Joint Commission Accreditation

Joint Commission Accreditation
There are many roles of the Joint Commission in accrediting medical facilities. The Joint Commission was founded in 1951 and is the nation's largest
accrediting body in health care. They evaluate nearly 21,000 health care organizations in the Unites States. (The Joint Comm, 2016) Once an
organization earns the accreditation they are re–surveyed every three years unannounced. They are responsible for making sure that healthcare facilities
are up to date on all standards, policies, and procedures. "Joint Commission accreditation can be earned by many types of health care organizations,
including hospitals, doctor's offices, nursing homes, office–based surgery centers, behavioral health treatment facilities, and providers of home care
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One in particular states, "The hospital is professionally and ethically responsible for providing care, treatment, and services within its capability and law
and regulations (Showalter,2013)." Patients may not always have the funds to be treated when their insurance coverage is not available. It would be up
to the facility to decide how they are going to continue care in these situations. They have policies on the destruction of medical records. Another policy
includes they must comply with the standards of emergency care. Also, that patients have access to interpreter services to include the most common
languages used in the healthcare facility. These standards of care are updated all of the time by healthcare experts, nurses, staff, to ensure the most
updated
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Interventions and Care for Patients
Evidence Based Practice Paper
Evidence–based practice uses current research and clinical judgment to provide interventions and care for patients (Kelly, 2012). It is important for
nurses and all healthcare team members to be up to date on current practices so patients can receive evidence–based interventions that improve clinical
outcomes. According to Kelly (2012), almost half of patients that receive care, receive interventions that are not based on evidence which can
ultimately compromise the safety of patients and their health outcomes. Peripheral intravenous therapy (PIV) is a common practice in the acute care
setting and evidence–based practices have been established to drive appropriate care for this intervention.
Almost all patients that are admitted into the acute care setting require peripheral intravenous therapy. PIV therapy is an important factor in the care of
patients in the hospital and it is most often used to maintain or correct fluid and electrolyte balances, administer medications, and replace blood or
blood products (Ignatavicius and Workman, 2013). PIV therapy is an invasive therapy that requires catheter insertion into the vascular system and
access is gained through the patient's skin. Because this is an invasive procedure, patients are at a risk of developing catheter related infections.
Catheter related infections are preventable and as nurses it is our responsibility to maintain the PIV site and use the appropriate protocols and
interventions to

Medical Errors And Unsafe Care Harm
Medical errors and unsafe care harm and kill thousands of Americans each year. Approximately two million healthcare–associated infections occur
annually in the United States, accounting for an estimated 90,000 deaths and more than $4.5 billion in hospital healthcare costs (Patient Safety, 2015).
Safety is one of the six competencies the QSEN faculty and National Advisory Board explained to be initiated in nursing pre–licensure programs in
order to increase the quality and safety of healthcare systems. Safety in healthcare decreases risk of harm to patients and providers through both system
effectiveness and individual performance. The integration of safety in healthcare, which is important for future nurses to utilize in practice, can be...
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With clinical expertise, a nurse can identify gaps in care that would result in critical patient outcomes and fix the gaps in time. Nurses are accountable
for speaking up for patients in situations when safety issues arise. For example, when there is a breach in sterilization and a nurse notices the breach,
the nurse is accountable to bring awareness of the breach to the staff no matter who is responsible or what the nurse who notices the breaches position
or seniority may be. If a medical error hurts a patient, then the involved organization and nurse is accountable and needs to take responsibility.
"Providing education about participating in crucial conversations and reviewing culture principles could improve a team's ability to speak up and
be accountable" (BattiГ‰, & Steelman, 2014). Being accountable and taking responsibility means informing the patient of the error and damage it
caused, apologizing and providing care for the injury or illness, performing a root cause analysis of the error, and learning from the analysis by
keeping the error from occurring again. A root cause analysis needs to be done after the error occurs. All staff associated in the error must participate
in the analysis in order to keep speculation from happening that will cover up the facts. The goal of the analysis is not to blame an individual for the
error, but rather to make changes to keep the error from happening again. Nurses are the most trusted

Risk Management : An Organization Of Patient Safety
According to ECRI Institute (2014), risk management did not emerge as a distinct profession in healthcare, primarily in the hospital environment, until
the mid–1970s, when the number of malpractice claims against physicians and hospitals increased dramatically, and settlements and judgments
skyrocketed. In 1977, the American Hospital Association encouraged hospitals to implement riskmanagement programs as a solution to malpractice
problems, calling risk management the "science for the identification, evaluation, and treatment of the risk of financial loss" (Dankmyer and Groves;
Holloway and Sax). Risk management's focus was to protect the financial assets and reputation of organization (Kuhn and Youngberg). During the
patient safety ... Show more content on Helpwriting.net ...
According to Mrs. Parker, Memorial Hospital of York "Is dedicated to excellence in healthcare for our community. We believe that a comprehensive
quality improvement program is a primary means of organizational goals and promoting our mission of providing the community with an array of high
–quality health care services." Memorial hospitals promote and adopt the six aims for improvement as identified by the Institute of Medicine; 1. Safe, 2.
Effective, 3. Patient–centered, 4. Timely, 5. Efficient, and 6. Equitable. The six aims for improvement set forth by the Institute of Medicine are the
basic foundation for Memorial Hospital structure of the Quality program.
Memorial Hospital of York, defines quality as a never–ending cycle of continuous improvement (parker, 2015). They accomplish this goal by
proactively identifying and improving systems causes of medical errors. Some goals of the hospital quality program include; improving the quality and
safety of patient–care processes and outcomes and to organize data into useful information, including comparison to an internal and external data
source, among other few, (parker, 2015). All employees and departments are expected to be actively involved in the program, the Board of Trustees,
Administration, Department Leaders and leaders of the organized

