Healthcare Quality Improvement Report: Patient Safety and Standards

This report delves into the critical aspects of healthcare quality improvement, emphasizing patient safety, accreditation standards, and the role of the Joint Commission. The report begins by defining accreditation and its importance in setting benchmarks for healthcare organizations, ensuring quality treatment, evidence-based practices, and accessibility. It then explores the National Patient Safety Goals (NPSGs), highlighting their influence on infection prevention, diagnostic accuracy, and overall healthcare environment. Furthermore, the report discusses the implications of non-compliance with Joint Commission standards, including potential loss of accreditation and funding. It also provides practical guidance on preparing for accreditation surveys, including mock surveys and staff training, and emphasizes the importance of professional behaviors, hygienic practices, and teamwork. The report concludes with a list of relevant references to support the findings.

Running head: HEALTHCARE QUALITY IMPROVEMENT
HEALTHCARE QUALITY IMPROVEMENT
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1HEALTHCARE QUALITY IMPROVEMENT
Question 1
Accreditation implies the establishment of qualitative standards which serve as
benchmarks for ensuring deliverance of patient care services by healthcare organizations. Hence,
accreditation standards ensure patient safety since they compel hospitals to certain acceptable
standards of healthcare in terms of quality treatment, diagnosis, evidence based practice,
accessibility and affordability (Lam et al., 2018).
Question 2
The National Patient Safety Goals (NPSGs), set standards for healthcare organization to
ensure patient safety, prevent medication and diagnostic errors, correct medication labeling,
improve patient monitoring and medication intake, optimum functioning of medical equipment,
patient assessment, hand hygiene and surgical procedures. Such NPSGs are associated with JCI
survey since the results are indicative of factors influencing infection prevention and control,
prevention of delays and erroneous diagnosis and provision of a coordinated healthcare
environment (Joint Commission, 2019).
Question 3
If hospitals do not adhere to the standards established by the Joint Commission, they will
be denied accreditation and funding of Medicare and Medicaid from the federal government
resulting in loss of patients and higher expenditures (Lee et al., 2016).

2HEALTHCARE QUALITY IMPROVEMENT
Question 4
To assess and organization’s readiness for the survey, managers and administrators can
conduct mock surveys, review all the existing patient care practices followed and compare the
same with the ‘Joint Commission Readiness’ online resources. The managers may also monitor
and interview healthcare staff to assess their knowledge and readiness (Ragusa et al., 2016).
Question 5
To prepare for the survey, healthcare staff must engage in professional behaviors, be
vigilant and observant, engage in hygienic healthcare practices, keep the organization free from
clutter, work collaboratively as a team and confident in knowledge and application of evidence
based practice (Johnson, 2019).

3HEALTHCARE QUALITY IMPROVEMENT
References
Johnson, K. (2019). Technical Tips: Surviving a Joint Commission Visit in the Neurodiagnostic
Department. The Neurodiagnostic Journal, 59(1), 1-22.
Joint Commission. (2019). Hospital National Patient Safety Goals. Retrieved from
https://www.jointcommission.org/assets/1/6/2019_HAP_NPSGs_final2.pdf.
Lam, M. B., Figueroa, J. F., Feyman, Y., Reimold, K. E., Orav, E. J., & Jha, A. K. (2018).
Association between patient outcomes and accreditation in US hospitals: observational
study. bmj, 363, k4011.
Lee, S. H., Phan, P. H., Dorman, T., Weaver, S. J., & Pronovost, P. J. (2016). Handoffs, safety
culture, and practices: evidence from the hospital survey on patient safety culture. BMC
health services research, 16(1), 254.
Ragusa, P. S., Bitterman, A., Auerbach, B., & Healy III, W. A. (2016). Effectiveness of surgical
safety checklists in improving patient safety. Orthopedics, 39(2), e307-e310.