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