The Joint Commission Is A Self-Governing, Nonprofitmaking
The Joint Commission is a self–governing, nonprofitmaking organization that accredits and certifies over 21, 000 health care organizations, hospital,
and programs in the United States. The body was formed in 1951. Since its creation, the organization has been working relentlessly to augment
healthcare for the people of U.S. and have continued inspiring healthcare organizations with an aim to promote and advocate for quality as well as
value in the healthcare ("About The Joint Commission | Joint Commission," 2016). Joint Commission creates performance standards for certification
and accreditation programs that healthcare organizations and hospital facilities are demanded to pass to get accreditation from the body. These standards
are ... Show more content on Helpwriting.net ...
The Joint Commission is the oldest and largest body mandated with the job of setting standards and accrediting health care organizations in America. In
addition, the commission has two affiliates that likewise focuses on improving the care quality in the United States: The Joint Commission Center for
Transforming Healthcare whose main objective is to solve problems relating to safety and quality of healthcare services in America. Joint Commission
Resources, which emphasizes on providing educational and consulting services, and publication associated with improved quality of care ("About The
Joint Commission | Joint Commission," 2016).
The commission normally employs modern approaches to assessing health care facilities and hospitals as well as collaborating with the healthcare
professionals and organizations to embolden the providers of healthcare to exceed or meet the expected quality of care. The Joint Commission seek to
enhance health care for U.S. Citizens, by collaborating with other relevant stakeholders, by assessing healthcare facilities and motivating them to excel
in offering

Accreditation Process : A New Concept
Some say that the accreditation process is a ritual that has no true value.
Hospital accreditation is not a new concept. In the 1860s, Florence Nightingale helped lay the foundation for health care quality assurance by
advocating a system for collecting and evaluating hospital statistics. Her results showed that mortality rates varied significantly from one hospital to
another. When the American College of Surgeons (ACS) was established in 1913, one of its primary goals was the improvement of hospital patient
care. In 1918, it introduced the Hospital Standardization Program which created hospital accreditation as a formal means of assuring good hospital
care. The result of the first survey revealed that many hospitals were not meeting the standards. However, by 1950, almost 95% of the hospitals
qualified for approval (Heuer, A., 2002).
As a nurse, I believe that accreditation process has true value. Accreditation is an important process designed to contribute to quality improvement in
health care facilities. It has been vital to the process of ongoing quality improvement ever since the process was first introduced in the United States
following World War I. Surveying is not an area that in the past has been considered or served as an educational opportunity for the health professionals
who conduct the surveys. Furthermore, external surveying is not usually undertaken as secondary employment for the purpose of satisfying
professional development requirements. However,

Relationship Of Msn Course Work
Relationship to MSN Course Work
Completion of coursework while enrolled in the Waynesburg University (WU) MSN program lends support to the AH Organization's alarm
management project through this author assimilating multiple MSN essentials. The major themes woven throughout the project are related to the
MSN Essentials II: Organizational and Systems Leadership; Essential III: Quality and Safety; Essential: IV Translating and Integrating Scholarship into
Practice; Essential V: Informatics and Health Care Technology and Essential; VII: Interprofessional Collaboration and Improving Patient and
Population Outcomes
Essential II
The Joint Commission stresses leadership as a foundational component of the NPSG Six. Evident throughout the literature ... Show more content on
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Quality and safety are directly tied to the purpose of the goal. Many of the tools and application of principals that have been assimilated in the alarm
management project have been part of the curriculum at WU MSN program course work. Strategies utilizing lean principals, critical thinking, data
analysis, PDCA cycles are a few of the means used to advance this project. Fundamental to the role as a patient safety leader is the use of advanced
safety, quality, and nursing theory that backs nursing practice regarding prevention of patient harm. Patient safety findings were brought to the
attention of the clinical alarm teams and the applications of the quality and safety principles were part of the litmus test for any actions steps.
Essential IV
Consequently, building onto the quality and safety principles, is the use of EBP, strongly present in the platform for every WU nursing course. The
WU program focuses on use of evidence in the literature and the assessment of the evidence. These principles are demonstrated throughout the project
with prominent use of AACN (2013) evidence based practical guidance kit. Consumption of science based information to impart practices for alarm
management was apparent in teams' participation in the literature reviews and the webinars attended. Discussions and making project decisions were
based on the strength of evidence and was a direct result of the course work from the MSN and DNP prepared participants.

Identification Of The Specific Standard, Guideline Or...
Identification of the specific standard, guideline or criteria The report makes it publicly known the harsh implications that errors in healthcare are
a leading cause of death and injury. In the late1999, Institute of Medicine (IOM) of the National Academies of the United States released the
report, To Err Is Human: Building a Safer Health System. The report cited the findings of a major study that found medical errors kill at least
44,000 and perhaps as many as 98,000 Americans in hospitals each year. Deaths due to preventable adverse events exceed the deaths attributable to
motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (l6, 5l6). Total national costs are estimated to be between $37.6 billion and $50
billion for these events. A depressing comparison of about 6,000 Americans die from workplace injuries every year and medication errors are
estimated to account for about 7,000 of this deaths (Gray, E., Gray, I., Yodice P., Rezai, F., Fless, K.). Computerized Physician Order Entry (CPOE) is
the process of entering medication orders and other physician's instructions electronically using a computer–based system to ensure standardized,
legible and complete orders. Its implementation has been recommended to improve patient safety and outcomes primarily by reducing medication
errors that usually arise from faulty prescriptions (Al–Dorzi, Hasan M., Tamim, Hani M., Cherfan, Antoine, Hassan, Mohamad A., Taher, S. and Arabi,
Y.). Hospitals are continuing to

Essay on Eliminating Abbreviations Errors in the Medical...
How can eliminating abbreviations reduce errors?
The use of abbreviations shortens length of many words thus really help healthcare professionals in saving time spent in writing notes. Abbreviations
however do not always provide positive contributions due to misconceptions, misunderstandings, and misinterpretations leading to commitment of
errors in the practice. Similarities in abbreviations for instance could root to a grave mistake. For instance the q.d. which an inscriber would like to
indicate as every day could be erroneously interpreted as q.i.d. which means four times a day. Such error could result to over dosage when a certain
medication is taken four times in a day instead of just once. Though some abbreviations can be easily ... Show more content on Helpwriting.net ...
Policies would need to provide lists of accepted abbreviations and their standard meaning. That would be one of the best ways of preventing
creation of abbreviations or assigning different meaning on a certain standard abbreviation. Despite of universal standard policies on the use of
abbreviations, organizations would know better the strength and flaws of using abbreviations in particular healthcare facility. Organizational policies
should therefore be also developed which would include the universal standard policies and organizational policies believed to maintain safety
practice. The policy should clearly specify the abbreviations that can be safely used and their standard meanings in the organizations and those that
should not be used providing the common errors generated. The policy must also indicate the forms of written paper that allows using abbreviations.
The Institute for Safe Medication Practices for instance has provided lists of abbreviations that should never be used to communicate medical
information (ISMP, 2007). Policies should also provide simple yet concise guidelines on the use of abbreviations. The methodologies of quality
control such as through periodic audit on proper usage of abbreviations should be also specified. The persons authorized to use abbreviations should
be also clearly specified. The policy would need regular updating and should therefore clearly specify the dates. If necessary, consequences of
non–obedience to the policy

