ASSIGNMENT 2. 1. Assignment 2 Institution Student Cours

Running head: ASSIGNMENT 2 1
Assignment 2
Institution
Student
Course
Date

ASSIGNMENT 2 2
Assignment 2
Health Law
Part 1
The role of the Joint Commission in accrediting medical facilities
The primary goal of the Joint Commission on Accreditation of Medical Facilities is to
incessantly improve the quality and safety of care provided to the people by offering health care
certification and other similar services which sustain performance development in health care
centers (Alkhenizan, & Shaw, 2011). The main role of Joint Commission in this endeavor is
ensuring proper Medication management, Infection control, information usage for improvement
purposes, and incomparable emergency preparedness. Some of its current accreditation
initiatives include conducting unannounced surveys, information-based intra-cycle monitoring,
intensified Life Safety Code compliance assessment. The Joint Commission also creates a
“Reporting for Learning” Model which sentinels event database and alerts, states database
legacy, national patient safety goals.
The Joint Commission is an autonomous, non-profit organization in the US which provides
voluntary certification programs for hospitals and other health care centers (Kamarajah, Burns,
Frankel, Cho, & Nathan, 2017).This commission comes up with performance standards which
address critical fundamentals of operation, like consumer rights, medication safety, infection
control, and patient care. It currently accredits about 20,500 health care programs and centers in
the United States (Kagan, Farkash-Fink, & Fish, 2016). In order to keep its Joint Commission
certified status, a health care association is subjected to an onsite assessment conducted by a
Joint Commission survey team at least after every three years. Laboratories also are expected to
undergo assessments after every two years. These surveys are independently designed for

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various healthcare organizations and they are all tailored to direct and assess the establishment’s
performance in different areas such as patient treatment, safety, and care quality. From 18 -36
months after a complete Joint Commission survey, certified centers can have impromptu surveys.
The Joint Commission benchmarks work as the base for medical facilities to determine and
improve their performances. These benchmarks or standards focus entirely on patient safety and
quality care. The Joint Commission creates the benchmarks criteria based on interactions and
feedback with various stakeholders such as government agencies, consumers, and healthcare
experts. The benchmarks undergo an inclusive development procedure that comprises of
dialogues with consultants, preparation of draft benchmarks and assessments by external
professionals. Potential benchmarks are as well published on the Joint Commission's website and
availed for public remark prior to approval by the association’s board of commissioners.
Which facilities can be accredited?
The Joint Commission certifies the following categories of medical facilities:
 Nursing homes plus other long-term healthcare amenities
 Freestanding or Independent clinical laboratories
 Children’s, general, rehabilitation, psychiatric and critical access centers
 Ambulatory healthcare facilitators, including office-based surgical practices as well as group
practices
 Behavioral care establishments and addiction services
 Homecare associations, such as medical equipment services, pharmacies and sanatorium
services

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The Joint Commission also accredits the following facilities provided in healthcare centers:
Illness-specific care accreditation, highly developed certification in illness-specific care and
palliative care, as well as accreditation for health care conscription services.
What are the goals of the Commission?
This commission aims at helping accredited healthcare establishments address various areas of
concern in regard to healthcare safety, and to concentrate on how to solve them. The Joint
Commission dictates the utmost main concern patient safety issues and as well whether an
objective is appropriate to a particular certification program and consequently tailors the
objective to be program-specific. Some of its recent National Patient Safety Goals and
corresponding Elements of Performance (EPs) include (Joint Commission, 2018):
 Proper patient’s identification
 Enhance the efficiency of communication among care providers
 Develop the safety and quality of using medications.
 Abate the damage associated with clinical alarm systems
 Lower the risk of healthcare-associated diseases
 Prevent patients from falling and so reduce injuries
 Ensure the hospitals identify safety risks intrinsic in their patient populations
How do existing Joint Commission guidelines impact facilities that are not accredited by
the Commission?
Patients who opt to go for medication in accredited facilities are more likely to receive higher
quality of healthcare than their counterparts who go to uncertified hospitals. This implies that the
patients will most likely prefer the accredited centers to unaccredited ones. Often Joint

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Commission sets some standards or guidelines which all healthcare organizations which opt to
be accredited have to follow to ensure optimum patient safety. They work positively by
attracting patients in certified hospitals but negatively by pushing away customers from facilities
that are accredited. This is one way through which Joint Commission guidelines indirectly
affects organizations which have not been accredited. These guidelines also lead to positive
effect on unaccredited hospitals because leaders in these organizations can borrow some of them
and use as benchmarks or standards. They can use to gauge and determine their performance in
regard to the guideline provisions in certified care centers.
What does it mean to a facility to be accredited by the Joint Commission?
An accredited medical facility means that the organization is ready to adhere to stringent
standards for cleanliness, performance, staff qualification, and safety to ensure that patients get
the most optimal quality care possible. Strict protocols required by Joint Commission lessen risk
for mistakes and ascertains that the functioning room staff respond speedily and efficiently to an
emergency, should one arise (Williams, Morton, Braun, Longo, & Baker, 2017). Accreditation
by this commission is a comprehensive process which requires a healthcare institution plus its
staff to spend considerable resource and time to achieve. In addition, accreditation by the
commission means that the institution takes part in continuing peer review, self-evaluation, and
education to unremittingly progress its care and clinical services. The establishment also devotes
to a scrupulous, on-site survey by the commission assessors, who are themselves, healthcare
experts, at least every three years. In short, an official approval by The Joint Commission is
viewed as the gold standard in healthcare.
Is it mandatory for organizations to be accredited by the Joint Commission? If not, what
impact does not having such accreditation mean in terms of reimbursement?

