Joint Commission accreditation Tutor wrote this paper for me and I got an FNow the tutor won’t respond to revise the paper for me I have attached the origi

Joint Commission accreditation Tutor wrote this paper for me and I got an FNow the tutor won’t respond to revise the paper for me I have attached the original paper, as well as the template the paper should follow which originally the template was NOT USEDPLEASE USE THE TEMPLATE ON THE REVISIONI HAVE ALSO ATTACHED key competencies that were missed throughout the paper that the teacher said we’re missed….Please ensure that all these missing components are added Running head: COLLABORATE ON QUALITY
Collaborate on Quality: Issue Analysis & Leadership Action Plan
Your Name
Assessment 3
Date:
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COLLABORATE ON QUALITY
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Collaborate on Quality: Issue Analysis & Leadership Action Plan
[Provide a brief introduction to this paper here and delete all statements within
brackets, such as this paragraph, and replace with your discussion. Also, before
you begin, review the “Scoring Guide” and understand the difference between
“Distinguished”, “Proficient”, “Basic” and “Non-Performance”. These “Scoring Guides”
are used to grade the assignment. This is why each Template is set up with headings
(below) that correspond with the “Scoring Guides” for this specific assignment. Please
leave the Headings (below) in the paper.]
IHI TRIPLE AIM
[Apply the IHI Triple Aim to develop a health care leadership strategy that
focuses on optimizing health care system performance.]
Propose Leadership Strategies
[Propose evidence-based leadership strategies that will help to establish a safety
and quality culture.]
Leadership and Collaboration Strategies
[Propose evidence-based leadership and collaboration strategies to enlist the aid
of key organizational leaders in establishing a safety and quality culture.]
Opportunities to Enlist Governing Board
[Determine opportunities to enlist the governing board’s aid in fostering a fair and
just culture.]
Conclusion
COLLABORATE ON QUALITY
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References
[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First
word after colon. The Journal or Publication Italicized and Capped, Vol# (Issue#),
Page numbers.
Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online
Journal Name, Vol#(Issue#), 159-192. doi: 10.1000/182
Lastname, W. (2009). If there is no DOI use the URL of the main website referenced.
Article Without DOI Reference, Vol#(Issue#), 166-212. Retrieved from
http://www.mainwebsite.org
NOTE: The above references are SAMPLES ONLY. For more information and example
related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE
FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE
CITATIONS.]
Running head: JOINT COMMISSION ACCREDITATION
Joint Commission accreditation
Institution affiliation
Name
Date
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JOINT COMMISSION ACCREDITATION
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Abstract
National Patient Safety Goals (NPSG) is a unique program of the Joint Commission that
is mandated with ensuring delivery of high quality and safe healthcare. These goals focus on
enhancing systematic-wide solutions. The NPSG is a considered as a special program by which
the Joint Commission involves in enforcement and promotion of critical changes in patient care
and safety for hundreds of the involved healthcare organizations in the United States and all
around the world. For instance, the NPSGs encompass regulatory mechanisms that target the
disease and infections spread as a result of catheter-related infections, multidrug-resistant
organisms, and surgical site infections. , the organization ensures regular updating of its
accreditation standards, expansion of the patient safety measures on an annual basis (Mehta,
2017). The organization also posts the vital information on their website for the interest persons
to do reviews and hence helps in making their knowledge and activities transparent to the
relevant stakeholders ranging from practitioners, institutions to their advocates and patients. The
aim and objective of the Joint Commission are to ensure a continuous promotion and
encouraging of patient safety. The organization works in collaboration with other institutions to
provide an improvement of quality of healthcare, and patient safety in the global community
through offering of publication, education, international accreditation, advisory services, and
certification, it operates in more than 100 nations, and partners with clinics, hospitals, health
systems, academic medical centers, government ministries, international advocates and academia
to promote and encourage effective standards of healthcare and in providing solutions for
ensuring achievement of better and enhanced performance. The newly implemented regulations
for SSI and CRBSI prevention apply not only to ambulatory care but also hospitals and
ambulatory surgery centers (Mehta 2017),. Besides, engagement of patient in patient safety
measures is another main newly implemented feature of the Joint Commission. The Universal
Protocol to help in reduction of surgical-related errors is an essential program of the Joint
Commission. Furthermore, Quick Safety is a unique program of the commission that allows
accredited organizations in dealing with healthcare challenges.
