Understanding Accreditation Discussion Paper
The use of case studies offers learners an opportunity to link theory to practice by applying knowledge to cases. Thus, the students get the opportunity to interact with hypothetical situations before facing real-world problems that impact patient health outcomes (McLean, 2016)Understanding Accreditation Discussion Paper. In the context of this case study, the student assumes the role of the executive director of a long-term care facility that plans to gain Joint Commission International (JCI) accreditation. As for this case study scenario, the learner draws on, applies, and cites the first seven chapters of the course textbook to articulate an Action Plan that lays grounds for an accreditation site visit. Also, using other outside sources will be crucial in supporting the Action plan.
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Background Information
Health care facilities must offer optimal and responsive care that ensures positive health outcomes. The quality of long-term care remains an area of concern across diverse stakeholder groups entailing the national, local, and state policymakers, the service users, and their families. In particular, the nursing home sector raises concerns over affordability, quality, accessibility of care, the adequacy of oversight, and implementation mechanisms. Despite improvements in the quality of long-term care in recent years, the problem persists, as evidenced by congressional hearings, government reports, press, criminal and civil court cases (Mollica, 2019)Understanding Accreditation Discussion Paper. A ranging debate also prevails concerning the effectiveness and appropriate scope of national and state policies to regulate long-term care, enhance the health and wellbeing of individuals receiving care and minimize the poor performance of providers. Long-term care offers a vast array of services over a continuous period to persons of different ages with functional limitations and chronic conditions. Such needs cover issues ranging from minimal assistance with the elementary personal assistance of routine activities to nearly total care. To this end, long term care plays a vital role in the lives of the service seekers, prompting the need to cultivate a culture of excellence in care, cost leadership and accessibility. Therefore, seeking Joint Commission accreditation would help the long term facility transform its practices while exceeding rigorous quality performance standards.
The acquisition of JCI accreditation harbors a profound effect on an organizational culture, performance, image and business operations. An effective and focused leadership that commits to the course while collaborating with the entire organization to implement performance standards is critical. Adhering to JCI Pathway steps to accreditation is critical to ensuring organizations meet the set standards. The long-term Care accreditation plan that JC established in 1966, aims at supporting the delivery of high quality and safe care to patients. According to JCI (2022), the commissions long term care standards cover individuals and their family’s rights, needs assessment, medication management, resident and family education, and access to care and services continuity. The JC addresses aspects such as skilled nursing services, ethical management, rehabilitative services and complex chronic care management. Therefore, a long-term care facility must strive to work towards such standards to meet JC’s expectations Understanding Accreditation Discussion Paper.
Justification for choosing Joint Commission Accreditation
The shift in demographics coupled with a constantly dynamic health care environment, requires long term care facilities to live the demands of their operating environment. As a benchmark for success, demonstrating a safe and high-quality care for patients and their family amidst the backdrop of continuous performance improvement through accreditation offer the long-term facility room to achieve such an end. With the Joint Commission accreditation, the long-term care facility would earn the widely recognized standard for evaluating and demonstrating high-end services. Given that payers and managed care contractors require Joint Commission accreditation, the long-term care facility will benefit for earning accreditation because it will attract reimbursements while adding up as a core element of their participation agreements. Therefore, and as the “Gold Seal of Approval”, which offers a comprehensive evaluation process in the sector (Lighter, 2016)Understanding Accreditation Discussion Paper. By earning the joint accreditation seal, the long-term care will enhance its competitiveness, strengthens community confidence, validates quality care, strengthens improvement efforts while improving liability insurance coverage and staff recruitment and education.
Understanding accreditation requirements
A long-term care facility preparing for an accreditation must consult The Joint Commission’s Comprehensive Accreditation Manual (CAMLTC). The guide offers all the bare minimum organizational needs for a continuum of operational improvements concerning the rationale, standards, Accreditation Participation Requirements, elements of performance (EPs), and scoring. Other organizational needs indicators encompass accreditation decision rules, National Patient Safety Goals, and accreditation policies and procedures (Joint Commission Accreditation Healthcare, 2011). By living the demands of the CAMLTC, the long-term care facility will attain a consensus-based and resident/patient-oriented performance standard that support safety and quality throughout the facility and across its leadership.
