The Joint Commission

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The Joint Commission is a non-profit organization in the United States that provides accrediting programs to approximately 20,500 hospitals and other healthcare institutions on a voluntary basis. The government has not authorized this commission. All recognized facilities are known for setting high standards in order to achieve accreditation requirements. The Joint Commission accreditation represents the quality that indicates that an organization is required to achieve performance requirements. Numerous government states have made Joint Commission certification of health care facilities a criterion for Medicaid reimbursement and licensing. The Joint Commission establishes performance standards that address vital elements of operation like patient care, consumer rights, infection control, and medication safety. It requires certain steps and organized plans to be implemented so as to achieve these certifications. The certifications are given to areas like advanced certification for palliative care programs, disease-specific care, and certification for medical staffing service. The Joint Commission not only evaluates but they also educate and provide information that is useful on the plan of action for non-compliance of an organization. For a team to earn and maintain the approval from the Joint Commission on the organization accreditation, it must go through on-site survey once every year.

The Role of Joint Commission in the Accreditation Process

The Joint Commission puts efforts together with universal precautions and OSHA in working together. The commission helps in enforcing safety policies so that healthcare workers are protected as well as prevent sentinel events. Sentinel event as explained by the Joint Commission is an unexpected occurrence that involves the death, serious physical or psychological injury. Quarterly statistics of the Joint Commission, the most common sentinel event, is wrong patient, wrong site, and illegal procedure. The Joint Commission evaluates the level of performance of an organization which is focused on the key areas that are addressed in the standards like patient treatment, patient rights, and infection control. When the evaluation takes place, the standards concentrate on the actual performance of the organization and its ability to give quality and harmless care to the patients. The ORYX initiative by the Joint Commission integrates the performance measurement data and outcomes into the accreditation process (International, J. C. 2013). This initiative has developed measurement requirements that support the organizations that have been accredited by the Joint Commission in their effort to improve quality. It is a requirement that all organizations that get accredited through the Joint Commission must be from the United States, provide services that are in the Joint Commission standards, as well as identify all the services rendered through direct contact and from another type of arrangements. The process of Joint Commission accreditation focuses on the functioning systems that are crucial to the safety and quality of patient care. The key mechanisms for the certification process include Periodic Performance Review, Tracer Methodology, Priority Focus Process, and Unannounced Surveys (Health, J. C. 2012). The Periodic Performance Review dictates that the organizations should annually assess their compliance the relevant standards and also identify all the areas of non-compliance then develop an action plan to be discussed by the Joint Commission for approval and a plan of action.

The Tracer Methodology is an assessment of the care that patients experience that is done on-site. Evaluation results of the operational systems and process that are related to the actual patient experience during the time they were at the organization are used. One patient chart is chosen by the surveyors and used as a roadmap of evaluating the compliance of the organization. Direct caregivers are involved in the accreditation process. Priority Focus Process is also an on-site assessment of high priority areas like the safety of patients and quality care. Automated systems are used in this process to gather pre-survey data from multiple sources. The sectors that are of high priority and relevance are identified and help in guiding the selection of patient traces as the process is ongoing. The Unannounced surveys are usually done without the organization being notified of their arrival. It is implemented so as to be an aid in the credibility of the accreditation process as well as ensuring that the surveyors see the functions of the organization under the normal circumstances. The surveyors during this survey approve the implementation of the organization and also monitor the action plan.

The State Licensure Requirements for Healthcare Facilities in Alabama

The applicant facilities for licensure must submit all the information required by the department which includes those that are also obliged by law. All the healthcare facilities are required to submit an application for a license which is accompanied by a statutory fee which is usually in accordance with the provisions of Section 22-21-24 of the Code of Alabama (Bianco 2016). The application must then be submitted on a form that the Board of healthcare facilities supplies. The health services must have a permanent and distinctive name that is used to apply for the licenses and cannot be changed unless there is prior written notice to the Board that specifies the name that is to be continued and the new name to be used. The facilities must have clinical records of all the residents that are in accordance with the accepted professional standards and practices. The health centers must also prove to have a plan and procedures to meet disasters and emergency which should be written in detail. Quality assessment and assurance committee must be maintained which will consist of a director of nursing services, a designated physician by the facility, and at least three other members from the facility. The Disclosure of Ownership requirements as stated in the Title 42 Code of Federal Regulations must be complied with by the facilities. If ownership is to change the facility must write a notice to the Alabama Department of Public Health. Each application for a license must specify the number of beds that facility wants the Department to approve.

Conclusion

A healthcare facility getting the Joint Commission accreditation means that they have to work hard so as to ensure that they provide exemplary services. The Joint Commission sets high standards and policies that medical organizations are required to follow. A facility that seeks accreditation portrays a picture of a service that values safety and model patient care to the public. Many people usually prefer to seek medical care from organizations who value the standards that are provided by the Joint Commission. It does not matter the method in which the Joint Commission accreditation process uses as all of them ensure that healthcare organizations are continually reviewed and evaluated so that the organizations are within compliance so that they maintain their certification. The Joint Commission accreditation and State requirements for licensure ensure that the healthcare providers give services that are within standards and those that do not put the patients as well as the staff at risk of disease or accidents because of negligence.

References

Bianco, D. P. (2016). National Directory of State Business Licensing and Regulation: A Descriptive Guide to State and Federal Licensing Requirements and Regulations for Specific Businesses. Gale Research.

Health, J. C. (2012). Hospital Accreditation Standards. Joint Commission Resources.

International, J. C. (2013). Joint Commission International Accreditation Standards for Hospitals. Joint Commission Resources.

May 17, 2023
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