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How the commission helps the organization comply with regulatory requirements, improve
quality and meet stakeholder needs
Introduction
Joint Commission is the United States’ non-profit organization that is primarily tasked with
accrediting healthcare programs and organizations. Its international branch involves in
accrediting medical services all around the world. It is noteworthy that most of the United States
governments consider the Joint Commission accreditation as a licensure program for the
Medicare reimbursements and Medicaid receipt. The Joint Commission has its main office in
Chicago and Illinois.
How the Joint Commission Ensures Quality of Care
The core mission of the Joint Commission is to ensure continuous improvement of the public
healthcare, work in collaboration with the involved stakeholders, through evaluation of the
healthcare organization and programs to inspire and motivate them to excel in offering effective
and safe care of the highest value and quality. Additionally, the organization ensures regular
updating of its accreditation standards, expansion of the patient safety measures on an annual
basis. The organization also posts the vital information on their website for the interest persons to
do reviews and hence helps in making their knowledge and activities transparent to the relevant
stakeholders ranging from practitioners, institutions to their advocates and patients. The aim and
objective of the Joint Commission are to ensure a continuous promotion and encouraging of
patient safety. The organization works in collaboration with other institutions to provide an
improvement of quality of healthcare, and patient safety in the global community through
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JOINT COMMISSION ACCREDITATION
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offering of publication, education, international accreditation, advisory services, and
certification, it operates in more than 100 nations, and partners with clinics, hospitals, health
systems, academic medical centers, government ministries, international advocates and academia
to promote and encourage effective standards of healthcare and in providing solutions for
ensuring achievement of better and enhanced performance (Howell, 2017).
National Patient Safety Goals (NPSG) is a unique program of the Joint Commission that is
mandated with ensuring delivery of high quality and safe healthcare. These goals focus on
enhancing systematic-wide solutions. The NPSG is a considered as a special program by which
the Joint Commission involves in enforcement and promotion of crucial changes in patient care
and safety for hundreds of the involved healthcare organizations in the United States and all
around the world. For instance, the NPSGs encompass regulatory mechanisms that target the
disease and infections spread as a result of catheter-related infections, multidrug-resistant
organisms, and surgical site infections. The newly implemented regulations for SSI and CRBSI
prevention apply not only to ambulatory care but also hospitals and ambulatory surgery centers
(Howell, 2017).
Besides, engagement of patient in patient safety measures is another main newly implemented
feature of the Joint Commission. The Universal Protocol to help in reduction of surgical-related
errors is an essential program of the Joint Commission.
Being a core part of its mission, the Joint Commission is omitted and dedicated to ensuring the
improvement of public safety through the establishment of critical standards that should be met
all hospitals across the United States and all around the world. Most of the Joint Commission
relate to addressing of medication usage, the safety of the patient, control of infections,
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anesthesia and surgery, seclusion and restraints, staff competency, fire safety, transfusion,
medical equipment, security and emergency treatment (Howell, 2017). Furthermore, the Joint
Commission has a particular manual for the programs’ accreditation that encompasses the
“Patients’ Safety Systems that provide guidelines of how leaders can make use of existing
requirements to help in achieving improved, enhanced healthcare and patient safety, and
integration of patient-safety system for the achievement of these objectives.