The preparation effort is a demanding affair that requires the long-term care facility to utilize project management tools to execute the preparation process. Therefore, the organizational leadership will appoint the project manager and a team from various departments to steer head the process. The team will document the current state of organizational standards and establish correspondence with the set Joint Commission standards, noting areas that require improvements to fill the identifiable gaps (Gonzalo et al., 2021)Understanding Accreditation Discussion Paper. The fields the team must consider, which the accreditation board also reviews include: crisis management, community of care, human resource, data control, disease prevention and maintenance and facility management. Other areas of review include patient rights, testing refusals, performance enhancement, patient Care, Treatment and Activities, and Documentation of Care, Treatment, and Activities.
The detailed account of all the activities to assist with completing the certification process is critical because it guides the team on areas that require attention, providing a platform to evaluate how the facility maintains such areas. According to Zimmerman & Sartin (2018), auditing of all completed documents and fact-checking for authenticity is critical; hence, the long-term care facility must employ data assessors to oversee its functions and audit staff on all levels and patients’ families.
In collaboration with the facilities leadership, the project team would create a mission and a vision for the facility, aligning resources towards meeting the set objectives. In the context of this case study, the core areas of focus that require concerted efforts to achieve the desired change entail streamlining the safety, health and wellbeing of all patients in the facility. Also, the team will lay grounds for continuous improvement to enforce compliance with the JC’s standards. The use of advanced technology will also come in handy in ensuring ease of meeting goals.
The project team also must establish the key deliverables and milestones against the commission’s standards a benchmark. The approach will be necessary to facilitate objectivity while ensuring each deliverable is met within the set time and budget while avoiding scope creep. The team must also engage all relevant stakeholders and ensure they optimally manage the interest of each to avoid conflicts (Carnall, 2018)Understanding Accreditation Discussion Paper. For instance, if the project team fails to consider the interest of the employees, end-user resistance may stifle the quality and improvement efforts. Hence, the project team must develop a framework that factors employees needs such as training, staff to resident ratio and shift timings, enhancing their satisfaction levels. Also, the project team must engage residents and their families, preparing them for the kind of questions they would expect from the JCI.
The project team would also seek the JCI’s advisory services when preparing for the accreditation. Such collaboration will be essential in health the team streamline survey preparation. Working with the JCI’s experienced consultants ensures that the team remains objective through the process from start to finish. Working with the consultants helps the project team leverage their skills in Robust, process Improvement to identify, plan and implement each crucial step for successful accreditation.
The long-term care facility will adopt the extended treatment goals as stipulated in the CMS survey and Certification group 2016/2017 Nursing Home Action Plan, 2017, promoting consumer knowledge, strengthening survey procedures, requirements, & education and standardizing security functions (Rowan, 2017)Understanding Accreditation Discussion Paper. Other areas will include advancing care initiatives and establishing partnerships with allies to strengthen the facility.
Improving consumer knowledge
The long-term facility anticipates creating channels that enhance collaboration with the community, residents, and families. Thus, the institution will develop programs that keep visitors, residents, and families informed of available treatment plans. The use of electronic channels to share the diagnosis, testing, and the proposed treatment with residents, enhances the patients’ ability to manage their care while holding the care system accountable. The approach acknowledges that patient participation is an essential part of enhancing the quality of care. In increasing customer knowledge, the project team will identify key tasks:
| Task | Responsible party |
| Benchmark quality protocols to promote employee accountability | Human resource department |
| Guarantee adequate shift coverage | Human resource department |
| Acquisition of resident ad family feedback | Chief communication officer |
Strengthening survey procedures, requirements, and education
The long-term facility will institute continuous initiatives to improve the effectiveness of annual standard surveys while strengthening channels for investigating residents and their families’ complaints. The facility will also set metrics necessary for improving collecting data, enhancing accuracy levels in client identification, and reducing adverse events emanating from preventable facility acquired conditions that potentially increase the cost of care for both patients and the organization (Gabor & Ing, 2017)Understanding Accreditation Discussion Paper.
Enhancing enforcement activities
The long-term facility commits to institute enforcement systems that advance resident-oriented health care and safety. Thus, the facility establishes a framework that enhances meaningful partnerships with consumer advocates local and state health care agencies, ultimately enhancing knowledge sharing base that positively contributes to resident positive health outcomes.
Promoting quality improvement
The long-term care would establish comprehensive quality improvement plans in principal areas, entailing, reducing the use of antipsychotic medication, physical constraints, and preventable pressure ulcers. The facility management team acknowledges that the mentioned aspects contribute to adverse health outcomes, prompting them to participate in culture change initiatives. Such an approach will promote customized care approaches.
