Healthcare Management - Preparing the Facility for Joint Commission Accreditation - Essay Example

Author Note

Abstract

Joint Commission Accreditation is important for any long-term care facility (JCI, 2011). The process helps organizations to gain greater control over scarce resources, influence strategic decision making, change organizational culture, among other benefits (Burns, Bradley, & Weiner, 2011). The accreditation process is somewhat complicated, and it requires the utmost dedication on the organization’s part. A negative review can have adverse effects on the body so it is pertinent to engage in thorough preparations before the on-site accreditation visit. This paper outlines an action plan written by the Executive Director of Twilight Health Care to prepare the facility for Joint Commission Accreditation. The process involves reviewing of the facility’s eligibility for accreditation by comparing JCI standards to the services offered at the facility. Twilight Care will then undertake to improve the quality of their care by developing policies and measures to address any shortcomings in standard-compliance. After the development of policies, the facility will assess their safety and emergency readiness especially for old buildings, the environment of care and fire safety among other areas. JCI will also help by conducting the Tracer Methodology Education Program, which will offer education on tracing patients, identifying failures in long-term care, and asking the right questions. The facility then carries out a mock survey after which identified gaps get solved in preparation for the actual review.

Keywords: Accreditation, Survey, Joint Commission

Twilight Health Care aims to offer the best customer service on this side of the hemisphere. We focus on providing long-term care and senior living facilities comprising rehabilitative services, expert nursing, autonomous and dependent living services, among others. Our talented and dedicated staff is specially trained to deliver services that honour and improve the lives of our residents through empathy and an assurance to surpass our client anticipations. As the executive director, I am tasked with overseeing all operations in the facility. I am also required to sustain an amicable relationship with the Community health delivery structure and maintain the licensure and certification of the establishment. Recently, Twilight Health decided to pursue Joint Commission accreditation. For our facility to acquire the certification, it should meet all the standards defined by Joint Commission International (Burns, Bradley, & Weiner, 2011). Operating in my capacity as the executive director, I came up with an action plan to prepare the facility for the accreditation site visit.

According to Woodworth, Kirsch, and Sayers-Rana (2012), accreditation is the process through which an independent association grants acknowledgment to an entity, based on that entity’s ability to meet predetermined standards. Accreditation organisations are responsible for assessing the quality of health services provided by healthcare organisations. The Joint Commission is one such organisation. It is an independent non-governmental, not-for-profit accrediting body that is well-recognised in the healthcare industry. The commission's initial concentration was on accrediting hospitals. However, today, the Joint Commission accredits various types of healthcare organisations, among them, ambulance service providers, surgerycentres, home care organisations, medical equipment service companies, and also long-term care facilities (Woodworth et al., 2012). The "Long Term Care Accreditation Program" established in 1966 supports the provision of safe, quality care to residents in long-term care facilities (The Joint Commission, n.d.). 

Acquiring accreditation is beneficial in many ways. It sets an institution apart in connection with the quality of services which provides a competitive edge over the other providers. Accreditation will also help insurers, managed care contractors, and other third parties to recognise the institution. Subsequently, the facility will have cheaper and improved access to insurance coverage. The facility will have to make significant improvements in performance concepts before the site visit. These improvements will result in improved overall quality of the care provided. The accreditation process is also educational, and it offers the staff valuable insight on strategies to improve their performance (The Joint Commission, n.d.). A Joint Commission site visit can be held at any time without prior notification to the facility seeking accreditation (Woodworth et al., 2012). A poor review can affect Twilight Health adversely, and it is pertinent that the organisation is sufficiently prepared for the site visit. I came up with an action plan outlining the steps to follow in preparing for the site visit.

