OutlineObjectives of the Presentation Rush Oak Park Hospital History To Learn And Understand What Accreditation IsAnd How To Obtain It Learn The History Of Joint Commission To Learn How JACO Operates. Discuss 2012 Standards And The Implications ForHospitals Describe How Specific Standards Will BeImplemented Make Recommendations For Improvement
Rush Oak Park Hospital Rush Oak Park Hospital located in Oak Park, IL has beenserving the community and its healthcare needs for over100 years. Rush Oak Park Hospital is a clinical partner with one ofIL’s best academic healthcare facilities Rush UniversityMedical center which enables them to provide moreinnovative care and services to patients. Rush Oak Park Hospital is also affiliated with WheatonFranciscan Healthcare which is a Catholic housing andhealthcare agency. Rush Oak Park Hospital is Joint Commission Certified.
What Is The Accreditation Of A Health CareOrganization?“A process whereby a professional association or nongovernmentalagency grants recognition to a school or health care institutionfor demonstrated ability to meet predetermined criteria forestablished standards” (Joint Commission, 2012).Healthcare organizations to become accredited, should meetspecific quality standards.• These standards are broad and cover different aspects of the care services.• Not only the clinical services which is provided, but also the managerialprocess, the outcomes of services, the qualification of providers and thepatient’s satisfaction.
What is the Joint Commission?• Joint Commission or JCAHO is a private not-for- profit USAorganization.• JCAHO operates accreditation programs for a fee to subscriberhospitals and healthcare organizations• JCAHO accredits more than 17,000 organization and healthcareprograms around the USA• The majority of state governments recognize Joint Commissionaccreditation as a condition of licensure and the receipt ofMedicaid reimbursement except in states of Oklahoma,Pennsylvania, and Wisconsin.
Why They ExistAccreditation: Helps inform and protect consumers Support improvement in the quality of the health care system overall Required by private insurance companies (Blue Cross, HMOs) Enhances community confidence. Provides a report card for the public. Offers an objective evaluation of the organizations performance. Stimulates the organizations quality improvement efforts. Aids in professional staff recruitment. Provides a staff education tool. May be used to meet certain Medicare certification requirements.
Joint Commission Standards Address the hospitals level of performance --not just theircapacity to perform. Set forth performance expectations for activities that affectthe quality and safety of patient care. Ask two kinds of questions: "Is the hospital doing the right things?“ "Is it doing them well?“ Also specify requirements to ensure that patient care isprovided in a safe manner as well as in a safe and secureenvironment.
Leadership StandardLD.03.01.01 Leaders define how members of the population(s) served can helpidentify and manage issues of safety and quality within the hospital. Effective Jan. 1, 2009 the new Joint Commission Leadership Standard(LD.03.01.01), Elements of Performance 4 and 5 require that hospitalshave a code of conduct that defines acceptable, inappropriate anddisruptive behavior (American Medical Association 2012). Leaders create and implement a process for managing disruptive andinappropriate behaviors (American Medical Association 2012) . . In response to these actions by The Joint Commission, the AmericanMedical Association adopted policy H-225.956, “Behaviors ThatUndermine Safety,” which calls for medical staffs to develop and implement their own code of conduct inthe medical staff bylaws, and that hospitals also have a code of conduct applicableto members of the board, management and all employees (American MedicalAssociation 2012) .
License, Certification & RegistrationVerification – Standard HR .01.02.05IT IS HR’S RESPONSIBILITY TO VERIFY LICENSE & CERTIFICATION AUTHENTICITY Primary Source verification is required for all licenses, certifications andregistrations upon hire and prior to expiration or at renewal time. Copies of a licenses or certifications are no longer acceptable A copy of the primary source verification from the Board’s website must be printed RENEWALS: On or prior to the expiration date of thelicense/certification The copy is date stamped electronically / one day after the expiration dateit is considered late and hospital is cited NEW HIRES: Prior to start date or on the employee’s first day of work. Employees cannot work with an expired license. Please make sure that any excused delay, employee on leave, employeewas suspended is documented in the fileA HOSPITAL CAN LOSE ITS OPERATING LICENSE IF STAFF ARE PRACTICING WITH EXPIRED CREDENTIALSREQUIRED FOR THE JOB.
Implementation of Standards Assign oversight of each chapter of standards to arespected leader who will identify team membersfrom throughout the hospital. Involve those who may also be skeptical of theprocess. Look for good people skills, time managementskills, and consensus building skills. Be prepared to change as new leadersemerge, and some leaders drop out.