Sentinel Event Policies – drafted and implemented in 1998, it was redrafted in 2015 to ensuring
incorporation of the contemporary patient safety measures and in clarifying of Joint Commission
measures and processes. For instance, if a sentinel issue arises, the concerned healthcare
organization is required to carry out an in-depth investigation and ensure that credible systematic
analysis is made. The healthcare organization is also necessary to involve in providing
improvements for risk reduction and in monitoring the effectiveness of the upgrades. The
conducted study is expected to investigate the root cause of the organizational problems and
evaluate the involved processes and systems that may be molded to reducing the future failure
and to protecting the patients from any form of harm if the failure/error does happen (Emmett,
2018).
Although strongly encouraged, organizations are not required to make a report of any Sentinelrelated event or issue to the Joint Commission.
Below are the benefits of self-reporting that organization can enjoy:
•
The Joint Commission can offer the required expertise and support during the reviewing
process of the sentinel-arising event
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JOINT COMMISSION ACCREDITATION
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The organization can have an opportunity of collaborating with the patient-safety experts
in the Joint Commission’s Office of Patient Safety and Quality.
•
Ensures that there is a transparency in the organization, which helps to promote safety
culture
•
The learned lessons from the occurred event can be incorporated in the Joint
Commission’s Event database, which aids in the dissemination of general understanding
of the sentinel event and measures that can be taken to reduce them
•
The concerned organization involves in conveying an important message to the general
public and hence helps in maintaining patient safety
Complimentary and consistency publications – the Joint Commission involves in writing of the
essential complimentary publications that tackle vital safety issues. Additionally, Sentinel Event
Alert involves in identifying specific patients’ safety issues and challenges, outlines their
common cause, and finally make suggestions for the steps that should be taken in reducing such
risks and in preventing future occurrences. Furthermore, Quick Safety is a unique program of the
commission that helps accredited organizations in dealing with healthcare challenges.
Patient safety eventualities – the Joint Commission usually receives reports relating to the patient
safety eventualities from families, patients, the public, government agencies, the media and staff
employed by such organization. Such information is primarily used in helping to improve the
safety and quality of the certified and accredited organizations.
Patient-safety research – Department of Healthcare Services is a unique program that works in
collaboration with the external stakeholders in evaluating and investigating interventions relating
to patient safety. For instance, the current initiatives mainly targeted on the hospital, ambulatory
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and nursing care. The projects implemented by the department include working with the “Center
for Disease Prevention and Control to help in improving on the dissemination and development
of infection controlling mechanisms in different ambulatory settings and researching on the
challenges that associate with respiratory protection measures in hospitals, repotting in nursingcare units, efforts to improving infection-control measures and evaluation of the healthcare
workplace environment, and in ensuring employee-safety and patient safety measures (Wang,
2015).
Patients’ safety measures – Joint Commission is an affiliated program of the Joint Commission
that involves providing different varieties of services and products including publications,
educational programs, and online software. It is also a Continuous Readiness Service program
and provides consultative technical assistance and consulting and accreditation for organizations
worldwide. The Joint Commission is committed to assisting healthcare organizations to improve
safety and quality across all sites of patients care (Wang, 2015).
Quality reports and quality check – the commission has a longstanding dedication to offering
meaningful information concerning the performance and nature of the accredited healthcare
organizations to the general public. For instance, the quality check website was launched in 1995
and allows the consumers and concerned persons to searching for Joint Commission certified and
accredited organizations. The site finds and explores healthcare organizations by the provided
services with a geographical location (Wang, 2015). On the other hand, Quality Reports may
encompass the organization’s certification and accreditation and the made decision.
Legislative efforts – the Joint Commission involves the monitoring of the legislative initiatives
both at the federal and state level. It also advocates for passage of strategies and measures to
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ensuring improved and enhanced patient safety. On the state level, the commission works closely
with the patient-safety authorities and state regulatory bodies to reducing duplicate expectations
for the accredited healthcare organizations subject to mandatory or voluntary reporting
requirements, and in engaging in state-regulatory mechanisms to advocating for the reliance on
authorizing for the state inspection licensure (Wang, 2015). The federal legislative priorities
encompass modernization of the healthcare organizations’ relationship to reducing duplications
and in focusing on survey activities on improvement of safety and quality.