Current Issues in Quality and Safety
Current Issues in Quality and Safety Current Issues in Quality and Safety The safety of medication administration has become a universal issue and
crucial for one 's wellbeing. The majority of hospitalized patients are treated with medications (Agyemang & While, 2010). The medical
treatment of patients has a direct effect on the patient 's quality of life. Srinivasan declared "patients have a right to know they are receiving safe care"
(as cited by Zhani, 2012, p. 1). The purpose of this paper is to identify current quality and safety issues in healthcare, share the impact the issues have on
health care delivery, identify quality improvement strategies, and to reveal a plan to implement quality improvement strategies. The... Show more
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Nurses were required to confirm the right patient, medication, dosage, time, and route. The five rights aided in the process but errors were still made.
Nurses working long hours, mandatory overtime, budget cuts, increased patient nurse ratio, and high patient acuities are also noted to contribute to the
increase of errors. For many of these issues there is not a quick remedy. Geiger shared the elimination of retribution for medications errors would help
decrease the effects associated with medication administration. Quality Improvement Strategies Plan Nurses on the Progressive Care Unit (PCU)
experience many interruptions during patient care, including medication administration. These interruptions can affect proper and safe medication
passage. The time taken to manage interruptions can be diverted back to the patients to assist in safe medication administration. * Plan – goal is to
improve safe medication passage by eliminating telephone interruptions during medication rounds and other non–emergent interruptions, perform
Plan–Do–Study–Act (PDSA) cycle for 5 days, Monday through Friday, during 0900 medication rounds * Targeted audience– dayshift registered
nurses, unit secretaries and the management team on the 21 bed Progressive Care Unit (PCU), patients, nurse technicians * Relevant Stakeholders –
patients, providers, employer, and payers * Needed Resources – PDSA Worksheet to evaluate the, additional part–time registered nurse to assist

Medication Errors From A Nursing
Medication Errors
Shonda Delmage
Baker College of Cadillac
04/24/2015
Medication Errors Each year, roughly 1.5 million adverse drug events (ADEs) occur in acute and long–term care settings across America (Institute of
Medicine [IOM], 2006). An ADE is succinctly defined as actual or potential patient harm resulting from a medication error. To expound further, while
ADEs may result from oversights related to prescribing or dispensing, 26–32% of all erroneous drug interventions occur during the nursing
administration and monitoring phases (Anderson & Townsend, 2010). These mollifiable mishaps not only create a formidable financial burden forhealth
care systems, they also carry the potential of imposing irreversible physiological impairment to patients and their families. In an effort to ameliorate
cost inflation, undue detriment, and the potential for litigation, a multifactorial approach must be taken to improve patient outcomes. Key components
in allaying drug–related errors from a nursing perspective include: implementing safety and quality measures, understanding the roles and
responsibilities of the nurse, embracing technological safeguards, incorporating interdisciplinary collaborative efforts, and continued emphasis upon
quality control. From a pragmatic standpoint, the nurse is ultimately the last line of defense before a potential ADE reaches the patient (Tzeng, Yin, &
Schneider, 2013). As such, methods which promote quality and safety play a

Midterm Patient Quality And Safety Paper
Midterm Patient Quality and Safety Paper Over time the health care industry has become more complex. Health care is rapidly evolving and
continuing to complicate our delivery of care, which in turn has the same effect on quality of care. This steady evolution and change results in nursing
shortages and an increase in the prevalence of errors being made. In hopes of preventing these errors and creating safe and high quality patient care,
with the focus on new and improved ways of thinking, The Quality and Safety Education for Nurses (QSEN) initiative was developed. The QSEN
focuses on the following competencies: patient–centered care, quality improvement, safety, and teamwork and collaboration. Their initiatives work to
prepare and develop the knowledge, skills, and attitudes that are necessary to make improvements in the quality and safety of health care systems
(Qsen.org, 2014). Question One Patient–Centered Care Patient–centered care refers to the view that patients and their family members are partners in
developing a care plan. This stems from the belief that the patient is in control and that the care provided is rooted in respect that addresses the
patient's personal needs and values (Barnsteiner & Sherwood, 2012). Creating a partnership with a patient that allows them to grasp the goals and
methods of their plan of care and includes them in the decision–making process can prevent errors from occurring. This gives the patient the
opportunity to correct any

A Career In EMS Profession
Wouldn't it be great to have too many paramedic students, so many that we have a waiting list for each course offered? In the growing field of
emergency medical services, more and more emergency medical technician and paramedic courses are becoming available. This is why our collegiate
institution needs to push to a higher level and become nationally accredited through the CoAEMSP. For a minimum investment cost, not only will this
accreditation show potential students that we are committed to their education, and that our programs will provide them with the educational
foundation that is now, more than ever necessary to have a successful career in EMS professions. Ultimately, it will also show that our program is a
sound institution, meeting ... Show more content on Helpwriting.net ...
The submission of the Initial Self Study Report (ISSR) begins the process. CoAEMSP Executive Director will review the study report and pass
along to establish a site visit with the site review team. After the site visit occurs, the review team completes their findings and holds an exit
interview with our staff. Formal recommendations will be written and forwarded to the Board of Directors for recommendation of approval or for
deficiencies that need to be corrected. If in the event there are deficiencies, we need to reply immediately because we will only have 14 days to
respond to their findings, with failure to respond leading to probation and possible

Nightingale Community Hospital Accreditation Analysis
In order for a hospital or facility to gain accreditation from the Joint Commission, there are several areas of requirement that the hospital or facility must
meet. Nightingale Community Hospital has met the requirements in the following areas; Accreditation participation requirements, this requirement is
important to maintain compliance in this area due to the fact that a this requirement must be maintained throughout the entire time of the hospital
having accreditation, Emergency Management, this area of requirement ensures proper safety and security of the hospital, including fire safety,
hazardous materials and waste, medical equipment as well as utilities, Human Resources this requirement is referring to the proper handling and hiring

