Assessment 4

Prepare a summary brief (10-12 pages) for senior leaders on how Joint Commission accreditation helps the organization comply with regulatory requirements, improve quality, and meet stakeholder needs. Include a recommendation about other accrediting bodies that might benefit the organization.

Introduction

Health care leaders and managers need to know the best approaches to regulatory compliance. Often, the industry refers to these as best practices. Compliance best practices require health care organizations to meet specific standards. Common standards include:

• Quality of care.
• Privacy and patient protection.
• Patient satisfaction.
• Ability to meet stakeholder needs, including serving the community.

How do health care organizations determine standards? How do they evaluate how well they are meeting those standards? Government agencies do set and enforce many standards; however, these standards stipulate the minimum requirement for compliance. Most government oversight organizations are not interested in providing a “scorecard” or a ranking system for health care organizations. They are more interested in whether or not health care organizations are meeting the regulatory standards.

Most health care organizations, on the other hand, want to performabovethe minimum standards. They want to pursue excellence. This type of approach to compliance helps ensure the organization is meeting regulatory requirements and helps the organization deliver high quality to its stakeholders.

To accomplish this, health care organizations often rely on standards set by accrediting organizations. Achieving accreditation from a third-party organization that sets high standards is often a vigorous and time-consuming process. It does, however, help the organization ensure it is meeting standards well above the regulatory minimums.

In most cases, accreditation is voluntary. However, some states require certain accreditation for licensure. Joint Commission accreditation is the most common and well-known voluntary accreditation in health care. The Joint Commission accredits a wide array of health care organizations. Many benefits to accreditation exist; however, helping to ensure compliance is the main one.

Now that your hospital has a robust compliance program and an all-staff compliance training program in place, senior leaders want to take the next step. They want the organization to perform an in-depth analysis of the benefits of voluntary accreditation. Senior leaders know the Joint Commission accreditation it currently possesses is good for the organization’s reputation and standing in the community. However, they also want to know what additional benefits might exist for the organization that it has not capitalized on yet. They hope to better justify the costs associated with voluntary accreditation.

Because of your involvement in developing and implementing the new compliance program, they have asked you to research and prepare a summary brief on how Joint Commission accreditation helps the organization comply with regulatory requirements, improve quality, and meet stakeholder needs. In your summary brief, they have also asked you to consider other accrediting organizations that could benefit the organization.

Instructions

To meet your senior leaders’ request, you will prepare a 10- to 12-page summary brief. Asummary brief is a common document in management that is used to summarize concepts, issues, products, or projects. Summary briefs often vary in format. For academic purposes, the required format for this summary brief is current APA format, a common format for health care research and academics. Consult these resources for additional guidance on the appropriate use of APA guidelines:

• Evidence and APA—This is a tutorial on the current APA style.
• APA 7th Edition Example Paper [PDF] Download APA 7th Edition Example Paper [PDF]—This is an example to help you make sure your summary brief conforms to APA formatting guidelines.

Use the following headings to organize your summary brief for leadership:

Accreditation in Health Care (3–4 paragraphs)

• Provide a short overview of accreditation in health care.

Accreditation Requirements (3–4 paragraphs)

• Include anoverview of the most common accreditation requirements.

Accreditation and Regulatory Compliance (1–2 pages)

• Compare and contrast accreditation and regulation requirements.
• Detail how accreditation helps health care organizations meet regulatory requirements.

Joint Commission Standards (1–2 pages)

• Analyze the key Joint Commission standards that apply to this organization.

Accreditation Best Practices (2–3 pages)

• Describe industry best practices for meeting accreditation requirements.

Other Accrediting Organizations (2–3 pages)

• Select one accrediting body other than the Joint Commission and analyze the benefits of its accreditation for the organization.

Conclusion (3–5 paragraphs)

• Share your informed opinion about whether the cost and required effort for meeting accreditation requirements have value to the organization. Note: You do not need to perform a full financial analysis here. You only need to share considered insights about the benefits and costs of voluntary accreditation.