Creating strategic mechanisms through partnerships
The long-term care facility acknowledges that collaboration facilitates comprehensive patient-centered care across care agencies. Thus, the facility will create a framework that supports resource coordination and mobilization through partnerships. Such an approach will ensure coordinated care, leveraging the contribution of governmental and non-governmental entities to better patient outcomes (Gabor & Ing, 2017)Understanding Accreditation Discussion Paper. A benchmarking process that factors internal and external processes towards enhancing resident satisfaction while eliminating instances of health-acquired conditions.
Improving communication and protecting employees
The long-term facility acknowledges its employees as the principal assets that keep the organization running. Therefore, providing a conducive environment that facilitates the optimal flow of communication is critical for enhancing professional collaboration during patient care while at the same time enhancing the organization’s capability to live the expectations of the CMS Emergency Preparedness Rule. The communication model will be more effective with incorporating employee well-being (Gabor & Ing, 2017). Using technological communication solutions for health care would be a critical step in allowing the organization to meet this standard, ultimately improving resource coordination and patient care while preventing accidents and workplace violence enhancing staff safety.
Several steps are necessary to ensure the project team achieves the above milestone successfully and in correspondence with JCI standards. The project team must collaborate with JCI consultants to facilitate the milestones evaluation process throughout the following steps.
Baseline Assessment
The long-term facility would invite the JCI consultants to conduct an onsite baseline assessment, establishing the institutions’ readiness for accreditation. This phase allows for an in-depth review that benchmarks the institutions’ current services and processes to JCI standards while noting the gaps; subsequently making improvements (JCI, 2022)Understanding Accreditation Discussion Paper. The project team must understand that even where the organization meets the standards of any other regulatory agency does not add up to being JCI ready.
Mock Survey
The long-term facility participation in a mock survey would be critical in establishing its readiness. This process will take place six months before accreditation, where the JCI consultants simulate the actual survey process while noting the gaps in compliance. The approach would engage senior leaders, allowing them to see areas the institution is falling short of while preparing staff for the actual survey (JCI,2022). The phase will enable the organization to work towards solutions that fill the identified gaps, leveraging leadership support to ease the process of resource mobilization.
Objective improvement support
The project team would work with JCI consultants to identify high-priority areas where the organization is struggling with compliance. This phase will facilitate the development of a custom plan through workgroups, mini-lectures, focused tracers, and hands-on training to synthesize and identify practical solutions. Such collaborations allow for brainstorming beyond the confines of the project team to include other parties who have experienced similar scenarios before, allowing for knowledge transfer (JCI, 2022)Understanding Accreditation Discussion Paper. Therefore, this session serves as a learning experience where the organization can utilize the knowledge in their future safety and quality improvement processes that require JCI standards criteria.
Education program through a tracer methodology
Exposing the staff to the tracer methodology tool would allow the staff to learn the best practices in tracing patients, seeking feedback through asking the right questions, and identifying breakdowns in care (JCI, 2022). The long-term facility staff requires skills in tracer techniques to reduce the possibility of medical errors that may emanate from wrongful resident identification.
The project team would invite all relevant stakeholders during the final preparation phase. This will expose the stakeholders to the entire preparation journey while soliciting their input in areas they feel require improvements. This step will ensure the organization is up to speed with the whole preparation journey, the gaps identified and the initiatives employed to meet the benchmark criteria.
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Concisely, pursuing Joint accreditation is a critical approach that will enhance the long-term facilitys’ ability to remain competitive while constantly embracing quality and safety standards to offer optimal care to residents. The facility’s’ management must consult with the JCs’ manual to stay privy to the requirements and implement them before the accreditation period. Any health care facility strives to offer the best patient care, and a long-term care facility is no exception. However, such an end requires concerted efforts to meet the set standards, eliciting the need to develop a structured approach that facilitates the benchmarking process. Notably, the safety and quality improvement process is not a one-off activity but instead must assume a regular check to ensure consistency. Therefore, this case study acknowledges that meeting the accreditation standards is key to its operations and would place the institution as a preferred destination for residents and their families. The organization would leverage the JCI consultant’s support to ensure it does not miss the point during the preparation process, leveraging the insights to guide subsequent improvement processes. A multi-faceted approach that identifies and plans for necessary changes steers the process of earning the accreditation seal, which positions the organization competitively in the market Understanding Accreditation Discussion Paper