Preventing Errors, Training And Track And Reduce Risks
prevent errors, training to improve safety and track and reduce risks to patient were low with a score of 14.55/40 and 80/129. The preventive
measures to reduce infection for handwashing was 30/30 and steps to prevent ventilator problem was 11.67/20. Communication in order to prevent
medication errors was 35/35. The hospital has a Never Events policy, in the event of errors or adverse event the hospital takes responsibility to
apologize to patient, report to external agency, perform a root cause analysis and wave all. Management and planning tools are used in an organization
to create, develop a quality culture; evaluate, organize priorities and decision making by using balanced scorecard, affinity diagram and other tools.
Some of the limitation would arise from random variation, wrong data or not enough data, methods of reporting and measuring medical errors and
adverse events. For example, most of the reporting is from a voluntary reporting system and "they are not the most reliable and underreporting is a
significant problem" (Joshi, Ransom, Nash, & Ransom, 2014, p.279). Each site has used different tools to compare, help the organization achieve the
desired goals and provide transparency between consumers and providers. In order to make any improvement, it is important to make an assessment of
current performance to find out the strength and weakness of current process. Demonstrate and verify whether the improvement had made any
difference and control of performance

Essay on Hcs 430 Week 2
Regulatory Agency paper Name HCS/430 Legal issues in Health Care: Regulations and Compliances September 27, 2010 Instructor Regulatory Agency
paper The Joint Commission is an agency that maintains partnership with the government to help improve the standards of health care within the
United States. The Joint Commission accredits health care organizations and health care programs by setting standards to help improve the quality and
safety of health care. The Joint Commission work closely and collaborates with government officials and legislation by ensuring health care
organizations in the United States meet specific guidelines, set by The Joint Commission, which health care services provided are delivered with the
highest... Show more content on Helpwriting.net ...
Day–To–Day Responsibilities The responsibilities of the Joint Commission are to set standards to help improve the quality of health care services and
provide safety guidelines for health care organizations. Their mission as a nonprofit organization is to continuously improve health care (The Joint
Commission, 2010). The Joint Commission accredits and certifies health care organizations by surveying facilities to ensure health care standards,
performance measurements, safety guidelines have been implemented and carried out for better patient. The Joint commission sets standards and
guidelines in compliance with federal laws to evaluate health care services. Health care organizations generally volunteer to seek accreditations from
the Joint Commission by allowing expert surveyors evaluate their facility. The surveyors are made up of a multi–disciplinary team that spends an
average of two days inspecting health care facilities. The purpose for the inspection is to evaluate a health care facilities standards, staff, regulations,
policies and procedures, and quality improvement, and performance measurement. The Joint Commission surveyors generally look to see if the
organizations governing board is taking part in ensuring that the facilities has facilitated safety and quality assurance program. In order for a health
care organization to qualify for an accreditation, they must certain requirements. The requirements that health care facilities must meet before

Case Study Nordstrom
Nordstrom A More Consistent And Augmentative Solution In Shopping
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Perfect where methods and deals are perception in deals you make on web to save by a large extent. See recognition and consider a cost decrease to
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See if there is discount store access with price curtailments to acquire and recover cost deductive methods is how you buy online. Settle having cost
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consideration to perceive cost markdown makes sensible cost amendments on web.
50% Off Sunglasses Using Discount Ascriptions Online To Get With Decreases
Attain with as much as 50% discounts on sunglasses to acclaim as rate deductions, selecting a price declaration online. Assess and seek rate discovery
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which is selective through rate dissimilarities online as you might accredit a rate cut

Implementing The Universal Protocol Procedure
In 2003, as an outcome of all the sentinel events reported to the Joint commission lead to the creation of the "The Universal protocol for preventing
wrong site, wrong procedures, and wrong person surgery" (Mulloy & Hughes 2008). So, one of the ways that could have potentially prevented the
situation from happening at the first place was implementing the universal protocol procedure. According to the protocol the conduction of proper pre
as well as post–operating procedures are extremely mandatory. Therefore, by enforcing a standardized routine pre–operating procedure such as
verifying the patient as well as the correct site for the procedure, by having the medical staff or preferably the physician marking the operating site
with his or her initials before the surgery will be an effective preventive measure (Mulloy & Hughes 2008). Also, by properly conducting a time–out
session where the patient is provided with a standardized briefing prior to the patient is sedated in the OR could also eliminate some the sentinel or
adverse events in the OR. Furthermore, follow a checklist, which not only pertains to the surgery itself, but also focuses on the other procedures
involved such as admissions, anesthesia equipment, and discharge (Mulloy & Hughes 2008). Using Technology to Improve Patient Safety Another
effective measure that could have potentially helped to avoid the situation at the first place was implementation of technology for instance having a
Electronic Medical

The Abandonment Of Professional Autonomy
follow modern requirement in providing the same care. The abandonment of professional autonomy could help to resolve some problem in compliance
with health care regulations. In healthcare, the goal of a provider is to treat patients and patient and the healthcare professional are pursuing one single
personal goal, which is treatment. Some medical providers are failing to follow policies or regulatory requirement when providing care. They should be
held account and must be required to follow policies or procedures when providing care. Reduced autonomy on healthcare that is supported by joint
pressure, safety rules, and institutionalized safety methods that is standardized could force provider to follow protocol. The strengthen approach to
process improvement through focus on quality care in the hospital and educating health care professionals on teamwork and strict regulations can help
reduced the autonomy of health care professionals. But the barrier of too much autonomy cannot be overcome when teamwork is not extended across
hospital wards or the departments. RenГ© Amalberti, Yves Auroy, Don Berwick, and Paul Barach (2005) stated that the increase in pressure from
medical malpractice liability and media scrutiny is creating the need for system–level decision. The reason for this is that as systems reaches safer level
of performance, the society seeks to hold people accountable or seek legal way out when injuries occur. The public and the media show disapproval to

XYZ Rest Home Case Study
The XYZ Rest Home has a unique and personal group with great commitment to eminent care and special individual needs. This facility has been
operating since 1996. Family owned and run, the facility puts great emphasis in giving compassionate and professional services in a safe haven that
they can call home (Anne Marie Rest Home, 2014, a). A 40–bed capacity aged care facility that offers hospital level of care with registered nurses on
duty in each shift (Anne Maree Rest Home, 2014,b). Weekly visits from the doctor helps keep the care going in the right track. A physiotherapist
visits weekly and is also on call whenever needed. There is a low ratio of residents to health care givers to ensure quality care at all times (Anne
Maree Rest Home, 2014, b). Staff is highly trained, ensuring safe and efficient care to the elderly. The organization train employees to be of
excellence because this ensures success of the body (Wentland, 2007). Residents engage in activities developed by the... Show more content on
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2004). To be honest, not all customers' needs are being met in the organization due to different reasons. An example would be, the quality of care
is jeopardised because of the lack of caregivers in a shift. The ratio of caregiver to residents is one caregiver is responsible for thirteen residents. As
contrast to ABC organisation, the ration of caregivers to resident is, one caregiver to six residents and another six residents shared by two caregivers
(Personal Communication, 2015). Quality of care is jeopardised mainly because there is a heavy workload and time restraint experiencing by the
carers. The health care facility is a rest home and at the same time, a hospital and in regards with that, there are different type of patients residing the
facility. Some are independent and mobile and there are also dependent and immobile