Twilight Health Care has decided to pursue Joint Commission Accreditation. First, we will assess our eligibility for accreditation. For any long-term care provider to be eligible for certification, they must have met some specified requirements. For instance, the facility should already be operating as a health care provider, and it should be licensed to provide long-term residential health care. The services we provide should also get addressed by JCI Long-Term Care standards. Twilight Health Care should also be ready to assume responsibility for improving the quality of care and services that we provide. For our facility to qualify, we must prove that we are a residential setting in which our inhabitants are not able to live independently. The residents must require services which necessitate staying for a period, for example, rehabilitation, psychiatric care, and post-surgical care among others. We must also offer multidisciplinary clinical care and support services rather than specialise in one area. For example, Twilight Health specialises in nursing, dietician therapy, occupational therapy, speech, and music therapy. We must also make sure that all clinical services identified in the site visit application are operating entirely by the time of the on-site accreditation survey. These clinical services should be immediately available for evaluation against all relevant standards, such as patient tracer activities, direct observation of patient care processes, and interviews of the patient. Our beds should have either been licensed as nursing home beds by the state; or they should fall under long-term care beds under a hospital license (JCI, 2011). 

Once we have done a satisfactory assessment of our eligibility to get accredited, we will request an Application for Accreditation from Joint Commission International (JCI). The request can be made by calling, e-mailing or writing to JCI (JCI, 2011). On receipt of our request, JCI should send us an email giving us the credentials to access the Application for Accreditation online. After receipt of this mail, I will assemble a team comprising staff members with excellent knowledge of Twilight Health Care’s services,programmes , and volumes. It is important to acknowledge the need for staff to participate in critical decision-making processes (Burns, Bradley, & Weiner, 2011). Together we will complete and return the Application for Accreditation with a required $1700 non-refundable fee (JCI, 2011) for the initial survey. After completing the Application for Accreditation, we will appoint a JCI Survey Coordinator within the facility. This person will be responsible for overseeing preparation activities, and he or she will help me to assess our facility’s readiness for accreditation. We will identify and eliminate standards-compliance deficits and then implement simulated surveys so we can get ready for the on-site accreditation visit. JCI will provide us with a copy of the standards which we shall review and then compare them to the services we provide. As a long-term care facility, we are required to comply with all standards that ensure sufficient support, quality and safety for everyone within the facility’s vicinities (JCI, 2011). Good leadership goes a long way in ensuring that the facility meets the required standards. 

Among the measures that Twilight Health Care will be required to comply with include maintaining a safe, practical, and supportive environment to adhere to the quality and safety requirements of the JCI. We will make sure our buildings and spaces offer a homelike, reassuring atmosphere that makes residents feel at home rather than feels confined. We should have access to all the equipment needed in safe resident or patient care. It is also quite important to make sure we manage risks in the care setting. We will have to make sure Twilight Health Care has a person designated with the responsibility of managing the environment risks and intervening in situations that pose threats to the residents, staff or property (JCI, 2011). Twilight Health Care will be required to adhere to security needs such as a secure environment, both physical and emotional (Burns et al., 2011). Our security assessment will also focus on fire safety, where we will hold fire drills, provide smoking zones which are free of combustible materials, and so forth. We shall address issues concerning hazardous materials and waste. We will make sure our disposal methods are safe for the patients and the environment as well. We will also test all medical equipment and provide measures to take in case of machinery failure. 

We shall also assess our readiness to deal with emergencies such as power failures, water and fuel shortages, and communication breakdowns, amongothers. We should have measures put in place to make sure we safeguard our patients/residents, the staff and the organisation at large.

Human resources contribute significantly to an organisation’s ability to provide safe, and quality care. We shall ensure that Twilight Health Care has excellent quality staff and licensed independentpractitioners. We shall make use of emotionally intelligent leadership techniques (Burns et al., 2011) to ensure job satisfaction among all members of staff. We shall also ensure that all our employees have up-to-date on-the-job training so they can ensure patient safety.Twilight Health shall also address the measures we have in place to ensure effective infection prevention and control. We shall review the JCI’s Infection Prevention and Control Standards that apply to all diseases or likely sources of infection that workers, practitioners, and administrators might come across, including an unexpected influx of communicable diseases among the residents. We will strengthen our infection prevention and control programme since it plays a significant role in improving patient/resident safety and the quality of care we provide. We will also begin to coordinate the infection and preventionprogramme with the larger community so even visitors know the role they can play in prevention and control of diseases.

