Reflective Journal Week 16: Accreditation Standards

1) I expected to learn about accreditation standards established by Joint Commission on Accreditation of Hospitals (JCAHO).

2) What I actually learned:

            Accreditation is a formal declaration of designated authority that an organization has met a predetermined set of standards (Sollecito & Johnson, 2013). Health organization accreditation standards were initiated by the American College of Surgeons in 1917 and called the “Minimum Standards for Hospitals”. Later, after collaboration with colleges and associations from the United States and Canada they created the Joint Commission on Accreditation of Hospitals (JCAHO) in 1951.  It is now referred to as The Joint Commission (TJC) in the U.S. and happens to accredit more then 4,000 organizations, or 82% of hospitals in the country (Sollecito & Johnson, 2013, p. 516).  From this beginning, accreditation has spread around the world and continues to be practiced (Sollecito & Johnson, 2013).  

            The common accreditation model is when an organization develops, implements, and continually reviews their quality improvement plan and self-assesses progress against the standards of the accreditation program (Sollecito & Johnson, 2013, p. 519). They then submit a written self-assessment report to the accrediting agency.  The agency will send a team to observe the facility, interview the staff, review documentation, and then at the end will give verbal feedback. The feedback is submitted afterwards in written form, and the facility will make the necessary corrections based off the recommendations. The accrediting organization will then assess the report of corrections and decide whether to grant accreditation status or not. The accreditation is usually for about 3 to 5 years.

            Chapter 18 of our text goes on to explain that despite global expansion of accreditation organizations, evidence on accreditation remains under-developed. Growth in accreditation requires more research, and systematic literature reviews are one important evidence source to be considered to better understand the relationship between quality measures and accreditation.

3) From the discussion, we were to determine two goals for our new hospital in order to obtain accreditation status by The Joint Commission. By referring to their website of National Patient Safety Goals (Joint Commission, 2016), we determined that the basics of hand hygiene and preventing all types of infections would be best to implement in our facility. These goals provide a foundation for quality and safe care to be given to all patients.

4) I plan to use this information in my nursing profession by showing the HCAPS survey questions to staff members at our next InstaCare staff meeting. This way we can all be informed of what patients are looking for and can plan ways to best meet their desires. Basically, we will be developing quality improvement plans from the survey questions.

5)  I enjoyed the material covered. I am actually disappointed the class is over, as I was able to learn new things about quality improvement in nursing each week and apply it to my own practice. I have learned much from this class and feel all nurses should take this course.

This course has helped me realize the reasons why hospitals continually implement change and strive to do better—even though change can be difficult for many. I learned the importance of being a nurse full of integrity and always adhering to check-lists, policies, and procedures, since they are standards of care based off of evidence-based practice meant to increase patient safety. My example can help motivate other nurses to do their best as well. I feel more empowered to create and implement change in my own work environment, and I plan to refer back to this course for ideas/processes/models of change in the future.

References

Sollecito, W. A. & Johnson, J. K. (2013). McLaughlin and Kaluzny’s continuous quality   improvement in health care. (4^th ed.). Burlington, MA: Jones & Bartlett Learning, LLC.

The Joint Commission (2016). 2016 jospital national patient safety goals. Retrieved from             http://www.jointcommission.org/assets/1/6/2016_NPSG_HAP_ER.pdf

Reflective Journal Week 15: Patient Safety Application

1) I expected to learn about different methods of patient safety that can be applied in a healthcare setting.

2) I learned about patient safety and became better informed about Joint Commission standards. Patient safety is essential in healthcare so patients can trust the care they receive and accidents or patient deaths can be prevented. The Joint Commission (2015) has been an advocate of patient safety for more than sixty years. They help health care organizations to improve the quality and safety of the care they provide by providing patient safety-focused initiatives and education for hospitals. This is aimed at encouraging and supporting organizations in their efforts to make patient safety a continuous priority. The Hippocratic Oath to “do no harm” requires physicians to abide by professional ethical standards and treat patients safely (North, 2002). Nurses have a code of ethics set forth by the American Nurses Association to have wholeness of character and preserve their integrity. This is entirely applicable to the patient situation when rendering care. Honesty, safety, and high ethical standards are needed for the provision of safe patient-centered care by practitioners.

           

The Joint Commission has set forth standards that hospitals must abide by for accreditation. If practitioners do not adhere to these standards, the hospitals can lose their accreditation, resulting in a loss of business for the company. Therefore, hospitals consider patient safety a top priority and much effort is aimed at quality improvement measures to create a safer environment for patients.

3) The team discussion involved a situation of witnessing another nurse place an unlabeled syringe filled with clear medication and an empty heparin vial on a patient’s bedside table. We were to discuss as a team if this was a violation of standards of care and what to do about it. We discussed that the nurse was breaching Joint Commission standards of handling medications safely. The best way to fix the problem was to confront the nurse and assess their knowledge of safe medication handling. Likely the nurse was poorly trained and needs more education involving standards of care. After speaking with the nurse, discussing the situation with the charge nurse, and then documenting an incident would be the next course of action. This way Risk Management teams can be informed and develop new process and education aimed at ensuring all staff are aware of safe medication handling policies and procedures.

4) I plan to document incident reports about unsafe patient experiences I witness or am involved in (hopefully I am not involved in any though!). This can lead to better process improvement system designs. I also plan to implement Just Culture in my own process and not shame or cast blame at practitioners who do make mistakes. They need to be supported and given more education to prevent future mistakes. The system needs to be fixed as well to prevent future patient fatalities or errors.

5) I enjoyed the material covered—as always, it was very insightful for me. I feel I have gained better ways to confront individuals about patient safety concerns, instead of assuming things and casting blame. I have also been better educated about Joint Commission standards and feel more informed about online resources available to me that promote and outline patient safety standards.

References

North, M. (2002). Greek medicine: The Hippocratic Oath. National Library of Medicine.   Retrieved from https://www.nlm.nih.gov/hmd/greek/greek_oath.html

The Joint Commission (2015).  Patient safety and quality. Retrieved online from             http://www.jointcommission.org/topics/patient_safety.aspx