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  • Rush Oak Park Hospital located in Oak Park, IL has been serving the community and its healthcare needs for over 100 years. Healthcare organizations such as Rush that want to become accredited, should meet specific quality standards. These standards are broad and cover different aspects of the care services. Not only the clinical services which provided, but also the managerial process, the outcomes of services, the qualification of providers and the patient’s satisfaction. Accreditation is “a process whereby a professional association or nongovernmental agency grants recognition to a school or health care institution for demonstrated ability to meet predetermined criteria for established standards” (Joint Commission 2012). Joint Commission or JCAHO is a private not-for- profit USA organization. JCAHO operates accreditation programs for a fee to subscriber hospitals and healthcare organizations.JCAHO accredits more than 17,000 organization and healthcare programs around the USA .The majority of state governments recognize Joint Commission accreditation as a condition of licensure and the receipt of Medicaid reimbursement except in states of Oklahoma, Pennsylvania, and Wisconsin. Joint Commission Standards:Address the hospital's level of performance --not just their capacity to perform.Set forth performance expectations for activities that affect the 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 is provided in a safe manner as well as in a safe and secure environment.There are several Joint Commission Standards that should be followed in order for a hospital to be in compliance.Two standards that we will address for Rush Oak Park Hospital will be: Leadership Information Management.We will also discuss how these two standards will be implemented within the facility.Finally we will discuss specific recommendation for improvement within the facility.
  • Rush Oak Park Hospital located in Oak Park, IL has been serving the community and its healthcare needs for over 100 years. Rush Oak Park Hospital is a general medical and surgical hospital in Oak Park, IL, with 177 beds (Rush Oak Park Hospital 2012). In addition to providing 24-hour emergency services, Rush Oak Park Hospital is also home to specialized health care options, including the Center for Rehabilitation, the Breast Center and the Center for Diabetes and Endocrine Care (Rush Oak Park Hospital 2012) .Rush Oak Park Hospital is a clinical partner with one of IL’s best academic healthcare facilities Rush University Medical center which enables them to provide more innovative care and services to patients. Rush Oak Park Hospital is also affiliated with Wheaton Franciscan Healthcare which is a Catholic housing and healthcare agency. “As part of our commitment to ensure quality health care, Rush Oak Park Hospital seeks accreditation from the Joint Commission on Accreditation of Healthcare Organizations” (Rush Oak Park Hospital 2012). The Joint Commission provides unscheduled inspections to determine whether the hospital is in compliance with their standards for quality, patient safety and the safety of the environment.Rush Oak Park has a "Gold Seal of Approval" by the Joint Commission on Accreditation of Healthcare Organizations (Rush Oak Park Hospital 2012).
  • Healthcare organizations that want to become accredited, should meet specific 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 managerial process, the outcomes of services, the qualification of providers and the patient’s satisfaction. Accreditation is “a process whereby a professional association or nongovernmental agency grants recognition to a school or health care institution for demonstrated ability to meet predetermined criteria for established standards” (Joint Commission 2012). In order to be eligible to receive payments from Medicare the federal program that provides health care benefits to over 42 million elderly and disabled beneficiaries, hospitals must meet certain criteria established by federal law. The Centers for Medicare & Medicaid Services (CMS), the federal agency within the Department of Health and Human Services (HHS) that administers Medicare, has established conditions of participation that hospitals must meet to be eligible to participate in the Medicare program. The Joint Commission on Accreditation of Healthcare Organizations (Joint Commission), a nonprofit corporation, has developed its own accreditation standards that are intended to meet or exceed Medicare’s conditions of participation.Hospitals accredited by the Joint Commission are, in general, must meet most of the conditions to be eligible for Medicare payment.In 2003, most hospitals, over 80 percent demonstrated that they met the applicable conditions of participation through accreditation from the Joint Commission (Joint Commission 2012).Healthcare organizations to become accredited, should meet specific 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 managerial process, the outcomes of services, the qualification of providers and the patient’s satisfaction.
  • The Joint Commission, a nonprofit organization founded in 1951, was created to provide voluntary health care accreditation for hospitals. The Joint Commission’s status as a hospital accrediting body was established by statute in 1965, and can only be changed by Congress.Although CMS has approved other organizations’ hospital accreditation programs, the Joint Commission is the only organization whose approval is expressly provided for in statute. As such, the Joint Commission is not required to periodically reapply to CMS for this approval. The standards established by the Joint Commission address a facility’s level of performance in areas such as patient rights, patient treatment, and infection control. To determine whether a facility is in compliance with those standards, the Joint Commission conducts on-site evaluations of facilities, called accreditation surveys. The Joint Commission recognizes a facility’s compliance with its standards by issuing a certificate of accreditation, which is valid for a 3-year period.In 2004, the Joint Commission implemented a new accreditation process in an effort to encourage hospitals to focus on continuous quality improvement, rather than survey preparation. Previously, facilities were told in advance when Joint Commission surveyors would conduct their evaluations. As a part of the new process, the Joint Commission began conducting unannounced surveys.
