Practice Standards JCAHO What is JCAHO The Joint

Practice Standards JCAHO

What is JCAHO? • The Joint Commission is an agency that provides accreditation status to health-care organizations that comply with their standards of patient care. • The Joint Commission has made their mission to research what practices provide the best health care to patients. • The joint commission is an independent, not-for-profit group in the United States that administers accreditation programs for hospitals and other health care-related organizations. (Mc Clinton, R. 2012. pp. 1 -4)

What is JCAHO’s Purpose? The commission develops performance standards that address crucial elements of operations, such as patient care, medication safety, infection control, and consumer’s rights.

JCAHO’s ongoing Mission • To promote specific improvements in patient safety • To hold healthcare organizations accountable for providing quality health care and putting patient safety first • To enhance the safety of patients with the intentions of improving patient outcomes • Most state governments require healthcare organizations be accredited by the commission as a condition for licensing and Medicaid reimbursement

History of JCAHO � Joint Commission on Accreditation of Hospitals was established in 1951 � Recognized by the Federal Government in 1965 ◦ This was when it was decided that if a Hospital met JCAHO standards then they would meet the Medicare standards

The benefits of joint commission accreditation include: • Helps organize and strengthen patient safety rules • Strengthens community confidence in the quality and safety of care, treatment and services • Provides a competitive edge in the marketplace

JCAHO Accreditation Benefits cont. • Improves risk management and risk reduction • May reduce liability insurance costs • Provides education to improve business operations • Provides professional advice and counsel, enhancing staff education (The Joint Commission. 2012. pp 1 -3)

The benefits of Joint Commission certification include: • Improves the quality of patient care by reducing variations in clinical processes • Provides a framework for program structure and management • Provides an objective assessment of clinical excellence • Creates a loyal, cohesive clinical team

JCAHO Certification Benefits cont. • Promotes a culture of excellence across the organization • Facilitates marketing, contracting and reimbursements • Strengthens community confidence in the quality and safety of care, treatment and services (The Joint Commission. 2012. pp 1 -3)

How are the Joint Commission’s standards implemented? • The Joint Commission performs on-site surveys which are data driven, patient centered and are focused on evaluating actual care processes. • The objectives of the survey are not only to evaluate the organization, but to provide education and “good practice” guidance that will help staff continually improve the organization’s performance. • Joint Commission on-site surveys are designed to be organization specific, consistent and to support the organization’s efforts to improve performance. (The Joint Commission. 2012. p 2)

National Patient Safety Goals (NPSG) � established in 2002 by JCAHO � established to help healthcare organizations address problem areas regarding patient safety � developed and updated by professionals with hands-on experience regarding patient safety issues � JCAHO decides on which patient safety issues are the highest priority and gives guidelines on how to best address these issues � JCAHO will determine if a NPSG is applicable to a certain accreditation program and will then tailor the goal to be program-specific

2012 NPSGs include: � Identify patients correctly � Improve � Use staff communication medications safely � Prevent infection � Identify patient safety risks � Prevent mistakes in surgery (The Joint Commission. 2012)

Core Measures � Developed by JCAHO to improve the quality of health care by implementing a national, standardized performance measurement program � Developed from quality indicators defined by the Centers for Medicare & Medicaid Services � Reduce the risk of complications, prevent recurrences, & treat patients who come to the hospital for treatment � help hospitals improve the quality of patient care by focusing on the actual results of care (Baylor Health Care System (2012)

33 core measures in 4 categories � Acute Myocardial Infarction � Community-acquired � Congestive � Surgical Pneumonia Heart Failure Care Improvement each category has specific actions that represent the most widely accepted, research based care processes for the best care in that category (Baylor Health Care System (2012)

Angela’s Practice standard “My job as a clinical manager in the hospital setting is influenced by JCAHO in several ways. I am responsible for making sure that the nurses on my unit are competent to provide safe, high quality care to all patients and are following the guidelines set by JCAHO’s core measure sets and national patient safety goals. I am also responsible for data collection to show that these standards are being met, that performance improvement projects are in place and staffing issues are addressed. All of these affect the quality of care delivered and ensure that patients are receiving safe, competent care. ”