We will also review our management information systems to ensure they meet our internal and external information needs efficiently and accurately (JCI, 2011). Confidentiality is also essential in healthcare management (Burns et al., 2011). Our information management systems will be strengthened to ensure the protection of privacy, security, and integrity of the facility’s data and information. We shall also train staff of the importance of maintaining accurate records both relating to the patients and otherwise. Effective information systems help leaders in ensuring proper running of all units in a facility. These systems encourage the use of hierarchy and as a result, there is sufficient information provided promptly (Burns et al., 2011). We will put measures in place to guarantee the protection of our information systems against all possible threats.

Leaders also have a significant role in shaping organization's culture (Burns et al., 2011). In turn, this culture determines how an organisation achieves its objectives. We should review factors such as the existent leadership groups to make sure they perform their duties efficiently. Twilight Health Care should have a broad mission, vision, and goals that are well-understood by all parties within the facility (JCI, 2011). Communication amongleaders should also be well defined. Effective communication is crucial for the efficient delivery of health care services (Burns et al., 2011). Ineffective communication can cause patients harm, and it is pertinent that we strengthen the measures we have put in place to maintain good communication throughout the facility. Twilight Health Care shall continue conducting forums to keep our staff updated on important matters affecting the service and to acknowledge them for their exemplary performance. These forums’ main objective will be to improve communication between our employees especially the care providers and our residents. We shall emphasise the importance of effective communication within the facility. As a result, there will be reduced stress, and improved quality of life for the residents as well as the staff within our facility. It will also help in ensuring patient safety, for example, by eliminating errors in drug administration (Woodworth et al., 2012). We shall also evaluate our medication management system to make sure it is safe and efficient. Twilight Health Care should have a system that ensures there is proper management of high-alert and hazardous drugs. There should be a good outline of methods used in selecting and procuring medications. Drugs should also get stored according to the specific instructions. Emergency medication should be readily available to the care providers. There should also be measures controlling medication brought into the facility by the residents, their families, or licensed independent practitioners. We should also review all standards relating to medication orders and preparing drugs for patients. We shall make sure that all medications are properly labelled to eliminate errors in drug administration (Burns et al., 2011). We will also stock all medication needed in the facility so that it is available when needed. Twilight Health Care evaluates patient needs before admittance for long-term care. After admission, we plan the resident’s care and provide them with all the treatment services they require. During the duration of their stay, we educate residents on different issues relating to personal health. To ensure we perform our duties effectively, we will evaluate all systems in place, to ensure we extend the best care to our residents from admission to discharge. We will also assess the systems we have in place for compiling and maintaining the clinical record. We will ensure correct documentation for all procedures including screenings, assessments and reassessments; restraint and isolation; clinical procedures; and discharge. We will implement policies and procedures to guide the assembling, completion, validation, maintenance, and release of records (JCI, 2011). Twilight Health Care shall also address the strategies for performance improvement. We will select significant measures that meet the needs of our residents. We will also improve our data analysis techniques. Data is only useful if it is correctly analysed (JCI, 2011; Burns et al., 2012). The study will help the facility to identify trends, patterns, and performance levels that suggest prospects for improvement. We will then make improvements based on the analysis. If many opportunities for growth present themselves, we will set priorities so we can improve on the most critical areas first.We will educate our staff on the importance of acknowledging the rights of patients in the facility. Recognising the residents’ rights provides an important aspect of care that encourages them to become more conversant and involved in their care (JCI, 2011). Residents become invited to ask questions and cultivate healthier relationships with their caregivers. The residents also feel supported by the persons involved in their care, treatment, and services. Recognising and respecting patient/resident rights directly affects the provision of attention. Twilight Health Care encourages service delivery in a manner that respects and nurtures our resident’s self-respect, self-sufficiency, positive self-regard, civil rights, and involvement in their care. We will emphasise on the importance of an atmosphere of respect and trust amongour staff so we can