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Accreditation by Joint Commission is not a mandatory activity rather a voluntary one for a
facility. Actually, there are other accreditation organizations other than Joint Commission on
Accreditation of Healthcare Organizations (JCAHO), which healthcare organizations can opt for
incase they want to certify self. These include the American Association for the Accreditation of
Ambulatory Surgical Facilities (AAAASF) and the Accreditation Association for Ambulatory
Health Care (AAAHC). Though it is a voluntary activity, these organizations are expected to
abide with written standards regarding the provision of care, the quality of care, and environment
of care. After accreditation, these establishments become eligible standards set by the USA
federal government which qualifies them for reimbursements from federally funded programs
and Medicaid or Medicare. If an organization does not have such accreditation then it is deemed,
ineligible to receive Medicaid and/or Medicare or any other form of government-facilitated
reimbursement (Kwon, & Lee, 2017).
Part II
MEMORANDUM
To: Personnel in Health Information Department
From: Administrator of the Health Information Department
Date: February 10, 2019
RE: Visitation by the Joint Commission
I have just been informed by the compliance officer that the Joint Commission will be visiting
our facility and will be focusing solely on our department. I therefore find it suitable to prepare
ourselves both physically and psychologically so that everything goes on well despite the spur-
of-the-moment visit.

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The Joint Commission is a sovereign, non-profit association based in the US which provides
discretionary accreditation programs for healthcare organizations such as nursing homes,
Ambulatory care providers, and freestanding clinical laboratories among others. This
commission sets up some performance standards which address essential rudiments of operation,
such as consumer rights, infection control, patient care, and medication safety. The US
government requires that healthcare organizations to receive Joint Commission official
recognition as a stipulation for Medicaid reimbursement and licensing. In addition, the Centers
for Medicaid & Medicare Services (CMS) acknowledges the results of Joint Commission
surveys, implying that medical centers that receive Joint Commission accreditation can take part
in the federal Medicare program. Currently, the Joint Commission certifies more than 20,500
health care organizations and programs in America. In order to keep its Joint Commission
accredited status, an institution offering medical services is subjected to an onsite valuation
carried by a Joint Commission survey group after every three years. These surveys are separately
designed for different institutions and are tailored to evaluate and guide the institution’s
performance in the areas of care quality, patient safety, and treatment.
The Commission might have some questions for us that revolve around the issue of compliance
and I have presented with you with sample questions which can be posed:
I. What efforts is the organization making to improve patient safety and the quality of
healthcare delivery?
II. How do you gather patient’s experience feedback after their encounter with your support
staff, doctors, and your facilities?
III. Have you set any performance standards or benchmarks for the caregivers and other staffing
stakeholders in your organization?

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IV. Do you have measures in place meant to preserve confidentiality with regard to patient safety
work product?
V. Does this organization ensure all reported issues revolving around quality of care are
punctually and efficiently investigated?
I ask every member in our department to be fully equipped to respond to such like questions. I
therefore urge all of you do a brief research regarding the Organization’s patient safety practices
and familiarize yourselves with all issues surrounding this subject matter. When it comes to their
actual responding please make sure you have understood the question clearly. Do not dance
around an answer only the visitor to say “‘No, that is not what I am asking. I’m asking something
simpler or different.’ Kindly make sure you are getting the questions right. Also take time to
respond. After the question is posed, give yourself some minutes or seconds to determine how
you want to respond and the go direct to the point. As you respond to the questions, also watch
your body language since it is an important tone. Those are some of the guidelines we shall use
to respond to the above or related questions.
In case of a negative finding during the visit, we shall not bury our heads in the sand. We shall
justify ourselves rationally and provide trustworthy feedback as to why there is a failure in
something. Definitely we cannot be entirely perfect in our operations and service delivery but we
will justify ourselves and promise that we are working on the negative finding. In order to deal
with this squarely, when answering the questions from the visitor try to divert the questions
vigilantly by diverting into a different topic. Say phrases like ‘What I think you really want to
know is…and this is how we are handling that,’” This is called bridging technique and it is not a
way of ignoring questions rather a way of acknowledging using statements like ‘That is an
interesting question, but I would like to point out that…’However, current noncompliance

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findings will be avoided gradually. After figuring them out after the visit we shall implement
necessary strategies meant to ensure full compliance and absolute patient safety. Every person in
our department will be responsible and fully involved in the undertaking.
Thank you for your time.
Department Admin

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References
Alkhenizan, A., & Shaw, C. (2011). Impact of accreditation on the quality of healthcare services:
a systematic review of the literature. Annals of Saudi medicine, 31(4), 407.
Joint Commission, 2018. National Patient Safety Goals Effective January 2018. Hospital
Accreditation Program.
Kagan, I., Farkash-Fink, N., & Fish, M. (2016). Effect of Joint Commission international
accreditation on the nursing work environment in a tertiary medical center. Journal of
nursing care quality, 31(4), E1-E8.
Kamarajah, S. K., Burns, W. R., Frankel, T. L., Cho, C. S., & Nathan, H. (2017). Validation of
the American Joint Commission on Cancer (AJCC) staging system for patients with
pancreatic adenocarcinoma: a Surveillance, Epidemiology and End Results (SEER)
analysis. Annals of surgical oncology, 24(7), 2023-2030.