Quality Improvement Essay

Quality Improvement Essay

Quality Improvement Essay

The provision of high-quality, safe, and efficient care to patients is imperative in healthcare. The care outcomes are achievable using best-practice interventions by healthcare providers. Healthcare institutions demonstrate excellence in their services through accreditation. Accreditation builds consumer confidence towards the safety, quality, and efficiency of care by an institution. It also strengthens organizational competitiveness by expanding market share. Healthcare providers play the role of ensuring the implementation of standards of care that would drive the required excellence (Alshamsi et al., 2020). For example, they incorporate best practice recommendations into their care to achieve the stated goals of patient care. Therefore, this paper examines an accrediting body that is suitable for my organization, requirements for accreditation, performance metrics, and financial impacts of quality performance.

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Accrediting Body

I work in a hospital setting. The Joint Commission is the most appropriate accrediting body for the institution. The Joint Commission is the country’s oldest and biggest institution involved in standards-setting and accrediting healthcare institutions. A not-for-profit organization aims at ensuring continuous improvement in health care for the American public. It collaborates with other stakeholders in health to dive safety, efficiency, and quality in healthcare. The Joint Commission is the most appropriate for the institution due to its well-known history of leading excellence in health care. For example, it has accredited more than 22000 hospitals and programs, 10,000 accredited surveys, and provided 4000+ certification reviews yearly in the USA(Jointcommission.org, n.d.-c). As a result, its consumer confidence is high translating into trust towards the accredited institutions.

Requirements to Obtain Accreditation

Hospitals should meet the developed requirements for their accreditation by the Joint Commission. One of the requirements for accreditation is the need for the hospital to be within the United States or its territories. Institutions outside the United States should be operated by the US government or governed by a charter of the US Congress. The hospital should also meet the requirements for the required number of inpatients or the volume of services offered. In this case, the hospital should serve a minimum of 10 inpatients with one active during survey time. A new hospital to the Joint Commission must further have an active inpatient case during the survey period (Jointcommission.org, n.d.-b). The additional requirements include being able to offer inpatient records for at least 10% of the hospital’s average daily census if it is 21 or more or a specialty. However, the records should not be less than 30 inpatient records during survey time.

A hospital should also provide 20 inpatient records if the Average Daily Census is less than 21 (1-20). The hospital should also be familiar with the Joint Commission’s tracer survey process alongside the SAFER scoring methodology used in determining the organization’s accreditation ability. Once ready, hospitals contact the Joint Commission to determine the procedures or processes that need to change and ways of meeting the stated requirements (Jointcommission.org, n.d.-b). Hospitals must also complete an application to the commission and deposit $1700 where it will receive a date within 12 months for the survey and accreditation.

Performance or Quality Metrics

The Joint Commission accredits hospitals on performance or quality metrics. One of the quality metrics that can be of focus for the hospital’s quality improvement project to be presented to the Joint Commission is open reporting of safety and quality problems or near misses. The hospital should be encouraged to implement the Speak Up program to achieve its safety and quality goals in patient care. The program aims at encouraging the staff to report any safety problems or near-miss events to enhance organizational systems and processes. The staff should not be subjected to any form of stigma or blame in such situations (Jointcommission.org, n.d.-a). The implementation of such a project will strengthen the culture of safety, quality, and excellence in the institution.

The other quality improvement project that the hospital can present to the Joint Commission relates to the prevention of patient falls in the patient care process. Falls among patients are a critical issue affecting hospitalized patients in the USA. It increases the risk of mortalities, injuries, high costs of care, and extended hospital stay. Patient falls have been rising in the practice setting. As a result, the Unit Practice Councils can be implemented for assessment by the Joint Commission where the hospital learns from the things that work and those ineffective in preventing falls and enhancing hand-offs. The hospital can also implement Daily Safety Huddles program for evaluation by the Joint Commission where the managers meet to review any safety concerns raised over the last 24 hours as an organizational routine. The review should focus on promoting a blame-free atmosphere in the organization and exploring the change processes or systems needed to address the issue (Dixon-Woods, 2019). The adoption of such a program will foster the realization of the desired safety and quality outcomes in the process of patient care in the institution.

The last quality improvement project that the hospital can present to the Joint Commission can also target hospital-acquired infections in the institution. Accordingly, hospitalized patients are increasingly predisposed to nosocomial infections such as urinary tract infections, ventilator-associated pneumonia, central line bloodstream infections, and C.diff infections. The impacts of nosocomial infections include mortalities, high costs of care, and poor quality of life for the patients. As a result, the hospital can implement a quality improvement project for assessment that seeks to eliminate nosocomial infections to its patients. The survey by the Joint Commission will provide it with insights into the effective programs contributing to the outcome and needed practice improvements. An example given by the Joint Commission is Roane Medical Center, which implemented a similar program leading to no catheter-associated urinary tract infections in 6 years, 1 central line bloodstream infection in 6 years, 1 pressure injury in 2019, and 1 C. diff in 2019 (Jointcommission.org, n.d.-a). Achieving such outcomes contributes to excellence in patient care in the institution.

