Accreditation and Licensure Analysis: St. Joseph Hospital

This report provides a detailed analysis of healthcare accreditation and licensure, focusing on St. Joseph Hospital and Medical Center in Phoenix, Arizona. The report begins with an introduction to accreditation and licensure, defining their roles in healthcare quality and regulation. It then delves into the accreditation process of St. Joseph Hospital, highlighting the role of the Accreditation Council for Graduate Medical Education (ACGME) and the necessity of accreditation for ensuring patient safety, community trust, and organizational improvement. The report also identifies the specific accreditation requirements and resources needed, as well as the potential consequences of losing accreditation. Furthermore, it explores the licensure requirements for the organization, emphasizing the importance of licensure for patient trust and organizational legitimacy. It examines the role of the State of Arizona Board of Behavioral Health Examiners in licensure and outlines the consequences of losing licensure. The report concludes by evaluating the overall consequences associated with accreditation and licensure, reinforcing their significance in maintaining high standards of care and establishing trust within the community.

Running head: HEALTH CARE ACCREDITATION
Health Care Accreditation
Name of the Student
Name of the University
Author Note

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Table of Contents
Introduction................................................................................................................................4
Discussion..................................................................................................................................4
Accreditation of St. Joseph Hospital and Medical Center.....................................................4
Necessity of the organization’s Accreditation...................................................................5
Importance of Accreditation..............................................................................................5
To the patient......................................................................................................................5
To the organization............................................................................................................5
To the community..............................................................................................................5
To the health care organization..........................................................................................6
Identification of Accreditation requirements for the organization and various resources
needed to maintain accreditation........................................................................................6
Consequences if the organization loses accreditation........................................................6
Type of accreditation and licensure requirements.............................................................7
Licensure in the St Joseph Hospital and Medical Centre.......................................................7
Necessity of the organization’s licensure...........................................................................7
Importance of Licensure....................................................................................................8
To the patient......................................................................................................................8
To the organization............................................................................................................8
To the community..............................................................................................................8
To the health care organization..........................................................................................8

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Identification of licensure requirements for the organization and various resources
needed to maintain licensure..............................................................................................8
Consequences if the organization loses Licensure.............................................................9
Evaluation of the consequences associated with accreditation and licensure....................9
Conclusion..................................................................................................................................9
References................................................................................................................................10

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Introduction
Accreditation is the method of reviewing the healthcare organizations to check their
ability to meet their regulatory needs and standards according to the established organizations
(Emer, Cowling, Mowlds & O'connor, 2014). Licensure on the other hand is the technique
used by the government agencies or boards to permit a particular organization’s engagement
in their work after verifying that they have met their standardized and predetermined
regulatory criterion. It registers boundaries of the organization (Seifert, 2015) The current
discussion deals with the detailed analysis of accreditation and licensure procedure of St.
Joseph's Hospital and medical center in Phoenix, Arizona, providing health care facilities for
more than 100 years.
Discussion
The chosen health care organization St. Joseph Hospital and medical centre was
founded in the year 1895, which was the first hospital in the area of phoenix. It is one the
largest healthcare system in the west with more than fifty hospitals in Arizona, California and
Nevada. This nonprofit organization has 595 beds, providing healthcare services and social
support.
Accreditation of St. Joseph Hospital and Medical Center
Hospital accreditation is the process setting standards of the hospital to ensure
whether the organization is able to maintain its quality standards according to the regulation.
Different recognized accreditation bodies are there that assesses the level of performance
based on the standards and points out the improvement processes. The Accreditation Council
for Graduate Medical Education (ACGME) monitors the accreditation procedure of the St.
Joseph hospital and medical centre. AGCME is an independent nonprofit organization that

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sets essential professional and educational standards in preparing physicians to deliver high-
quality safe medical care to all Americans.
Necessity of the organization’s Accreditation
The process of accreditation is mandatory in case of St. Joseph Hospital and medical
centre. There are many reasons for conducting the accreditation program, which are as
follows:
 Helps in ensuring and strengthening the patient’s safety.
 Increases the community self-confidence in terms of safety and quality of service and
treatment.
 Improvisation of risk management and risk eradication.
 Helps in the reduction of liability insurance cost.
 Fulfils the regulatory requirements of specific states.
Importance of Accreditation
To the patient: Patients are benefited the most in the process of accreditation, it results
high quality service due to time-to-time verification and ensure the safety in the treatment
process. The patient satisfaction is regularly evaluated.
To the organization: The regular governing provides continuous learning and a better
working environment for the staffs; it provides supervision and job satisfaction to them.
To the community: The community is benefited in many ways, which are follows:
 Ensures that the institution meets the minimum quality standards.
 Provides assistance to institutions to determine whether the transfer credits are
acceptable or not.
 Helps employers determine eligibility for employee tuition reimbursement programs.

