problem was given by the Joint Commission on Accreditation of Health Care together with the Occupational Safety and Health Administrators. They responded by setting up regulations that ensured every healthcare facility have a system of handling the hazardous materials that are used in the hospital or available in the institution by whatever means. Material Safety Data Sheet (MSDS) were as management systems that are an indication of compliance by the hospital to the regulations (Tweedy, 2005). Generally, JCOHA has ensured that healthcare issues are well addressed. Its accreditation and evaluation processes have ensured that patients in the United States receive the best healthcare services and also matters of the hospital employees are well looked at. It has ensured that hospital employees observe healthcare ethics and operate within the legal framework (Fremgren, 2009). Conclusion Joint Commission on Accreditation of Health Care has played a great role in ensuring that hospitals in the United States function within certain standards. The commission has been given authority by the federal laws and the Center for Medicare & Medicaid Services (CMS) that allows it to accredit healthcare facilities. The commission has therefore set up various standards that govern elements of performance including the environmental care and the human resource. The Joint commission through Hospital accreditation has therefore ensured that patients receive optimum health care and at reasonable cost. Generally, it has resulted in positive impacts in the healthcare industry in the United States both to the patients and the hospital employees. References Fremgren, B. (2009). Medical Law and Ethics, 3e. New York: Pearson Education, Inc. JCOHA, & Joint Commission Resources, (2005), Accreditation process guide for laboratories. New York: Joint Commission Resources. Tweedy, J. (2005). Healthcare hazard control and safety management. London: Taylor&Francis. Astarita, T.; Materna, G. & Blevins, C. (2000). Competency in home care. Kansas: Jones & Bartlett Learning. Read More