A New Set Of National Patient Safety Essay
Introduction
In health care settings across the country patient care is compromised by various preventable mistakes. Health care workers (HCW) are continuously
pushing the boundaries of time constraints. As these demands are increased the possibility for poor patient outcomes also increase. Prevention is the
first line of defense and promotes healthy practices for HCW and patients. The Joint Commission (TJC) collects data pertaining to the incidences,
information surrounding each case and establishes a national quality and safety standard. TJC accredits thousands of health care establishments with the
goal to provide safety and increase the quality of care provided in each setting. In 2016 TJC released a new set of National Patient Safety Goals
(NPSG). The goals are meant to bring awareness to the accredited facilities and HCW of concerning hazards that need to be focused on. For instance,
using two identifiers when identifying a patient to prevent medical errors, and preforming hand hygiene to reduce the risk of infections.
Accuracy of Patient Identification
The Joint Commission, NPSG.01.01.01 is the goal for improvement of accurately identifying a patient. The use of two patient identifiers such as name,
date of birth, or a type of security number that will assure the right patient gets the right treatment, care, or service. Complications that arise from
misidentification of a patient may range from mild to Sentinel event. One could consider an occurrence such

Risk Management Helps to Prevent Errors Essay
Ways that the risk manager could prevent this type of event happening in the future would be to establish and maintain a functional pediatric formulary
system with policies for drug evaluation, selection and therapeutic use. To prevent timing errors in medication administration, standardize how days are
counted in all protocols by deciding upon a protocol start date. Limit the number of concentrations and dose strengths of high alert medications to the
minimum needed to provide safe care. Assign a practitioner trained in pediatrics to any committee that is responsible for the oversight of medication
management. Develop preprinted medication order forms and clinical pathways or protocols to reflect a standardized approach to ... Show more content
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On the management side of the event would include: the charge nurse, director of the unit, risk manager, and the CEO of the organization. An event of
this significance would catch the attention of numerous management staff, due to the legal action that could be taken from the parents. The Joint
Commission, Medication Errors Reporting program, and The National Council for Medication Error Reporting and Prevention would be the
organizations involved to report the event to and aide in the prevention of it never happening again. This type of an event could catch the eye of the
media. If the hospital were completely honest to the parents of the mistake, they could report it to the media for awareness of the fault of the
organization, sympathy or education for prevent this event happening again. Active failures are the unsafe acts committed by people who are in direct
contact with the patient or system. The forms vary but they are easier to pinpoint such as: slips, lapse, fumbles, mistakes, and procedural violations.
Active failures have a direct and usually short lived impact on the integrity of the defenses (Reason, 2000). Active failures are the main issues that stand
out when a risk happens. Latent conditions are the inevitable "resident pathogens" within the system. They arise from decisions made by designers,
builders, procedure writers and top level management. Latent

Computerized Provider Order Entry
Adoption and Usage rate Because the system is capable of advancing quality of care in numerous ways, the healthcare service providers have been
considering to implement the technology in their institutions since the system has been commercially available in the market place since 2006 (Ford,
McAlenrney, Phillips, Menachemi, and Rudolph, 2008). Although a good number of institutions have been analyzing the possibility of adopting the
system, until recently, it was estimated that only 5% of U.S. hospitals had the system in operation (American Hospital Association Archive). Another
study, a 2003 report from First Consulting Group for the American Hospital Association and the Federation of American Hospitals, says that an
estimated 5% of American hospitals used CPOE in 2002. Moreover, a report found that the amount of U.S. hospitals with completely available CPOE
system was estimated only 9.6% in 2002 [Ash et al, 2004]. Another report from the Leapfrog Group titled "Healthcare Benchmarks and Quality
Improvement" has estimated that about 10% of all U.S. hospitals would have completed CPOE implementation by the end of 2006 [Ash et al, 2004].
Add a transition clause here, according to the Leapfrog Group CPOE evaluation tool, it was reported that a mere 8% U.S. hospitals were using the
system (Anderson, 2009) 120. Not only the implementation rate but also the usage rate of the system is very slow in recent time. In support of this
statement, it was reported that a group of top

Healthcare : Enhancing Patient Safety
Pyxis in Healthcare:Enhancing Patient Safety
NR 340: Information Systems In Healthcare
Instructor: Amy Johnson
Team Yellow
Pyxis: An Introduction
The Pyxis medication dispensing system is used in a wide variety of medical settings to aid in the safe administration of medication.
The Pyxis system simplifies the inventory, stocking, ordering and distribution of medications through the use of information systems.
Objectives
Discuss the purpose and use of the Pyxis.
Discuss the history and background of the Pyxis medication dispensing system.
Discuss the impact Pyxis use has had on healthcare.
Discuss the effectiveness of Pyxis use in regards to patient safety
Discuss the advantages and disadvantages of Pyxis use.
History
Los Angeles, Doctor and founder John McLaughlin, came up with the idea to reduce health care costs and improve patient safety
Pyxis Corporation based in San Diego, CA, first manufactured and introduced the MedStation System (Pyxis Machine) around 1989–90
In 1996, Ohio based organization, Cardinal Health obtained rights from Pyxis Corp
By 2009, Cardinal Health separated, into what we know today as CareFusion
Cont.' HistoryBefore Pyxis

Ward trolley used for storing medications dispensed bypharmacy for individual patients
Stockpiling of items not kept organized due to frustration in obtaining medications
Current UseBackground
Automated unit used for the distribution and storage of medicine in clinical areas
Interfaces with Patient Management System