Angela’s Field of Study General Hospital Standards • A hospital can have an unannounced survey 18 -36 months after its previous full survey • The purpose of an unannounced survey is to ensure that the performance of the organization is observed under normal circumstances and the organization is continuously following the standards of care • The focus of the on-site survey is continuous operational improvement in support of safe, high quality care , services and treatment • The survey uses tracer methodology, which focuses on actual patients to assess standards compliance

General hospital Practice Standards continued • Individual tracers follow the patient’s experience of care throughout their hospitalization • System tracers evaluate the communication and coordination of care among the various disciplines and departments within the organization • System tracers may evaluate medication management, infection control, performance improvement, and compliance with national patient safety goals and core measures within the hospital setting • The on-site visit also includes an assessment of staff competencies and a review of credentials

Andrew’s Practice Standard “In my current practice area of Emergency Nursing, JCAHO practice standards influence my nursing practice by establishing a level of standards that I must meet. This enhances the quality of care I can deliver to the patient by ensuring that I hold current certifications, training and knowledge to administer and monitor the treatment of the vast array of complaints that arrive in my emergency department. ”

Tara’s Practice Standard “I am currently practicing in Emergency Nursing. JHACO affects my nursing career by insuring that I abide by the State of Michigan’s “Nurse Practice Acts”. I must obtain educational and job requirements yearly. I must also keep all licenses current. Nursing is an every changing field and you must be willing to accept change. “

Andrew & Tara’s Practice Standards Emergency Department Practice Standards In addition to the Practice standards of the Hospital, JCAHO places additional requirements that are unit specific. • Monitor timeliness of critical lab results to physician • Obtain complete medication lists prior to admission • Assess patients at fall risk • Provide safe and effective care during an emergency to patient, family and staff

Christine’s Practice Standard “In my profession of home healthcare nursing, the practice standards are modeled after JCAHO (Joint Commission on Accreditation of Health Care Organizations), but for my particular agency it is actually enforced by CHAP (Community Health Accreditation Program). There are several different accreditation agencies that enforce the standards for home health care agencies which include both JCAHO and CHAP. The influence on my actual practice is in regard to the requirements for licensure, educational requirements and actual practice standards which I am required to use in my daily interactions and treatment practices with the patients in my care. These standards dictate the care standards and regulations addressing the entire treatment plan for the patient from admission to discharge. Additionally it also addresses the proper documentation requirements mandated by Medicare standards to assure reimbursement and payment. ”

Christine’s Field of study • Home care organizations are surveyed every 18 to 30 months after their initial accreditation • The focus of the survey process is on the patient’s experience with the care process • The surveyor also focuses on the health care organization’s operational systems to determine compliance • The surveyors actually ride with the home care nurse/case managers and evaluate our provision of care for the patient and evaluate • In addition to evaluation of patient care for JCAHO compliance, the nurse is also evaluated for nursing practice standards as designated by the Michigan Nursing Association, American Nursing Association and State Of Michigan Licensure and Regulation Board (LARA)

In Conclusion "Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. 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. "

References Baylor Health Care System (2012). Core measures. Retrieved from http: //www. baylorhealth. com/ABOUT/FACTSSTATS/QUALITYDATA/Pages/D efault. aspx Mc Clinton, R. (2012). What is joint commission? Retrieved from http: //www. ehow. com/facts_5618893_joint-commission_. html The Joint Commission. (2012). 2012 Hospital national patient safety goals. Retrieved from http: //www. jointcommission. org/assets/1/6/2012_NPSG_HAP. pdf The Joint Commission. (2012). Retrieved from http: //en. wikipedia. org/wiki/Joint commission The Joint Commission. (2012). Facts about the national patient safety goals. Retrieved from http: //www. jointcommission. org/assets/1/18/National_Patient_Safety_Goals_6_3_111. PDF The Joint Commission. (n. d. ). Retrieved from http: //searchhealthit. techtarget. com/definition/The Joint Commission. (n. d. ). Retrieved from http: //www. jointcommission. org/about_us/about_the_joint_commission_main. aspx