Patient safety and collaborations – the JCR and Joint Commission collaborate with other
organizations as a way of promoting patient safety. For instance, “National Patient Safety” is a
program that was established in February 2017. It is a voluntary collaboration of national,
prominent patient-safety organizations that function collectively on the identified mutually
safety-concerns. Some of the member organizations of the National Patient Safety include ECRI
Institute, Association for Medical Advancement Instrumentation, the Joint Commission and
Institute for Safe Medical Practices (Wang, 2015).
Patient protection
Patients are considered as vulnerable in a healthcare setting. This is primarily because patients
involve in sharing confidential information with the medical practitioners in an organization.
Therefore, the Joint Commission ensures that patient privacy is protected to safeguarding the
confidential information they share in hospitals. Assisting patients to feel comfortable enough in
sharing their information helps the medical professional to offer the most effective and efficient
care, and hence strengthening the physician-patient bond. Protection of the patient information
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helps to preserve and safeguard their rights, dignity, respect, and individuality as clearly stated
by the Joint Commission.
It should be noted that patients heavily on their information and data for processing and storage
in a secure computerized system, and hence free of insecurity and damages. As healthcare
information technology is becoming more and more complex, the information distribution
through electronic mechanisms and means are increasingly becoming common (Wang, 2015).
Therefore, the healthcare personnel is solely responsible for taking precautionary measures to
ensured that privacy of patients’ data is preserved.
The Joint Commission requires the healthcare organizations to instill strong measures in their
medical practices as a way of instilling confidence in patients to believing that their information
is held secure, confidential and that their privacy is guaranteed. Therefore, the healthcare
organizations are required to make use of information technology as a way of decreasing
excessive spending and in conducting better wellness and health care outcome. Under the
circumstance that patients feel that their personal information is not kept securely, they may end
up not disclosing such information, and hence not be accorded the needed care. However, if an
organization does not have strong privacy and security measures in place, the healthcare
information system may be jeopardized and hence resulting in cyber attacks. Consequently, this
can negatively impact the reputation of the organization and put the patient’s health at risk
(Wang, 2015). For this reason, therefore, Joint Commission puts well-coordinated measures in
place for ensuring that privacy and security of the patients in guaranteed.
Below are the steps that the Joint Commission ensures are implemented by health care
organizations all across the world to provide data protection and privacy of patients:
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a) Usage of firewall – helps to protect devices with enforcement of security software
b) Protection of mobile devices – health care organizations are advised to use mobile
devices that are fully encrypted
c) Plans for unexpected eventualities – it is recommendable for the healthcare organizations
to make sure that patients’ files are backed up in case of unexpected crashes
d) Usage of strong passwords for data protection – it is recommendable to use a strong and
complicated password and be changed often
e) Controlled physical access – it is important to consider making sure that the user devices
are securely regulated and safely controlled
Privacy rule – the Joint Commission sets the foundational baseline for preservation for
patients’ confidentiality in regards to their health and status information. The rule protects the
patients’ health confidential information and other such related data. Also, the rule gives the
patients’ right to obtain, examine and to maintain copies of the health records. Furthermore,
the covered individual is required to have a written legal contract with healthcare providers
(Wang, 2015).
Security rule – the rule is only applicable to the health data stored in electronic form. It
requires the health care provider(s) to performing technical and physical tasks and securing
of the data.
Ability to meeting stakeholders needs, including serving the community
The Joint Commission sets clear standards for accreditation of the healthcare organizations in
the behavioral field, which helps in providing families and individuals with a level of
confidence and trust when choosing treatment programs. Acquisition of the Joint
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Commission seal shows that an organization wants to be held to the highest standards and
that it is open and accountable to the public (Wang, 2015). Further, the commission ensures
that the accredited organizations are providing services and treatment within different
varieties of settings all across…
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