How Accreditation Affects Health Care Quality for Hospitals and Nurses

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Several studies have proven that accreditation programs contribute towards healthcare services’ quality. One specific piece of research – which utilized numerous databases including Medline, Embase, Healthstar, and Cinhal from 1980 to 2009, and covered varying medical conditions including pain management, infection control, surgical care, trauma and more – have concluded that accrediting bodies contributed to an improvement in hospitals’ organizational structure, quality of care and clinical outcome.

Origin of Accreditations

While most accrediting bodies are voluntary in nature – i.e. sponsored by non-government organizations (NGOs), hospital organizations, and medical societies for physicians or other clinical practitioners – the origin started with the government. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) formally started accreditation of hospitals in 1951.

Accredited Versus Non-Accredited Hospitals

According to data involving cases of myocardial infarction (AMI) provided by Centers for Medicare and Medicaid Services (CMS), accredited hospitals showed lower mortality rates for AMI compared with medical facilities which are not accredited.

A similar result was derived based on the information available from the Society of Chest Pain Centers. Hospitals accredited by the society were more quick to administer aspirin and beta-Blockers than medical facilities which are not part of the society. Hospitals which have undergone accreditation are also more compliant to the (AMI) core measures set by The Joint Commission.

Research proves that accrediting bodies contribute to an improvement in hospitals’ organizational structure, quality of care and clinical outcome.

Why Accredited Hospitals Perform Better

Accrediting bodies normally follow a tried and true process for care based on their own evaluations, which are backed up by studies as mentioned above. However, not all hospitals undergo accreditation due to a number of reasons, such as membership or accreditation fees required when joining certain societies or skeptical medical professionals – particularly, physicians who need to be educated about the value of accreditations.

Joint Commission Core Measures

One way to educate health practitioners about the effect of accrediting bodies on hospital quality is to show evidence based on research.

The core measures include the following:

  • Myocardial infarction (MI) management
  • Congestive heart failure management
  • Community-acquired pneumonia management
  • Ventilator-associated pneumonia prevention
  • Surgical site infection (SSI) prevention
  • Central line associated bloodstream infection (CLABSI) prevention
  • Prevention of falls
  • Deep Vein Thrombosis prophylaxis
  • Medication reconciliation and prevention of adverse drug effects
  • Rapid response team utilization
  • Transitional care planning (care coordination/discharge planning)

In general, there is a significant difference between accredited and non-accredited hospitals based on the Joint Commission’s core measures. The research study linked above also noted improvements in participating hospitals using JCAHO’s performance assessment factors.

 

Accredited hospitals usually perform better than non-accredited ones because they follow standards imposed by the accrediting organization.

 

Quality and Safety Education for Nurses (QSEN)

Another notable body in terms of measuring healthcare quality and safety is the QSEN or the Quality and Safety Education for Nurses. It combines principles from The Joint Commission (TJC) and the Magnet Recognition. QSEN aims to provide a walkthrough for nurses to be competent in both recognizing bodies above, and treating them as one, instead of two separate entities.

QSEN incorporates TJC and Magnet standards into its own. The comparison and combination is as follows:

QSEN Joint Commission Magnet
Patient Centered Care Leadership

Provision of Care, Treatment, and Services

Rights and Responsibilities of the Individual

Structural Empowerment

Exemplary Professional Practice

Teamwork and Collaboration Human Resources

Leadership

Medication Management

Medical Staff

Nursing

Provision of Care, Treatment, and Services

Transformational Leadership

Structural Empowerment

Exemplary Professional Service

New Knowledge, Innovations, and Improvements

Evidenced-Based Practice Leadership

Medical Staff

National Patient Safety Goals

Transplant Safety

Exemplary Professional Service

New Knowledge, Innovations, and Improvements

Quality Improvement Accreditation Participation Requirements

Infection Prevention and Control

Environment of Care

Emergency Management

Leadership

Medication Management
Medical Staff
Performance Improvement
Transplant Safety
Waived Testing

Transformational Leadership

Exemplary Professional Practice

Safety Accreditation Participation
Requirements Environment of Care
Emergency Management
Infection Prevention and Control
Leadership
Life Safety
Medication Management
Medical Staff
National Patient Safety Goal
Universal ProtocolProvision of Care, Treatment, and Services
Transplant Safety
Waived Testing
Structural Empowerment

Exemplary Professional Practice

New Knowledge, Innovations, and Improvements

Informatics Information Management
Leadership
Record of Care, Treatment, and Services
Transformational Leadership

New Knowledge, Innovations, and Improvements

Training and education is more effective if there are different elements involved, such as lecture, observation and simulation.

Education and Training

Although most accrediting organizations such as the Joint Commission, Magnet and CMS utilize constant checklists to measure performance, quality, safety and other factors, the healthcare scene is constantly changing. There is a need to keep up with medical advances and improvements, even for established bodies like the above. In the same manner, further education and training is also needed for all medical personnel as a refresher.

The frequency of learning will vary depending on the topic. Some areas may only need an annual re-training; others will need periodic updates. Topics which are recommended for yearly updates include Multi-Drug Resistant Organisms (MDRO), CLABSI, SSI, and waived testing. Training for MDRO, CLABSI, SSI, and the use of restraints should be conducted right after hiring too.

As for the method of training, most agree that education is more effective if there are different elements involved, such as lecture, observation and simulation.

Tine Health

Tine Health uses just-in-time training (JITT) to reinforce nurse training for Joint Commission compliance as well as other healthcare-related education.

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