Financial Impacts of Quality Performance

Quality performance has several financial implications for the Organization. One of the implications is efficiency improvement. Quality performance improved efficiency in healthcare by eliminating redundancies and duplication of roles. The consequence includes a reduction in the costs incurred in healthcare institutions and improvement in systems and processes (Mosadeghrad, 2021). The quality performance also improves the safety of patient care. Accordingly, healthcare providers focus on utilizing best-practice interventions and continuous improvement to enhance care outcomes. They also utilize interventions, including inter-professional collaboration in the care process to achieve optimum care outcomes. Quality performance also enhances the quality of patient care. For example, the use of evidence-based practices minimizes the occurrence of issues such as hospital-acquired infections among hospitalized patients (Dixon-Woods, 2019).Consequently, quality performance improves safety, quality, and efficiency, which have cost-benefits to an organization.

Quality performance also standardizes processes in an organization. Standardization assures patients high-quality care and optimum care outcomes. It also enables the determination of the cause-effect relationship between the different interventions to achieve optimum care outcomes (Trinchero et al., 2019). Hospitals are business entities that exist to achieve profit in their service provision. Quality performance improves productivity and profitability in healthcare institutions. For example, the reduction in safety and quality issues results in high income to the institution due to efficiency in resource utilization. Quality performance also influences stakeholder confidence in the organization. For instance, patients trust the care services offered in the institution. As a result, organizations benefit from a large market share and competitiveness, which drive their success in service provision (Sultana et al., 2019). Therefore, hospitals should strive to achieve a high level of quality performance to realize their desired outcomes.

Conclusion

Overall, accreditation of healthcare organizations is important. Accreditation reflects the safety, quality, and efficiency of care given to patients. The Joint Commission is an appropriate accrediting body for my hospital. Its appropriateness is seen from the high number of institutions it has accredited and its impacts on performance. The hospital has to meet the developed requirements for its accreditation by the Joint Commission. The quality projects that may be implemented for accreditation by the Joint Commission in the hospital include those focusing on nosocomial infections, safety and quality events reporting, and managerial active involvement in strengthening patient safety culture. Quality performance has significant financial implications. It improves efficiency, safety, and quality in healthcare. Therefore, hospitals should strive to implement projects that improve the existing systems and processes for excellence in the patient care process.

References

Alshamsi, A. I., Thomson, L., & Santos, A. (2020). What Impact Does Accreditation Have on Workplaces? A Qualitative Study to Explore the Perceptions of Healthcare Professionals About the Process of Accreditation. Frontiers in Psychology, 11, 1614. https://doi.org/10.3389/fpsyg.2020.01614

Dixon-Woods, M. (2019). How to improve healthcare improvement—An essay by Mary Dixon-Woods. BMJ, 367, l5514. https://doi.org/10.1136/bmj.l5514

Jointcommission.org. (n.d.-a). Our Standards for Hospital Accreditation | The Joint Commission. Retrieved January 7, 2022, from https://www.jointcommission.org/accreditation-and-certification/health-care-settings/hospital/learn/our-standards/

Jointcommission.org. (n.d.-b). Process and Pricing for Hospital Accreditation | The Joint Commission. Retrieved January 7, 2022, from https://www.jointcommission.org/accreditation-and-certification/health-care-settings/hospital/learn/process-and-pricing/

Jointcommission.org. (n.d.-c). What is Accreditation | The Joint Commission. Retrieved January 7, 2022, from https://www.jointcommission.org/accreditation-and-certification/become-accredited/what-is-accreditation/

Mosadeghrad, A. M. (2021). Hospital accreditation: The good, the bad, and the ugly. International Journal of Healthcare Management, 14(4), 1597–1601. https://doi.org/10.1080/20479700.2020.1762052

Sultana, S., Andersen, B. S., & Haugen, S. (2019). Identifying safety indicators for safety performance measurement using a system engineering approach. Process Safety and Environmental Protection, 128, 107–120. https://doi.org/10.1016/j.psep.2019.05.047

Trinchero, E., Farr-Wharton, B., & Brunetto, Y. (2019). Workplace Relationships, Psychological Capital, Accreditation and Safety Culture: A new Framework of Analysis within Healthcare Organizations. Public Organization Review, 19(1), 139–152. https://doi.org/10.1007/s11115-017-0390-6

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Write a 1,250-1,500-word essay about quality improvement. Include the following points in your essay:

Evaluate which accrediting body would be most appropriate for your health care organization.
Summarize the requirements to obtain accreditation.
Based on your research and experience, what performance or quality metrics could you focus on for a quality improvement project to present to the accrediting body?
How does the quality performance financially impact the organization?
Include at least three references, including the textbook.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.