  • Accreditation is a key measure to ensure the safety and quality of hospital services provided to Medicare beneficiaries and other members of the public. The Joint Commission’s role in accrediting the majority of hospitals participating in Medicare makes the issue of ensuring the independence of the Joint Commission’s accreditation process vitally important. Accreditation is not just about standard-setting: there are analytical, counseling and self-improvement dimensions to the process (Kate Jackson 2004). There are issues around evidence based medicine, quality assurance and medical ethics, and the reduction of medical error is a key role of the accreditation process (Kate Jackson 2004). Hospital accreditation is therefore one component in the maintenance of patient safety. However, there is limited and contested evidence supporting the effectiveness of accreditation programs.The following is what in essence accreditation does for patients as well as for healthcare organizations. Accreditation: 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 organization's performance; Stimulates the organization's quality improvement efforts; Aids in professional staff recruitment; Provides a staff education tool; May be used to meet certain Medicare certification requirements (Kate Jackson 2004).
  • The Joint Commission's hospital standards address important functions relating to the care of patients and the management of hospitals. The standards are developed in consultation with health care experts, providers, measurement experts and patients. Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance (Joint Commission). The standards focus on important patient, individual or resident care and organization functions that are essential to providing safe, high-quality care. “The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable,” the commission’s website noted (Joint Commission).Each accreditation program has a specific set of standards. The standards for hospitals are provided in the Comprehensive Accreditation Manual for Hospitals (CAMH). Each standard has one or more elements of performance (EPs). Many of the standards and EPs appear in the accreditation programs for several facility types. Others may be unique to a particular accreditation program.The standards are organized into functional sections. For example, following are the standards for the Hospital Accreditation Program:Accreditation Participation Requirements (APR)Environment of Care (EC)Emergency Management (EM)Human Resources (HR)Infection Prevention and Control (IC)Information Management (IM)Leadership (LD)Life Safety (LS)Medication Management (MM)Medical Staff (MS)Nursing (NR)Provision of Care, Treatment, and Services (PC)Performance Improvement (PI)Record of Care, Treatment, and Services (RC)Rights and Responsibilities of the Individual (RI)Transplant Safety (TS)Waived Testing (WT)
  • Every hospital has a leadership structure to support operations and the provision of care. In many hospitals, this structure is formed by three leadership groups: the governing body, senior managers, and the organized medical staff. In some hospitals there may be two leadership groups, and in others only one. Individual leaders may participate in more than one group. The hospital identifies those responsible for governance. The governing body identifies those responsible for planning, management, and operational activities. The governing body identifies those responsible for the provision of care, treatment, and services. Leaders define how members of the population(s) served can help identify 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 hospitals have a code of conduct that defines acceptable, inappropriate and disruptive behavior (American Medical Association 2012). Leaders create and implement a process for managing disruptive and inappropriate behaviors (American Medical Association 2012) . . In response to these actions by The Joint Commission, the American Medical Association adopted policy H-225.956, “Behaviors That Undermine Safety,” which calls for medical staffs to develop and implement their own code of conduct in the medical staff bylaws, and that hospitals also have a code of conduct applicable to members of the board, management and all employees (American Medical Association 2012) .The following are the compiled leadership standards as outlined by Joint Commission:Leaders regularly evaluate the culture of safety and quality using valid and reliable tools (Joint Commission 2012).Leaders prioritize and implement changes identified by the evaluation (Joint Commission 2012).Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives (Joint Commission 2012).Leaders develop a code of conduct that defines acceptable behavior and behaviors that undermine a culture of safety (Joint Commission 2012).Leaders create and implement a process for managing behaviors that undermine a culture of safety (Joint Commission 2012).Leaders provide education that focuses on safety and quality for all individuals (Joint Commission 2012).Leaders establish a team approach among all staff at all levels (Joint Commission 2012).All individuals who work in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and quality (Joint Commission 2012) .Literature and advisories relevant to patient safety are available to all individuals who work in the hospital (Joint Commission 2012).Leaders define how members of the population(s) served can help identify and manage issues of safety and quality within the hospital. (Joint Commission 2012)
