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Accreditation Standards

Used with Permission. Accreditation Standards. George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004. Standards – the foundation. All standards extensively reviewed and modified An external task force assisted JCAHO

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Accreditation Standards

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  1. Used with Permission Accreditation Standards George Mason University College of Nursing and Health Science Regulatory Requirements for Health Systems Summer 2004

  2. Standards – the foundation • All standards extensively reviewed and modified • An external task force assisted JCAHO • Standards were rewritten and formatted to provide • a paradigm that organizations can use to provide safe, high quality healthcare • appropriate evaluation criteria – disclosure of elements of performance

  3. Standards – the changes • 25-60% decrease in the number of standards in the functions • Leaner more clear standards • Appropriate evaluation criteria – disclosure of the elements of performance

  4. Improved 2004 Standards • Standards are more precise and concise statements of performance expectations • A rationale offers additional text describing the standard’s purpose and background • Elements of performance (EP’s) are statements of objective performance expectations scored via simple, objective criteria. • EP’s are the same in the manual, in Periodic Performance Review and in the surveyor’s laptop • Scoring is based on an aggregation of compliance with all EP’s

  5. Elements of Performance (EPs) • Clearly defined statements of performance expectations • Only part of the standard that is scorable • EP’s replace the narrative “intent” statements • List of scorable requirements identical to list used by surveyors to score standards • No hidden information

  6. JCAHO Standards Patient Focused • Patient Rights • Patient Care • Assessment • Treatment • Continuum • Education • Medication Use • Surveillance, Prevention and Control of Infection Organization Focused • Improving Organization Performance • Leadership • Governance • Management • Environment of Care • Management of Information • Management of Human Resources

  7. JCAHO Standards (continued) Others • Medical Staff • Nursing

  8. Example of a Leadership Standard • Standard LD.4.30 The leaders ensure that an integrated patient safety program is implemented throughout the organization. • Rationale for LD.4.30 The leaders should work to foster a safe environment throughout the organization by integrating safety priorities into all relevant organization processes….

  9. Examples of Elements of Performance for LD.4.30(3 of 8 EP’s) The patient safety program includes: (1) one or more qualified individuals or an interdisciplinary group assigned to manage the organization-wide safety program; (2) definition of the scope of the program’s oversight, typically ranging from no harm frequently occurring "slips" to sentinel events with serious adverse outcomes; (3) integration into and participation of all components of the organization into the organization-wide program;

  10. Application for Accreditation

  11. Extranet Application for Accreditation Represents the first JCAHO e-business venture • Available on a secure, password-protected web space • Improves the quality and consistency of data • Allows for efficiency in analysis of information provided by the HCO

  12. Benefits of the Improved Application for Accreditation • Key areas are pre-populated • HCO cannot submit unless all required fields are complete • Account Rep can view on line to assist HCO with timely, accurate submission • Surveyor can view via laptop technology • Information contributes to the Priority Focus Process

  13. Sources • Blomme, Jane (2002) ppt. Shared Visions – New Pathways: Sharpening the focus of the accreditation process on care systems critical to the safety and quality of care. Joint Commission on Accreditation of Health Care Organizations. • Massaro, Russ (May 2003) ppt. Executive Briefings, JCAHO Shared Visions—New Pathways: 2004 Accreditation Process, Joint Commission on Accreditation of Health Care Organizations. • SMART: Staff Maintaining Accreditation Readiness Together (2003) ppt. Shared Visions – New Pathways: Update on the Survey of the Future. Inova Health System.

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