Additional Requirements

• Written communication: Use the Compliance Program Implementation and Ethical Decision-Making Template linked above. Your workplace brief needs to be clear, concise, well-organized, and generally free of errors in grammar, punctuation, and spelling. The title page, citations, and references need to be in the current APA format. 
• Length: Approximately 8–10 typed, double-spaced content pages in Times New Roman, 12-point font, including the reference page. See the APA 7th Edition Example Paper [PDF] Download APA 7th Edition Example Paper [PDF].
• Title page: Develop a descriptive title of approximately 5–15 words. It should stir interest, yet maintain professional decorum. Ensure that your title page conforms to the current APA format.
• References: Include a minimum of six current, authoritative citations and references in the current APA format. See Evidence and APA for more information.
• Scoring guide: Please review the scoring guide for this assessment so that you understand how your faculty member will evaluate your work.

Competencies Measured

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

• Competency 2: Explain the concept of accreditation in health care.
  • Explain the concept of accreditation in health care.
  • Compare and contrast accreditation and regulation requirements.
  • Analyze how accreditation helps health care organizations meet regulatory standards.
  • Describe best practices for meeting accreditation requirements.
  • Summarize the benefits a specific health accrediting organization provides to a health care organization.
• Competency 5: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
  • Write a scholarly, clear, well-organized, and generally error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting.

Resources

Use the resources linked below to help complete this assessment.

Accreditation

VitalSource Resources

• Moseley, G. B., III. (2015). Managing legal compliance in the health care industry. Jones & Bartlett. Available in the courseroom via the VitalSource Bookshelf link.
  • Chapter 16, “Physician Practices,” pages 285–310.
  • Chapter 17, “Nursing and Long Term-Care Facilities,” pages 313–336.
  • Chapter 18, “Hospices and Home Health Agencies,” pages 339–361.
  • Chapter 19, “Clinical Laboratories,” pages 365–376.
  • Chapter 21, “Third Party Billing Companies,” pages 393–408.
  • Chapter 22, “Medicare Advantage,” pages 411–434.

Capella Library Resources

• Algunmeeyn, A., Alrawashdeh, M., & Alhabashneh, H. (2020). Benefits of applying for hospital accreditation: The perspective of staff. Journal of Nursing Management, 28, 1233–1240.
• Brooks, M., Beauvis, B. M., Kruse, C. S., Fulton, L., Mileski, M., Ramamonjiarivelo, Z., Shanmugan, R., & Lieneck, C. (2021). Accreditation and Certification: Do they improve hospital financial and quality performance? Healthcare, 9(887), 1–15.
• Danis, M., Fox, E., Tarzian, A., & Duke, C. C. (2021). Health care ethics programs in U.S. hospitals: Results from a national survey. BMC Medical Ethics, 22(107), 1–14.
• Kocakulah, M. C., Austill, D., & Henderson, E. (2021). Medicare cost reduction in the US: A case study of hospital readmissions and value-based purchasing. International Journal of Healthcare Management, 14(1), 203–218.

Internet Resources

• The Joint Commission. (n.d.). https://www.jointcommission.org/

Voluntary Commitment

Capella Library Resources

• Davis, C., & Son, H. (2021). A ‘culture of expectation’ nets Children’s Mercy its fifth magnet recognition. Healthcare Leadership Review, 40(2), 1–3.
• Dennis, E. (2018). An analysis of accreditation and its impacts on receiving funding in mental health hospital. Hospital Topics, 96(3), 80–84.
• Hartman, N. M., Holskey, M. P., Adler, M., Karas-Irwin, B. S., Lisner, L., Redulla, R., Russ, A., Sansolo, C., Shelley, A. N., & Tischler, P. (2021). Navigating excellence during a pandemic: The magnet program director’s role. American Nurse Journal, 16(1), 34–37.
• Jha, A. K. (2018). Accreditation, quality, and making hospital care better. Journal of the American Medical Association, 320(23), 2410–2411.
• Santalo, O. (2021). Before it is too late: Implementation strategies of an efficient opioid and pain stewardship program. Hospital Pharmacy, 56(3), 159–164.
• Slakey, D. P., George, J. S., Anderson, E., Willeumier, D., & Gugielmi, K. (2020). Applying international organization for standards 9001 to create an effective surgical quality committee. The American Journal of Surgery, 221(3), 598–601.
• Stoddard, H. A., Johnson, T. M., & Brownfield, E. D. (2019). Outcomes, accreditation, interprofessional education, and the Tower of Babel. Journal of Interprofessional Care, 33(6), 805–808.
• Vivian, E., Brooks, M. R., Longoria, R., Lundberg, L., Mallow, J., Shah, J., Vo, A., Mejia, A., Tarnasky, P., & Puri, V. (2021). Improving the standard of care for all- A practical guide to developing a center of excellence. Healthcare, 9(6), 1–14.