Accreditation In Health Care
Accreditation is an activity through which a nongovernmental authority allocates acknowledgement to a school or health care organization for proven
proficiency in carrying out preset criteria for validated standards. For example, the accreditation of hospitals by The Joint Commission (TJC) on
Accreditation of Healthcare Organizations or schools of nursing by the American Academy of Nurse Practitioners (AANP) (Sollecito, W. A., &
Johnson, J. K., 2011). To assist in understanding the objective of, and differences betweenaccreditation and licensure I will discuss both. Accreditation
means the procedure by which an authoritative body bestows official acknowledgement that a compliance evaluation in conformance to the standards
is proficient to carry out specific tasks. Licensure is an activity whereby a government authority awards time–restrained consent to an individual to
practice in a specific profession following validating that he or she has met preset and regulated criteria (usually education, experience, and
examination). The difference between accreditation and licensure is that one is a governmental authority and the other is a ... Show more content on
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This means that an organization is not required to participate in the accreditation process. However, many exterior shareholders require health care
organizations to exhibit efforts at advancing quality and safety, which would involve participating in an accreditation program. Government, insurers,
and consumers are reassured through the idea that organizations are striving to reach published standards or addressing quality and safety. To improve
quality and safety is it feasible to make accreditation mandatory? If it were mandatory what effects would it have on accrediting agencies, health
organizations, and surveyors? Would it alter the operation of accreditation? Would it produce more burdens for accreditation agencies and health
organizations to attain a positive accreditation

Risk Management Is A Essential Component Of Any Business
Risk Management is a vital component of any business, especially health care. Risk management can be generally defined as recognizing, preventing,
and monitoring situations that could result in injury or liability, monetary loss, or noncompliance of regulations (Chubb Health Care, 2004, 9). In a basic
risk management system, risks are identified in separate risk area. Each risk area is handled by a different department. It addresses the risks to an
organization at the department level. In the basic risk management system, the risks are evaluated at a reactive approach rather than a proactive
approach. In comparison, the Enterprise Risk Management (ERM) system addresses risks as an organization, or enterprise, level and is proactive ...
Significant risk events must be identified. The risks are analyzed based on impact and evaluated as an inherent basis or a residual basis. Risk response
is determined by the method that best fits the organization's objectives and risk tolerances. This can be by avoidance, acceptance, reduction, or sharing.
The organization implements policies to respond to the risk and carry out the policy. Communication of the risk and its response is timely and
appropriately disseminated through the organization. The ERM system allows for monitoring, updating, and maintaining through ongoing evaluations
of processes and policies (Brannan and Taylor, n.d).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has moved their focus to patient safety. JCAHO now performs
unannounced surveys of accredited facilities to ensure that their standards are being followed and patient safety is being addressed. When a survey is
being conducted, the surveyor evaluates compliance with JCAHO standards through staff responds and documentation review as if they were a patient
in that facility that was receiving care. Health care organizations must be in the mode of continual readiness and compliance and National Patient
Safety Goals. The National Patient Safety Goals address slips and falls, communication,

Surgical Site Infections At Hospitals, Accreditation...
Surgical site infections occur when a patient experiences infection following surgery, often as a direct result of the care received in a hospital or other
medical facility. While these infections can often be easily treated while the patient is still at the hospital, the incidences of these infections can have
significant and lasting impacts on patients and the hospital itself, even resulting in a patient's death if the infection is not detected and treated
appropriately. Since these infections occur while patients are under the care of professionals and during hospital stays, it is imperative that all involved
in patient care follow procedures and policies established by the facility to reduce the risk of infections in patients. This involves not only information
about surgical site infections and their prevention, but the impact of these infections on patients, hospitals, and staff members, as well as how surgical
site infections impacts a facility's accreditation. The purpose of this paper is to discuss surgical site infections, the implications of their occurrences at
hospitals, accreditation expectations, and outcomes related to cost and quality.
Surgical Site Infection
A surgical site infection is, quite simply, an infection that occurs at a surgical incision point following a surgical procedure (Nursing Standard, 2013).
As with any medical procedures, there are risks of infection following surgery, and surgical site infections can and do occur, even in the safety and

Hospital Accreditation : A Self Assessment Process
Chapter 1 Introduction and Background
1.1Introduction
According to Myers (2011), Hospital Accreditation is a self–assessment process carried out by health care bodies to determine the level of performance
by the set standards. The process of hospital accreditation not only sets the standards for operation but also provides and support to the stakeholders on
how to improve the performance. Although the accreditation bodies set the standards of service, there is little evidence supporting the credibility and
effectiveness of the certification programs.
Healthcare accreditation isan important activity in the Kingdom of Saudi Arabia bearing in mind the vast population of the country and the high
number of hospitals operating in the kingdom. Saudi Arabia has approximately 27 million people and more than 415 hospitals (Central Department of
Statistics, 2010). In addition, the Kingdom of Saudi Arabia is the second largest oil producer (Ramady, 2010). The kingdom also occupies 830, 000sq
mi, approximately four–fifths of the Arabian Peninsula. The country shares borders with Iraq and Jordan to the north, Qatar and UAE to the eastwhile
Yemen and Oman border the country on the south and southeast respectively. Most of the country's land is arid and inhospitable due to the barren
landforms.
Oil exploration hassignificantly fuelled the growth rate of the kingdom and consequently improved the welfare of the citizens (WHO, 2007). The high
growth rate has necessitated the

Seeking Accreditation Paper
Professor & class, The nursery school that I did my practicum course at was NAEYC accredited. Seeking accreditation is a good way to evaluate an
early childhood education program because there are many standards and criteria a program needs to uphold in order to obtain or maintain
accreditation. To be NAEYC accredited, a program has to go through four steps in the process which include meeting: eligibility requirements,
candidacy requirements and site visit requirements. Some of NAEYC's important requirements that ensure high–quality programs include: Maintaining
a good standing in its licensing or regulatory status within the last year or since its last inspection, providing a description of the collaborative process
used to complete

Patient Safety Is A Major Concern For All Health Care
Patient safety is a major concern for all health care providers. Two areas of safety that are relevant to my practice in an outpatient surgical center
are medication errors and the electronic error reporting. The Association of periOperative Registered Nurses (AORN) is the organization that was
used to support my project. The Quality and Safety Education for Nurses (QSEN) Initiative competency that was chosen for my indirect clinical
project (ICP) was safety. Everyone in the health care environment wants to be kept safe. A discussion on how medication errors and the electronic
error reporting affects everyone from the staff to the community will be discussed. Safety is an integral part of health care. Considering the Joint
Commission (2015) believes patient safety is so important that it has dedicated and entire chapter on the subject and made it free to view.
Throughout this paper safety related to medication errors and electronic error reporting will be discussed. Along with the topic of medication errors
and electronic reporting will be two plans to reduce safety related events. Overall the paper will cover medication errors and their prevention with
how electronic error reporting can help prevent frequent errors from occurring. It is our job as health care providers to prevent or abolish safety risks
to the patient and to ourselves. Considering Ulrich and Kear (2014) show that four to eight million people are injured in the United States due to safety
issues in the

