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Quality Improvement Essay: Joint Commission

Student’s Name

Institutional Affiliation

Course Number and Name

Instructor’s Name

Due Date
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Joint Commission: 1,250-1,500-word essay about quality improvement. Include the

following points in your essay:

Describe which accrediting body would be most appropriate for your health care

organization.

Joint Commission on Accreditation of Hospitals was established as an independent non-profit

organization with the purpose of voluntary accrediting hospitals (The Joint Commission, 2010).

The Joint Commission on Accreditation of Hospitals has matured since 1951 to become the

leading provider of accrediting healthcare organizations. The Joint Commission on Accreditation

of Hospitals' mission statement is "To continuously improve the safety and quality of care

provided to the public through healthcare accreditation and related services that support

performance improvement in healthcare organizations" (Withrow, 2003, p. 1).

"The sources of the Joint Commission's highest level of authority are the federal and state laws

within each jurisdiction" (Shams, 2007, p. 1). The next level of authority falls under the Joint

Commissions policies and procedures developed to address different circumstances when a

healthcare facility is experiencing accreditation. The Joint Commission can offer accreditation to

health care facilities that follow policies and procedures. If policies and procedures are not

followed, the Joint Commission "does not have the authority to cite or fine healthcare

organizations for not meeting standards. However, failure to meet these standards can result in

loss of accreditation, which can mean the loss of millions of dollars from Medicare and Medicaid

programs" (Franko, 2002, p. 1). Because of the loss of money, hospitals that want accreditation

will adhere to the Joint Commissions policies to obtain and maintain accreditation. Without

accreditation, health care facilities cannot continue to provide quality health care for patients.
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The Joint Commission Authority's scope is determined by federal or state laws. The scope

determines the limits of practice. The Joint Commissions scope of practice includes accreditation

for services such as home health care, long term health care, ambulatory care, hospitals, and

other facilities relating to health care (Shams, 2007). The Joint Commission monitors health care

facilities ensuring that they are within the scope of policies and standards for accreditation. If

danger is found to risk patients' safety, the Joint Commission will issue a sentinel event alert. A

sentinel alert can be for reasons such as medical gas mix-ups, causes of death and injury among

newborns with normal birth weight, and wrong-site surgeries. Health care facilities that receive

accreditation from the Joint Commission are aware of where deficiencies are and given the

knowledge to improve in these areas. Accreditation ensures that patients will receive safe and

quality health care. Sentinel event alerts can happen in an accredited hospital because healthcare

standards are constantly changing; human error can result in patient safety becoming

compromised.

Summarize the requirements to obtain accreditation.

Health care facilities are allowed to request accreditation with The Joint Commission. The

Joint Commission relies on surveys filled out by experienced behavioral healthcare

organizations; surveyors must pass a certification examination. The Joint Commission remains in

contact with health care personnel during the period between surveys. To earn and maintain

accreditation, the organization will be surveyed every three years or sooner if needed. After the

surveys and an inspection of the health care facility, a score is given, and if the facility obtains a

passing score, the health care facility then receives accreditation. The Joint Commission will

advise the healthcare facility of the policies and procedures to maintain their accreditation
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(Brennan, 1998). Once a health care facility receives accreditation, it must maintain optimal

standards to maintain accreditation.

 Based on your research and experience, what performance or quality metrics could

you focus on for a quality improvement project to present to the accrediting body?

 How does quality performance financially impact the organization?