Best Practices

Capella Library Resources

• Brenner, J. M., Blutinger, E. B., Ricke, B., Vearrier, L., Kluesner, N. H., & Moskop, J. C. (2021). Ethical issues in the access to emergency care for undocumented immigrants. Journal of the American College of Emergency Physicians Open, 2(3), 1–8.
• Bruce, C. R., Feudner, C., Davis, D., & Benner, M. B. (2019). Developing, administering, and scoring the healthcare consultant certification examination. Hastings Center Report, 49(5), 15–22.
• Estrella, S. G., Schmidt, R. N., & Dame, M. (2021). The potential of telemedicine in the emergency room. Journal of Business and Behavioral Sciences, 33(1), 36–47.
• Halm, M. A. (2021). Specialty certification: A path to improving outcomes. American Journal of Critical Care, 30(2), 156–160.
• Matheny, A. H., Feudtner, C., Benner, M. B., & Cohn, F. (2020). The healthcare ethics consultant-certified program: Fair, feasible, and defensible, but neither definitive nor finished. The American Journal of Bioethics, 20(3), 1–5.
• Wanser, L., & Luckel, H. (2021). The role of leadership in change in healthcare facilities: A qualitative study. American Journal of Management, 21(1), 16–31.

Rubric

Criterion 1

Explain the concept of accreditation in health care.

Distinguished

Explains the concept of accreditation in health care. Explanation includes multiple examples, specifics, and references to current, authoritative sources.

Proficient

Explains the concept of accreditation in health care.

Basic

Attempts to explain the concept of accreditation in health care; however, omissions and/or errors exist.

Non Performance

Does not explain the concept of accreditation in health care.

Criterion 2

Compare and contrast accreditation and regulation requirements.

Distinguished

Compares and contrasts accreditation and regulation requirements. Narrative includes multiple examples, specifics, and references to current, authoritative sources.

Proficient

Compares and contrasts accreditation and regulation requirements.

Basic

Attempts to compare and contrast accreditation and regulation requirements; however, omissions and/or errors exist.

Non Performance

Does not compares and contrast accreditation and regulation requirements.

Criterion 3

Analyze how accreditation helps health care organizations meet regulatory standards.

Distinguished

Analyzes how accreditation helps health care organizations meet regulatory standards. Analysis includes multiple examples, specifics, and references to current, authoritative sources.

Proficient

Analyzes how accreditation helps health care organizations meet regulatory standards.

Basic

Attempts to analyze how accreditation helps health care organizations meet regulatory standards; however, omissions and/or errors exist.

Non Performance

Does not analyze how accreditation helps health care organizations meet regulatory requirements.

Criterion 4

Describe best practices for meeting accreditation requirements.

Distinguished

Provides a comprehensive description of best practices for meeting accreditation requirements. Description includes multiple examples, specifics, and references to current, authoritative sources.

Proficient

Describes best practices for meeting accreditation requirements.

Basic

Attempts to describe best practices for meeting accreditation requirements; however, omissions and/or errors exist.

Non Performance

Does not describe best practices for meeting accreditation requirements.

Criterion 5

Summarize the benefits a specific health accrediting organization provides to a health care organization.

Distinguished

Summarizes the benefits a specific health accrediting organization provides to a health care organization. Summary includes multiple examples, specifics, and references current, authoritative sources.

Proficient

Summarizes the benefits a specific health accrediting organization provides to a health care organization.

Basic

Attempts to summarize the benefits a specific health accrediting organization provides to a health care organization; however, omissions and/or errors exist.

Non Performance

Does not summarize the benefits a specific health accrediting organization provides to a health care organization.

Criterion 6

Write a scholarly, clear, well-organized, and generally error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting.

Distinguished

Writes a scholarly, clear, well-organized and error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting. Summary brief contains multiple examples, specifics, and references to current, authoritative sources.

Proficient

Writes a scholarly, clear, well-organized, and generally error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting.

Basic

Attempts to write a scholarly, clear, well-organized, and generally error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting; however, significant lapses, omissions, and/or errors exist.

Non Performance

Does not write a scholarly, clear, well-organized, and generally error-free summary brief that conforms to APA formatting requirements and is reflective of professional communication in a health care setting.

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