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 Encourages institutional self-improvement goals.
 Provides a self regulation programs as a alternative for state oversight functions.
To the health care organization: Accreditation stimulates continuous improvements in the
quality and standard. It promotes a good will in the community, enabling more patients to
come for treatment.
Identification of organization’s requirements for accreditation and various resources
needed to maintain accreditation
The Accreditation requirements for ACGME are as follows:
1. The location of the organization must be located in the United States or in its
territories, if outside must be operated by the us government.
2. The organization must have a license facility or must be registered to conduct the
scope of the services.
3. The organization must ensure that it will continuously examine the quality of
treatment and improvise accordingly. Reviews by clinicians and knowledgeable
people terms of treatment and service must be taken in care.
4. The organization may provide services that ACGME can evaluate.
5. The parameters for the minimum number of patience according to ACGME should be
met by the organization.
Consequences if the organization loses accreditation
The accreditation consistently checks the performance of the organization and
improves the process of care provided by them by assessing the quality of professionals,
staffs, nurses and the treatment equipments. If the organization loses accreditation then it may

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observe a failure in the clinical outcomes in terms of quality and that would affect the
goodwill. The consumer brand loyalty will be detorated.
Type of accreditation and licensure requirements
Different types of credentials are provided by many non-government organizations
that are involved in planning, designing, building, renovating, or maintaining procedure of
the healthcare facilities. In the given organization of St. Joseph Hospital and Medical Center,
the Accreditation Council for Graduate Medical Education (ACGME) monitors the
accreditation.
The type of licensure in the organization is regular license named as Master Social
worker, which is issued to the nonprofit organizations that meets statutory and regulatory
requirements for licensure.
Licensure in the St Joseph Hospital and Medical Centre
Licensure is the procedure of authorizing an organization by a specified registered
governing association ensuring their performance and outlining their boundaries. State of
Arizona Board of Behavioral Health Examiners is board that licenses this organization after
verifying their standards.
Necessity of the organization’s licensure
The process of licensure is mandatory in case of St. Joseph Hospital and medical
centre.
The purposes for licensing the organization are as follows:
 To ensure that the public health and safety is protected.
 To check the eligibility requirements of the organization

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 To authorize the organization various assessments ad examinations are done that
checks the performance of the doctors and their services.
 The professional associations do not grant licensure if the regulatory criteria are not
met, thus a check on the boundaries of organization is done in the process.
Importance of Licensure
To the patient: Health is important to all. The patients have to rely on the medical
organization in terms of quality and service. Thus, a patient can trust a certified organization
more.
To the organization: Getting the organization certified under a recognized board is one the
basic requirements especially in case of a health organization.
To the community: hospital and medical centre plays an important role in the lives of people
especially in the critical stages. A medical origination gives the community a service that
needs trust and reliability; therefore, it needs to be licensed under a recognized body. A
properly licensed hospital is well examined and equipments used for treatment is well
assessed.
To the health care organization: licensing means verification of the whole organization’s
conduct and certification the same, including the treatment procedures and the physicians.
The health organization can ensure its patients about quality of service and can establish a
sound goodwill.
Identification of requirements of the licensure for the organization and various needed
resources for its maintenance.
The requirement for licensing for States of Arizona Board of Behavioral Health
Examiners includes proper credential verification by an authorized organization, in the

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present case by ACGME. All the information and engagements of St. Joseph Hospital and
medical Centre must be completely verified and well assessed. The licenses granted to the
physicians must meet all requirements of the state and are at the discretion of the board. The
licensed must be issued to the professionals, physicians, directors, nurses, councilors and
other individuals working in the organization should be qualified under requirements and
ensure whether they are 21 years and older (American Medical Association, 2015).
Consequences if the organization loses Licensure
Once the organization obtains the license, it is permanent in nature as long as the met all the
legal requirements.
Evaluation of the consequences associated with accreditation and licensure
The study highlights the various purposes and requirements of the accreditation and
licensure of the health care organization: St. Joseph Hospital and Medical Centre in phoenix.
The accreditation and licensing process ensures the quality of the treatment and service and is
mandatory to register to meet regulatory requirements of the board and maintain a sound
goodwill.
Conclusion
The accreditation and licensing program improves the process of care provided by the
health care services. Thsese are tool that improves clinical outcomes and establishes trust
among the patients.

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References
American Medical Association (2015). State Medical Licensure Requirements and Statistics
2014. Table 21. Continuing Medical Education for Licensure Registration. Chicago:
American Medical Association, 65-9.
Emer, L., Cowling, M., Mowlds, E., & O'connor, J. (2014). Oregon public health division:
building a collaborative approach to accreditation across a state public health
system. Journal of Public Health Management and Practice, 20(1), 93-95.
Seifert, H., (2015). Clinical Laboratory-Centralized Licensure and Accreditation
Management. American Journal of Clinical Pathology, 144(suppl_2), A201-A201.