The Importance of Accreditation and Addressing Issues for Healthcare Facilities

QUESTION

Accreditation by a nationwide agency provides any healthcare facility many benefits, including but not limited to: improving risk management and risk reduction, helps organize and strengthen patient safety efforts, and enhances staff recruitment and development, among many others (The Joint Commission). Accrediting agencies provide a standard for which the facilities must maintain their operations, otherwise they lose their accreditation, and along with that, their reputation within the community, not just the healthcare community. Being accredited means the facility has met all requirements to that agency, and one of the requirements is to have a certain standard for risk management compliance, and handling issues a certain way

At the end of August, of this year, The Joint Commission placed Chapel Hill, N.C. based UNC hospitals’ accreditation on probation after discovering multiple issues (Kommers, 2019). These issues included “inadequate suicide screening documentation and assessment, lack of “ligature resistant hardware and furniture” in behavioral health areas and incomplete or inadequate documentation of physician medication orders, according to an internal UNC System document”. Adequate screening of suicide could have implemented within the triage screening, adjusting the furniture and hardware adequately per suggestions could have prevented that citation, and ensuring an EMR or some other electronic record keeping of physician pharmaceutical orders could completely eradicate errors.

ANSWER

The Importance of Accreditation and Addressing Issues for Healthcare Facilities

Introduction

Accreditation by nationwide agencies holds significant importance for healthcare facilities, providing various benefits such as improved risk management, strengthened patient safety efforts, and enhanced staff recruitment and development. Accreditation ensures that facilities meet specific standards, guaranteeing quality care and operational excellence. However, recent probationary action taken against Chapel Hill-based UNC Hospitals by The Joint Commission highlights the need for addressing issues promptly to maintain accreditation and preserve the facility’s reputation within the healthcare community and the broader public. This essay will emphasize the significance of accreditation, examine the specific issues faced by UNC Hospitals, and propose practical measures to address those concerns effectively.

The Importance of Accreditation

Accreditation offers numerous advantages to healthcare facilities, including improved risk management and patient safety, enhanced staff development, and increased community trust. It serves as a benchmark for maintaining high standards of care and organizational performance. Accrediting agencies provide guidelines and requirements that help facilities organize their operations, ensuring compliance with industry best practices and standards.

Addressing the Issues at UNC Hospitals

The probationary status placed on UNC Hospitals was a result of identified issues, including inadequate suicide screening documentation and assessment, lack of ligature-resistant hardware and furniture in behavioral health areas, and incomplete or inadequate documentation of physician medication orders. These issues can be effectively addressed through the following practical measures:

Enhance Suicide Screening and Documentation: Implement comprehensive suicide screening protocols during the triage process. Train staff members to accurately and thoroughly document screening assessments, ensuring compliance with established standards. Utilize electronic health records (EHR) or similar systems to facilitate proper documentation, reducing the risk of oversight or incomplete records.

Upgrade Behavioral Health Facilities: Collaborate with architectural and safety experts to assess and address ligature risks in behavioral health areas. Replace or modify furniture and hardware to ensure a safe environment for patients. Implement regular inspections and maintenance protocols to ensure ongoing compliance.

 Implement Robust Electronic Medication Order Systems: Develop and implement an electronic medication order system that integrates with the facility’s electronic health records. This system should include checks and balances to minimize errors and improve documentation accuracy. Provide comprehensive training to physicians and staff members on the use of the system to ensure its effective utilization.

Continuous Quality Improvement: Establish a dedicated quality improvement team that conducts regular audits and performance reviews to identify areas of concern and implement corrective actions. Encourage a culture of ongoing learning and improvement among staff members, ensuring that issues are addressed promptly and effectively.

Conclusion

Accreditation serves as a crucial benchmark for healthcare facilities, signifying their commitment to quality care and operational excellence. Addressing identified issues promptly is essential to maintain accreditation status and preserve the facility’s reputation. The specific issues faced by UNC Hospitals, such as inadequate suicide screening, lack of ligature-resistant hardware, and incomplete medication order documentation, can be effectively resolved through comprehensive suicide screening protocols, facility upgrades, robust electronic medication order systems, and a continuous quality improvement approach. By implementing these measures, healthcare facilities can strengthen their operations, improve patient safety, and ensure continued compliance with accreditation standards.