  • Why is the HR Compliance important? HR Joint Commission Chapter defines the standards and expectations. HR compliance is the right thing to do in managing people in a Health Care environment. The hospital must be at 100% in all areas to avoid citations. Every entry must be completed timely to be reflected on the hospitals bi-weekly reports. During Joint Commission Surveys there are always file reviews to ensure appropriate documentation of competency assessment, performance evaluations, training documentation The HR Standards are the responsibility of HR but strong partnership with the all departments within the hospital departments is needed in order to meet the requirements. HR Standards include: License, Certification, Registration Verification; Upon Hire and Renewal Job Description Orientation; House-wide and Dept. Unit Specific Education; Experience and Clearance to Work Annual Education and Training Competencies; Initial and Annual Performance Evaluation Other Personnel; Non-Employees brought in by independent licensed practitioners/students/volunteers/temporary staff Measurement; and Competency Tracking System Documentation. The specific standard we will be discussing is the License, Certification & Registration Verification – Standard HR .01.02.05. It is imperative that this standard is understood by all HR personnel and that it is implemented as well as executed. It is HR’s responsibility to verify license & certification authenticity. Primary Source verification is required for all licenses, certifications and registrations 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 the license/certification: the copy is date stamped electronically / one day after the expiration date it 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, employee was suspended is documented in the file. A hospital can lose its operating license if staff is practicing with expired credentials required for the job.
  • It is imperative that Rush Oak Park Hospital has a definitive plan for implementing all Joint Commission standards. The hospital should do an assessment with the use of hospital personnel. Using the findings of the baseline assessment we should develop a detailed project plan with assigned responsibilities, deliverables, and timeframes. Start first with priority areas of the core standards. Example: Revise informed HR certification and recert. policy, develop a new informed consent statement, educate staff HR in the next two month time period If available, use a software program such as MS Project or Excel to confirm project plan in writing. Hold leaders and staff accountable to plan. The following is how the implementation process should begin:Assign oversight of each chapter of standards to a respected leader who will identify team members from throughout the hospital. Involve those who may also be skeptical of the process. Look for good people skills, time management skills, and consensus building skills. Be prepared to change as new leaders emerge, and some leaders drop out.
  • In addition to overall project plan, it is often helpful to compile a list of all required policies and procedures that will need development and revision. These may take some time to get revise or develop, undergo organizational review, and obtain final approval. Be certain that our policy reflects our actualpractice, as this is what the surveyors will evaluate our organization against the standards. Rush should continue to monitor our progress in meeting the standards, such as through a mini-evaluation of each chapter at regular intervals (e.g quarterly). Don’t be afraid to adjust your project plan to be more realistic change often takes longer than one expects. Continue to involve as many staff as possible in the process make it an organizational quality goal that together the hospital is wishing to achieve. The hospital should then plan for a final “mock survey” at least 4-6 months in advance of the target date of the actual accreditation survey. Use evaluators (internal or external consultants) who were not involved in the baseline assessment and preparation, who will look at the organization with a fresh and objective eye. Finally we will need to plan final revisions and corrections based on the findings of the final mock survey.
  • Leaders must create and maintain a culture of safety and quality throughout the hospital.Safety and quality thrive in an environment that supports teamwork and respect for other people, regardless of their position in the organization. Leaders demonstrate their commitment to quality and set expectations for those who work in the organization. Leaders evaluate the culture on a regular basis. Leaders encourage teamwork and create structures, processes, and programs that allow this positive culture to flourish (Kate Jackson 2004). Disruptive behavior that intimidates others and affects morale or staff turnover can be harmful to patient care. Leaders must address disruptive behavior of individuals working at all levels of the organization, including manage­ment, clinical and administrative staff, licensed independent practitioners, and governing body members (Kate Jackson 2004)..Leaders must regularly evaluate the culture of safety and quality using valid and reliable tools.Leaders prioritize and implement changes identified by the evaluation. Leaders provide opportunities for all individuals who work in the hospital to participate in safety and quality initiatives (Kate Jackson 2004)..The hospital should have code of conduct that defines acceptable, disruptive, and inappropriate behaviors.Leaders must create and implement a process for managing disruptive and inappropriate behaviors.Leaders provide education that focuses on safety and quality for all individuals.Leaders establish a team approach among all staff at all levels. All individuals who work in the hospital, including staff and licensed independent practitioners, are able to openly discuss issues of safety and quality.Literature and advisories relevant to patient safety are available to all. individuals who work in the hospital (Joint Commission). Leaders must define a process to verify any license, registration, or certification required by theorganization but not required by law in order to practice. In this situation, the organization mustidentify, by job title, all licensure, certification, or registrations it requires of staff members in certain job groups/job titles and to determine the process for verifying that the individual possesses the required certificate, license, or registration (Kate Jackson 2004).. It is up to the organization to determine the process it will follow for this verification.An example might be the organization that requires all respiratory therapists (RTs) to maintain current certification in basic life support (BLS). The process for verifying this certification should, at a minimum, include viewing the original document issued to the individual.
