This is a point-by-point report that outlines in detail any corrective action undertaken by the organization to address the cited RFI. The ESC must be accompanied by an MOS, also known as measure of success, which is a report generated by interviewing staff, conducting an audit and facility inspections to determine the effectiveness of the corrective action. The MOS is quantifiable with the performance tiers defined as follows: non-compliance for a 79 percent and below MOS, partial compliance for an MOS between 80 to 89 percent and satisfactory compliance for an MOS 90 percent and higher.
Aside from the general guidelines for accreditation, there are also specific guidelines for specialties that some facilities will provide while others do not. The Joint Commission awards certificates for facilities that achieve one or more additional sets of guidelines. Those certificates include palliative care, advanced cardiac care, primary home medical care, and perinatal care among others.
These subcategories contain requirements for member organizations. For example, to be rated under the Clinical Care Classification System, or CCC, an organization must have performed at least coronary artery bypass graftings.
Additionally, it must have done at least 50 valve replacements, percutaneous coronary interventions, and 36 primary PCIs. Patient identification is also essential on a purely practical level. Facilities must maintain patient privacy as part of their compliance with the Health Insurance Portability and Accountability Act.
The organization must also have extensive and adequate diagnostic testing facilities and a cardiac catheterization laboratory that is accessible all day every day. As far as the education of staff is concerned, all are required to study a certain number of hours annually based upon their personal qualifications. The organization must also sponsor six or more community outreach programs about cardiac health. According to the CCC system, the leader of the medical facility must be a physician.
For a facility or organization to be designated Advanced Certification Heart Failure, it must have a leadership staff that has extensive experience with heart failure patients. In ACHF facilities as well as facilities with the other classifications, patients must be able to receive an EKG with 12 leads within 10 minutes of arrival. After acute treatment, these facilities provide patients and their families with long-term solutions. They discuss treatment options, general prognosis, and other considerations for the future.
When it comes to the PHAC classification, STEMI-qualified staff members must maintain their qualifications annually both by performing the associated procedures themselves or by working to refine and improve the procedures to improve patient outcomes.
They, too, focus on STEMI patients and have much the same requirements for staff training and continuing education as facilities that meet the criteria of these other cardiac programs. The organization stands for excellence in patient care at hospitals and other healthcare facilities in the United States. As can be seen, the accreditation process is both thorough and complex.
Few facilities achieve accreditation in every discipline and category, but doing so is not necessary for accreditation in one or more of the categories the Joint Commission implements. Through diligence and a desire to serve patients as safely and comprehensively as possible, healthcare facilities and other organizations can rely upon the stalwart professionalism, complete transparency, and desire to serve of the Joint Commission.
It is important for health care facilities to maintain compliance with JCAHO standards to assure stakeholders that they are operating effectively guided by the highest standards of care for the safety of patients and staff. Think about the difficulty of holding every facility, department, and team member accountable to follow oversight for each licensed or certified provider. It is critical that leaders have the ability to remove communication barriers and supply an environment for quick action and trust between all contributors in the credentialing, verification, and renewal process.
Doing so will help with routine audits and surveys from the Joint Commission, and ensure that the right people are delivering care for your organization. Get the latest healthcare news, advice from industry experts, and all things related to monitoring solutions delivered straight to your inbox. Search Contact Us Log In. Contact Us. Log In. Link to Open Side Menu.
February 14, Share on facebook Facebook. Share on twitter Twitter. Share on linkedin LinkedIn. License Monitoring Solution Checklist Next. This will inspire community confidence in the organization and signal their focus on quality care. This may give the organization an edge in a competitive healthcare marketplace. Joint Commission standards are designed to help improve quality of care. Using these standards will help an organization manage and reduce the risk of error or low-quality care.
The Joint Commission standards are developed by experts in their field and periodically put up for field review. Through this process, practitioners may submit comments and suggestions to continuously improve standards and make sure they stay up to date with current practice.
Accreditation may make liability insurance easier to obtain and possibly lower the cost. Depending on the location of the organization, accreditation may fulfill local or state regulatory requirements. Accreditation can satisfy requirements for Medicare and Medicaid without additional surveys required. Accreditation is increasingly a requirement for contract bidding for insurance companies. Accreditation and ongoing review can aide an organization in developing improvement protocols.
The survey is conducted by experts in their field who can provide tools for improving quality and maintaining structural improvement. Maintaining high quality care will attract and help recruit high quality personnel while developing current personnel. Organizations that wish to pursue accreditation, may contact the Joint Commission to determine if they are eligible.
After obtaining access to the accreditation standards, the organization can compare the standards to their own performance standards to determine if the organization is ready for the accreditation process.
The organization can then submit an application to begin the process. The next step is a comprehensive on-site survey of the organization.
Once an organization is approved for accreditation, the Joint Commission will assist in publicity to promote the newly achieved accreditation. In order to maintain accreditation, organizations will need to have an on-site survey every three years, except for laboratories which are surveyed every two years.
States that undertake this effort on their own are in a minority at this juncture in time. There are other nonprofit certifications in the country.
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