Medication Error Prescribing Essay
Medication Error Prescribing Medication mistakes is a critical global issue and the utmost principle widespread dilemma that terrorizes patient safety
that might spearhead to disability or death if not detected, and medication error are virtually never deliberate and regrettably occur in healthcare
(Gorgich, Barfroshan, Ghoreishi, & Yaghoobi, 2016). According to Arcangelo and Peterson (2013), approximately eight percent of the outpatient
prescription have errors and about three percent are undoubtedly avoidable out of the eight percent noted. The disclosure and nondisclosure of
medication errors are contemplated to be the utmost ethical and legal deliberations amidst the healthcare field, and the advanced nurse practitioner
prescriber needs... Show more content on Helpwriting.net ...
Arrays of research analysis conveyed that medication error is indeed not the issue, however, how the error handled by the advanced nurse practitioners
is the problem. It is imperative that advanced nurse practitioner mindful to the trust bestowed by being truthful and ethical with their patient and ensure
that errors are promptly reported to the correct channels and patient alike when it befalls. Medication errors are never intentional, and instituting a dual
stop check methodology in prescribing script can avert errors and protect our license from being at peril's and certify that their patient trust is upheld

Patient Safety And The Medical Errors
In today's fast paced healthcare environment, patient safety as well as healthcare quality has become a major priority. A growing focus on patient
safety and the increasing medical errors has made various healthcare management teams more proactive in identifying and preventing potential risks
for patients. While a great deal of progress has been made in recognizing most medical errors, it is also important to note that in a healthcare
environment there are a number of factors involved, therefore the strategies used to reduce them vary as well. So, despite a healthcare provider's
overall reputation, experience, skills or knowledge in the healthcare field, there is always a slight possibility for a medical error to take place, similar
to our case of Mrs. Jonesky and Samantha Jones. Root–Cause Analysis Definition According to Dattilo and Constantino (2006), "The most
fundamental reason for the failure or inefficiency of a process, in any work setting even the healthcare environment, is referred to as a root cause".
Root cause analysis (RCA) is the tedious process under which the healthcare providers take a step back and analyze their potential mistakes, adverse
events, or sentinel events in the operating room and all areas of healthcare (Croteau, 2003). The primary goal of RCA is to overcome their mistakes,
in order to prevent future risks or damages caused to their patients. According to The Joint Commission, most RCA is expected to take place within a
45 days limit, after

Medication Administration Essay
Medication Administration The intended use of medications is meant to improve a person' health, it is very important the individual administering
medication or self–medicating use the drugs correctly, by following the doctors' instruction for the medication prescribed. Medication is given to
diagnose, treat, and prevent illness. Medication can be very dangerous, which can potentially cause harm or even deaf if it's not used properly.
Administering medication requires the understanding of how the medication is to enter the body such as orally, transdermal, or intravenous. It also
requires the knowledge of when the medication needs to be administered, the possible side effects, and its toxicity. Doctors, nurses, and a few other...
According to the Food and Drug Administration (FDA 2009), the wrong route of administrating medication accounts for 1.3 million injuries each year.
An article published in September issue of the Journal of Patient Safety estimates there are between 210,000 and 400,000 deaths per year associated
with medical errors. This makes medical errors the third leading cause of deaths in the United States, behind that comes heart disease and cancer. To
prevent medical errors always follow the Three Checks and most importantly the Rights of Medication Administration. The "Rights of Medication
Administration" helps to ensure accuracy when administering medication to a patient. When administering medication the administer should ensure
they have the Right Medication, Right Patient, Right Dosage, Right Route, Right Time, Right Route, Right Reason, and Right Documentation. Also
remember the patient has the right to refuse, assess patient for pain, and always assess the patient for signs of effects.
Medication administration is not just giving medicine to a patient; it also involves observation of how the patient responds to the drug after
administration. As a nurse or health professional we're trained to know medication effects. Knowing how medication move through the body and what
effects the medication has or what adverse effects may occur is most important when preventing

Is Right Time Administration And Explores The Causative...
Introduction In this paper, a meaningful clinical event, regarding delayed medications, is examined. The paper explores the importance of right–time
administration and explores the causative factors and preventative measures of wrong–time errors. As a final point, I describe how I would handle the
scenario differently after learning strategies to reduce late medication administrations, thus reducing patient harm. Look Back/Elaborate During week
five, I was assigned to two patients (A and B), one of whom is a shared client (patient B) between me and a colleague. Strategically, my colleague and
I planned out the first half of the shift, such that we would perform vital signs and head–to–toe assessments first, administer medications in... Show
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In the event, I felt distressed and frustrated because I failed to perform daily tasks on time, most importantly medication administration. Furthermore,
these emotions were heightened by feelings of not being able to deliver the best possible care and thoughts of my nurses being disappointed in me
because of my poor performance. Essentially, these negative feelings arise from my values and beliefs of being punctual and providing safe and high
quality care. These values are shaped by my family and profession as I was always disciplined and taught the importance of being on time and
promoting patient safety, respectively. Essentially, one significant key issue from the event previously discussed, relates to my inability to deliver
medications at the specified time. It is important to administer drugs on time to maintain patient safety, since late medications may result in ineffective
treatments and unstable patient conditions. Analysis As previously mentioned, right–time medication administration is important to prevent patient
harm. Medications are considered late when they are delivered beyond 30 minutes of the scheduled time or depending on the hospital policy. Certain
medications, such as antibiotics and Parkinson disease drugs, follow strict schedules to provide and maintain therapeutic blood levels. In particular,
antibiotics should be administered on time to prevent bacterial resistance and