enhance communication and prevent issues that might lead to safety problems or compromise the quality of care (JCI, 2011). We will also train our staff on carefully planning of services so as tohonour our resident’s values, principles, and inclinations (Burns et al., 2011). We will also communicate with patients so that they can be aware of their obligations. Acceptance of their responsibilities will foster the concept of partnership between patients and their caregivers. Twilight Health Care opts to get accreditation under the Traditional Long Term Care accreditation option rather than the Medicaid Certification-Based option. We will, therefore, be required to comply with the JCI’s life safety standards which outline specific construction and operational conditions in the facility as a way to minimise fire hazards and offer a security system in case of fire. Our buildings have life safety designs which include fire escapes, push doors, smoke barriers and fire windows, among others. However, some of our structures need maintenance so as to meet these specifications. For instance, we need to add fire alarm notification systems and make sure that the older systems such as audible and coded alarms are working as they are supposed to. We will also add sprinkler systems and increase exit chutes.We will also conduct training to familiarise our caregivers with waived testing. Waived testing refers to simple laboratory tests performed by caregivers at a resident’s bedside or point of care. They involve simple processes such as glucose testing and rapid strep screens. We should make sure that our policies and procedures for waived tests get outlined clearly so that all our caregivers understand them. There should also be proper maintenance of all records relating to these tests. The JCI will also require Twilight Health Care to comply with the National Patient Safety Goals. The goals are a series of actions that we are expected to take to avoid medical errors, for instance, miscommunication among caregivers or prescription errors (JCI, 2011). Twilight Health will make sure that we have measures to ensure proper identification of patients. We will also encourage our staff to use effective communication techniques. We will implement measures to improve the safety of high-alert drugs. We will also put up procedures to reduce risks of infections and also prevent residents’ harm as a result of falls. Conflict can have a nullifying effect on the accreditation process especially if the staff are at loggerheads. When the team come together and use similar tactics and share information appropriately, they can help the organisation to meet its accreditation requirements (Burns et al., 2011). Twilight Health Care will train staff to employ the use of the AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) communication structure. Anxiety or fear in patients sometimes manifests as anger. AIDET helps caregivers to establish trustful relationships with their patients (Burns et al., 2011) by reducing anxiety and increasing compliance (AltaMed, 2014). A – Acknowledge entails acknowledging the other person for example, by smiling. 'I' stands for Introduce yourself because it is easier to build a relationship with someone when you know who they are. 'D' denotes Duration. Inform the patient how long the session will take and what they should expect. 'E' means Explanation – Explain what you are doing and why. Finally, 'T' means Thank you. Appreciate patients for waiting and provide a positive closing to the encounter. As a result, we expect there to be increased patient and caregiver satisfaction. We will also encourage our staff to use the techniquesamongst themselves since it also reduces anxiety, improves teamwork, fosters clear communication and helps in building loyalty to one another (AltaMed, 2014). 

Once we are satisfied that we have complied with all the required standards, we will train our staff to participate in the on-site survey. We will then review the Survey Activity Guide to familiarise ourselves with the particular proceedings that encompass an on-site investigation. We will then compile all the necessary documentation that we might need during the on-site review. Over the entire preparation process, we will maintain contact with our assigned Account Executive so we can have all the information we need to prepare ourselves for the mock survey that will get conducted around six months before the actual on-site visit. After the mock review, we will address any gaps identified so we can fix them before the actual survey.

In conclusion, accreditation is important for any long-term care facility. Preparation for the on-site accreditation visit involves assessing the facility’s readiness for accreditation by reviewing the eligibility. The long term care organisation then undertakes to improve the quality of the care by developing policies and measures to address any shortcomings in standard-compliance. After the development of policies, the facility assesses their safety and emergency readiness especially for long-standing structures, the environment of care and fire safety among other areas. JCI also helps by providing education on tracing patients, identifying failures in patient services and asking the right questions. The facility then conducts a mock survey after which identified gaps are solved. The service then waits for the actual study whose success benefits the organisation significantly. Careful preparation is, therefore, paramount.