Implementation of Standards In addition to overall project plan, it is often helpfulto compile a list of all required policies andprocedures that will need development andrevision These may take some time to get revised ordeveloped, undergo organizational review, andobtain final approval Be certain that our policy reflects our actualpractice, as this is what the surveyors willevaluate our organization against the standards.
RecommendationsLeadership Leaders must regularlyevaluate the culture of safetyand quality using valid andreliable tools. Leaders prioritize andimplement changes identifiedby the evaluation. Leaders must create andimplement a process formanaging disruptive andinappropriate behaviors.License, Certification &Registration Verification Leaders must define a process toverify any license, registration, orcertification required by theorganization. The organization must identify, byjob title, all licensure, certification,or registrations it requires of staffmembers in certain job groups/jobtitles and to determine the processfor verifying that the individualpossesses the required certificate,license, or registration.
SWOT AnalysisStregnths Rush Oak Park Hospital have strength derived from itsparental company’s perceptive and transparent policiesand visionary leadership, as well as financial stability forfuture development (Rush 2012). Rush Oak Park hospital has directly benefited from being apart of the Rush and Wheaton network by delivering samelevel of quality services as its sister companies does, thishas become one of the strength in marketing our productsand services. The hospital is situated in the thriving community of OakPark a western suburb of Chicago. The area providesaccessibility and proximity to all modes of transports fromall corners of Oak Park.
SWOT AnalysisWeaknesses A high nurse turnover has continued to affect nursingservices at the institution. Due to inadequate funds some planned activitiesespecially in the Primary Health Care department have notbeen undertaken, for example creating a larger primarycare group as well as a group of specialist. Despite being a leading community hospital in terms oftechnological development, some surgeries andprocedures are still too complex to perform at Rush OakPark (for example complex neuro surgeries) which meansthat patients have to be referred to a more advancedhospital for treatment.
SWOT AnalysisOpportunities Expansion of hospital services especially in PrimaryHealth Care department. Oak Park hospital may benefit from trends of patients withhigh blood pressure, heart diabetes , diabetes, at the sametime, our hospital may have more people looking forpreventive healthcare services due to awareness in healthprevention. A Joint Commission Certified Stroke Care Hospital in theOak Park Area.
SWOT AnalysisThreats Competition At lease 2 hospitals within close proximity to our facility. Financial position of the hospital has not been well duringthe past few years. There is a real need for the hospital to explore other means ofsustaining the running of their institutions through incomegenerating activities and other donors especially for communitybased activities.
CONCLUSIONJoint Commission is doing a very good job specially in making a national andinternational health care standard, and it plays an important role in improvingthe quality of the health care. However, as everything in the world, standardsfor Joint Commission should be evaluated from time to time for efficiency.
ReferencesCTU Online (2011). HCM387-1104B-02: Management Principles in Healthcare Retrievedfrom websitehttps://campus.ctuonline.edu/pages/MainFrame.aspx?ContentFrame=/Default.aspxJoint commission, (2012). Facts about the Joint Commission. Retrieved fromhttp://www.jointcommission.org/facts_about_the_joint_commission/Allan Tobias, MD JD. (n.d). Need JCAHO, Retrieved fromhttp://www.medicalaw.net/new_page_11.htmKate Jackson, (2004), Beyond JCAHO: There’s More Than One Path to Accreditation, For theRecord, Retrieved from http://www.fortherecordmag.com/archives/ftr_053104p30.shtmlJoint Commission International, (n.d), Costs of Accreditation. Retrieved fromhttp://www.jointcommissioninternational.org/Cost-of-Accreditation/
ReferencesMichael Wolfe, (2010), Benefits & Disadvantages of the Joint Commission, eHow,Retrieved from http://www.ehow.com/list_6900079_benefits-disadvantages-joint-commission.htmlLiz Kowalczyk, (2007), Surprise check faults MGH quality of care, Boston Globe,Retrieved from http://www.allbusiness.com/health-care/health-care-facilities-nursing/11897140-1.htmlQuality Check (2012) Facts about Quality Check and Quality Reports, Retrieved fromwww.qualitycheck.org/help_qc_facts.aspxHealth care quality news (2009) The Joint Commission updates sentinel event statistics,Retrieved from http://www.hcqualitynews.com/home/2009/10/25/the-joint-commission-updates-sentinel-event-statistics.htmlThe Washington Post (2005) Accreditors Blamed for Overlooking Problems, Retrievedfrom http://www.washingtonpost.com/wp-dyn/content/article/2005/07/24/AR2005072401023.htm