Effective Communication, And Conflict Management
"Patient safety is a top priority for all healthcare providers. Yet medical errors are ranked the eighth leading cause of death. Medication administration
errors often result from multiple environmental and individual factors" (Yoder, Schadewald, & Dietrich, 2015, p. 140). Nurses are faced with several
interruptions including other health care professionals, patients, and family members. Environmental factors such as: phone calls, call lights, alarms,
malfunctioning equipment, and emergency situations can distract the nurse and prevent the nurse from administrating medications successfully.
Research has shown that the most interruptions were from conversations with other personnel or stopping to do another patient care task (Yoder et al.,
2015). The purpose of our paper is to discuss how collaboration, effective communication, and conflict management can improve the nursing medication
administration process by both the intraprofessional and the interprofessional teams. The intraprofessional team is comprised of nurses that work on
the unit and nurses who work on other units who may try to communicate with the nurse who is administering medications. The interprofessional team
is made up of patient care technicians, the unit secretary, physicians, and other disciplines such as physical therapy, social work, pharmacy, and case
management. The interprofessional team can also distract or disrupt the nurse trying to administer medications by asking about another patient being

Medication Administration : A Multi Step Process That Is...
Medication administration is a multi–step process that is handled by multiple healthcare professionals. It begins with the prescription that is transcribed
mostly by the physician, then dispensed by the pharmacist, and ends with the administration of the medication by the nurse. Throughout this multi–step
process, medication errors can occur at any stage of the medication administration process. As expressed by L. Cloete in "Reducing medication errors in
nursing practice," "One third of the errors that harm patients occur during the nurse administration phase: administering medication to patients is
therefore a high–risk activity." Because the nurse is responsible for administering medication to the patient, he/she is considered and viewed as the
most accountable in regards to the patient's safety. Medication errors are one of the most common medical errors that can result in an adverse event
that may pose a serious threat to the patient's safety and well–being. In the article, "An inside look into the factors contributing to medication errors in
the clinical nursing practice," Savvato and Efstratios defined and characterized medication error as "any preventable event that may cause or lead to
inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer. Such events
may be related to professional practice, health care products, procedures, and systems, including prescribing; order communication;

Health And Drug Administration Of The Health Care Setting
Work Place Distractions Lead to Deadly Outcomes Effective Ways to Reduce Medication Errors in the Health Care Setting Lincoln University Suzanne
Norman–Ybarra One of the greatest fears of any nurse is harming or killing a patient by making a critical medication error. The U.S. Food and Drug
Administration reports that a person dies accidently every day from a medication error and approximately 1.3 million sustain an injury from medication
errors (U.S. Food and Drug Administration, 2016). Medication errors can result from the initial prescribing of the order, transcribing the order, entering
the order, dispensing the medication, repackaging the medication with improper labeling, administering the medication incorrectly,... Show more
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In an effort to reduce the occurrence of medication errors, JHACO has thoroughly investigated and implemented new safety standards of care. JHACO
implemented a new standard referred to as the "10 Rights of Drug Administration." 1. The Right Drug, 2. Right Patient, 3. Right Dose, 4. Right Route,
5. Right Time and Frequency, 6. Right Documentation, 7. Right History and Assessment, 8. Drug approach and Right to Refuse, 9. Right Drug to Drug
Interaction and Evaluation, and 10. Right Education and Information. Failure to follow the 10 Rights of Medication Administration can result in a
patient's injury or death (Potter, Perry, Hall, & Stockert, 2013). Further research in safety has proven that reviewing the physicians order three times
significantly reduced transcribing errors or entering the order incorrectly into the electronic medical record. Training new nurses and experienced
nurses to review every order three times has shown beneficial in patient safety and has reduced medication errors. Nurses and medical staff involved in
medication administration are encouraged to have a buddy system, where there are two nurses or trained staff members who double check all
medication calculations and assist with verifying high risk medication dosages. When there is a discrepancy concerning any medication administration,
a Stop, Think and Call policy is implemented and the medication is held until proper documentation and verification have been obtained.

National Patient Safety Goals
THE JOINT COMMISSION Patient safety one of the driving forces of healthcare. Patient safety is defined as, " the absence of preventable harm to
a patient during the process of healthcare or as the prevention of errors and adverse events caused by the provision of healthcare rather than the
patient's underlying disease process. (Kangasniemi, Vaismoradi, Jasper, &Turunen, 2013)". It was just as important in the past as it is day. Our
healthcare field continues to strive to make improvement toward safer care for patients across the country. The Joint Commission was founded in
1951 with the goal to provided safer and better care to all. Since that day it has become acknowledged as the leader in developing the highest standards
for quality... Show more content on Helpwriting.net ...
For the purposes of this paper, the author will only focus on National Patient Safety Goals 01.01.01: Identifying patients correctly and 01.03.01
Eliminate transfusion errors related to patient misidentification. NPGS 01.01.01: Identifying Patients Correctly In 2003, The Joint Commission made
one of their first goals to improve the accuracy of identifying patients to reduce or eliminate patient identification errors. This continues to be an
accreditation requirement. Their recommendations to do this are to use at least two patient identifiers when administering medications, and when
providing treatments or procedures. Acceptable identifiers may be the individual's name, an assigned identification number, telephone number, or other
person–specific identifier. Patient room number or physical location may not be used as an appropriate identifier. Healthcare provides should
re–identify the patient with each encounter, each medication pass, and each procedure. There have been procedures and protocols throughout the
country have been put into place to make the care provided to patients safer. Another element of this requirement is that all containers should be labeled
in the patients presences after using the patient identifiers

The Role Of The Joint Commission On Accreditation Of...
The role of accreditation in the hospital setting.
The history of the Joint Commission on Accreditation of Hospitals is a story of the health professions' commitment to patient care of high quality in
the 20th century. According to Dr. Ernest Codman, founder of the accreditation system, which would enable hospitals to track every patient it treat
long enough to determine whether or not the treatment was effective. If not, the hospital would figure out how to prevent similar failures in the future
(Roberts, Coale & Redman, 1987). At present, the accreditation is a process of review that health care organizations participate in to display the ability
to meet approved criteria and standards of accreditation. Accreditation represents agencies as credible and reputable organizations dedicated to ongoing
and continuous compliance with the highest standard of quality. Professional accrediting agency work together with the health care industry experts to
create standards to ensure that quality is maintained throughout all aspects of an organization (Accreditation Commission for Health Care, 2008;
Greenfield, Pawsey & Braithwaite, 2010). However, the on–site surveys are conducted, today unannounced, by health care industry experts. A inclusive
review is conducted of organizational structure, policies and procedures, compliance with federal, state, and local laws, leadership, patients' rights and
responsibilities, fiscal operations, human resource management, provision of

Joint Commission Accreditation

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