Importance of Accreditation and Addressing Performance Concerns in Healthcare Organizations

QUESTION

ccreditation demonstrates an organization’s dedication, ability to establish a better level of achievement, and ability to provide superior patient care. An organization’s compliance with specific set performance requirements relating to safety and quality care is evaluated by a competent panel of external peer reviewers (Alkhenizan & Shaw, 2011). Studies have shown that general accreditation programs enhance the care’s process and structure, reducing risk compliance concerns and enhancing therapeutic outcomes (Alkhenizan & Shaw, 2011). As a result, accreditation programs are greatly desired and promoted to raise the standard of healthcare.

According to The News & Observer, as cited by Kommers, 2019, the Joint Commission placed the North Caroline UNC Hospitals’ accreditation status on probation just over a year ago for “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.” By highlighting building features like utility system risks, the dependability of their emergency power system, and fire safety systems, UNC Health Care representatives claimed that there was no evidence of immediate threats to patient health and safety. However, the Joint Commission cited the organization with 44 performance issues that were found (Havlak, 2019).

It might take several departments to collaborate with the city to restructure and fix performance concerns relating to the building’s characteristics, and it might take time. To start these crucial reforms, the organization’s executive and administration board should be more proactive. Staff should get continued training in accurately reporting these daily assessments on the patient’s EHR and patient assessments of fall risk and substance addiction disorders. To provide documentation of ongoing safety assessments in the patient’s chart, patient safety evaluations should be appropriately documented at admission and once every shift.

ANSWER

 Importance of Accreditation and Addressing Performance Concerns in Healthcare Organizations

Introduction

Accreditation plays a vital role in healthcare organizations, demonstrating their commitment to quality care and patient safety. Compliance with performance requirements evaluated by external peer reviewers helps establish higher standards and improve patient outcomes. However, instances of accreditation probation, such as the case of UNC Hospitals, highlight the need for proactive measures to address performance concerns and ensure a safe environment for patients. This essay will discuss the significance of accreditation, the repercussions of probation, and propose practical steps to address performance concerns and enhance patient safety.

Significance of Accreditation in Healthcare

Accreditation signifies an organization’s dedication to providing superior patient care and maintaining a higher level of achievement. It ensures compliance with safety and quality care standards set by competent external reviewers. Research has shown that accreditation programs enhance the care process and structure, reducing compliance concerns and improving therapeutic outcomes. It is a widely desired and promoted mechanism to elevate healthcare standards.

The UNC Hospitals’ Accreditation Probation

The North Carolina UNC Hospitals faced accreditation probation due to concerns regarding suicide screening, ligature-resistant hardware, and incomplete documentation of physician medication orders. While the organization claimed no immediate threats to patient health and safety, the Joint Commission cited 44 performance issues.

Addressing Performance Concerns

To address performance concerns and enhance patient safety, several practical steps can be taken:

Proactive Executive and Administration Involvement: The organization’s leadership should take a proactive approach in addressing performance concerns. They should collaborate with relevant departments and engage with the city to initiate necessary reforms and rectify building-related issues promptly.

Continued Training for Staff: Comprehensive training programs should be provided to staff members, focusing on accurate reporting of daily assessments in the electronic health record (EHR). Emphasis should be placed on patient assessments of fall risk, suicide risk, and substance addiction disorders. This will ensure consistent and thorough documentation of safety assessments.

Documentation of Ongoing Safety Assessments: Patient safety evaluations, including assessments of fall risk and other potential hazards, should be appropriately documented during admission and at least once per shift. Implementing standardized protocols and checklists can help ensure consistent documentation and promote a culture of patient safety.

 Quality Improvement Initiatives: Establishing robust quality improvement initiatives is crucial. Regular audits, performance reviews, and feedback mechanisms can help identify areas of improvement, address performance concerns, and monitor progress in real-time. This fosters a culture of continuous learning and improvement.

Collaborative Approach: Engaging interdisciplinary teams and involving all stakeholders, including frontline staff, in performance improvement initiatives is essential. Encouraging open communication, active participation, and shared accountability will help generate innovative solutions and improve overall performance.

Conclusion

Accreditation serves as a benchmark for healthcare organizations to demonstrate their commitment to patient safety and quality care. Addressing performance concerns and ensuring a safe environment for patients requires proactive leadership, ongoing staff training, comprehensive documentation, and a collaborative approach to quality improvement. By implementing these practical steps, organizations can address performance issues, regain accreditation status, and foster a culture of continuous improvement in healthcare delivery.