  • It is important that when considering opening a healthcare organization such as nonprofit hospitals that all variables, the feasibility, challenge and so on are considered. A SWOT analysis is a great method and or means to determine the organizations strengths, weaknesses, opportunities, and threats that may be associated with the development, and opening of the facility. There are a few strengths that should be considered. Being one of the subsidiary companies in Rush and Wheaton Franciscan healthcare organization, Rush Oak Park Hospital have strength derived from its parental company’s perceptive and transparent policies and visionary leadership, as well as financial stability for future development (Rush 2012). Rush Oak Park is a well known recognized brand name in the Oak Park and surrounding community areas as providing the most comprehensive medical care to patients. Rush Oak Park hospital has directly benefited from being a part of the Rush and Wheaton network by delivering same level of quality services as its sister companies does, this has become one of the strength in marketing our products and services.The success of Rush Oak Park Hospital came from their visionary leadership management and perceptive healthcare policies (Rush 2012). Rush Oak Park is definitely inherited the good management approaches and polices into their organization management, this will be their major strength in managementLocation: The hospital is situated in the thriving community of Oak Park a western suburb of Chicago. The area provides accessibility and proximity to all modes of transports from all corners of Oak Park. .
  • There are some weaknesses that should be considered in the strategic plan. A high nurse turnover has continued to affect nursing services at the institution. As for the pay as compared to other hospitals in the area is somewhat less than what is offered at Oak Park. Due to inadequate funds some planned activities especially in the Primary Health Care department have not been undertaken, for example creating a larger primary care group as well as a group of specialist. The hospital has been discussing possibilities of embarking on income generating activities, however, the poor prevailing economic situation makes such ventures risky.Despite being a leading community hospital in terms of technological development, some surgeries and procedures are still too complex to perform at Rush Oak Park (for example complex neuro surgeries) which means that patients have to be referred to a more advanced hospital for treatment.
  • We have great potential and opportunities here at Rush Oak Park Hospital. The hospital continues to excel in its various endeavors because of committed staff and a supportive working environment. These factors offer opportunities for expansion of hospital services especially in Primary Health Care department. The hospital with financial, material and human resources available would go a long way in strengthening community-based interventions.Changing in lifestyle are boosting the spending on healthcare, this is due to unhealthy urbanized fast food which causes obesity problem, as well as increasing number of smokers, all these leading to lifestyle related diseases like respiratory diseases and cancer, high blood pressure and heart-related diseases, while treatment for all these will increase healthcare spending and demanding, Oak Park hospital may benefits from this trends, at the same time, our hospital may have more people looking for preventive healthcare services due to awareness in health prevention.
  • As there are opportunities for Rush but there are also some threats. One ne major threat and a huge factor is the Competition. There are at least 2 hospitals within close proximity to our facility that offers the same and or similar services to patients. One hospital has just been purchased by a for profit organization and is now offering services such as heart transplants that we do not. Financial position of the hospital has not been well during the past few years. Additionally while staff are committed to working in an indigenous Christian institution, the rising costs of food and school fees combined with more lucrative offers from external non-profit organizations for highly skilled staff, often requires the hospital to pay top-ups to retain staff. The hospital therefore struggles to meet the salary requirements. There is a real need for the hospital to explore other means of sustaining the running of their institutions through income generating activities and other donors especially for community based activities.

Joint commission standards Presentation Transcript

  • 1. Joint Commission StandardsAalia AmeenHCM612-1301A-01: Management of Healthcare OrganizationsJanuary 23, 2013Dr. Rockie McDaniel
  • 2. 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
  • 3. 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.
  • 4. 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.
  • 5. 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.
  • 6. 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.
  • 7. 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.
  • 8. 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) .
  • 9. 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.
  • 10. 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.
  • 11. 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.
  • 12. 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.
  • 13. 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.
  • 14. 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.
  • 15. 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.
  • 16. 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.
  • 17. 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.
  • 18. 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/
  • 19. 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