Health Organization and the Accreditation Process

Health Organization and the Accreditation Process

Questions 1

1. What is the difference between accreditation, licensure and certification, and accreditation ( 1.2 mark)

Accreditation is when a private organization evaluates an organization to determine whether it meets the set standards, especially healthcare institutions on the other hand licensing is the process of granting a legal permit to the health institutions and certification is the formal confirmation of the fulfillment of an organization in meeting the criteria set.

1. Describe the Joint Commission International (JCI) accreditation process. ( 1.2 mark)

The process begins with the appointment of a JCI survey that will be in constant communication with the Commission. The survey coordinator oversees all the survey activities of the organization, and a report compiled after the survey process is submitted to the JCI. The process can last up to two years.

1. What are the barriers to Accreditations? ( 1.2 mark)

Clarity of the objectives of the organization

Appropriate technology; when the institution fails to differentiate the methods of accreditation, licensing and regulation

Transparent relationships between government bodies and other institutions

External technical assistance- failure to learn from accreditation of other states

Sustainable resources- underestimation of the resources needed to establish a program

1. Provide & discuss three of the Joint Commission International components. ( 1.2 mark)

Standards- it is one of the components that have to be met for any organization for the accreditation process to be successful

Health care organization management – under this element, JCI evaluates how the organization is being operated.

Patient safety goals- one of the aims of JCI is to ensure that the needs of every patient are met.

1. List 5 international healthcare accreditation agencies. ( 1.2 mark)

Australia council on Healthcare International

Accreditation Canada

Central Board for Accreditation of Healthcare Institutions

Health care Accreditation Council Project

Trent Accreditation Scheme.

Q2.  Answer the following

1. Explain briefly what is the tracer methodology for medication management?(2 marks)

Tracer methodology is a patient based method that ensures that the patients’ needs are fully met. It is done through a follow up on the patient’s response to the medication given.

1. Discuss three barriers to accreditation for a hospital in Dubai? (2 marks)

Government domination of program direction leading to conflict of interest in the assessment of the public service

Failure of the hospitals in Dubai to comply with the defined procedures for the assessment of the organization

Inadequate resources for the accreditation process to take place

1. List three of the JCI accreditation eligibility. (2 marks)

The health care institution is outside the United States

The hospital is a fully working hospital and has been licensed.

The hospital provides services addressed by the JCI accreditation standards for hospitals.

Q3.  Answer the following:

1. Explain the meaning and use of Overview, The Standard, Intent, and measurable elements of JCI standards. (3 marks)

Overview- the agency looks at the general outline that the hospital and how whether it has the necessary equipment to facilitate its operation

Standard- refers to the criteria that have to be met in every unit and department in the hospital to ensure the needs of the patients are met adequately.

Intent – the JCI looks at the intent of the hospital to adapt to new mechanisms to help in attaining the patient safety goals.

Measurable- refers to the extent of the standards met by hospitals in provision of services

1. What is the role of JCI Survey Coordinator? (3 marks)
2. A connection between the organization and the JCI accreditation program.
3. Conduct the survey activities with JCI surveyors
4. The JCI Survey Coordinator makes a report and submit to the agency

Q4. Hospital ABC operates in Dubai and wants to get accredited by Joint Commission International, Put a list of actions that the hospital needs to do in order to be accredited. (4 marks)

The hospital requires being in a position to address emergencies.

The hospital has to be fully in operation and not on the verge of closing down

The hospital requires an increase in the number of staff members to help during the survey of the accreditation process.

1. Explain the base line assessment and what the benefit that the healthcare organization achieve by conducting it. (2 marks)

Baseline assessment refers to the process of conducting a patient safety survey by health care institutions. This process is very beneficial to the hospital as it helps to determine the areas where hospitals can improve in rendering their services to patients.

Q5.For the following questions, you need to describe what the accrediting agency such as JCI will be looking for.  

1. 1.3.1 The initial medical and nursing assessment of emergency patients is appropriate to their needs and conditions.  Elaborate on this standard by explaining and provide examples to support your explanation.  

The agency will look at how the hospital is equipped to provide emergency care during emergencies. The reason why the agency looks at this standard is to analyze the safety of patients.

5. 5.2 AOP.1.7 The organization conducts individualized initial assessments for special populations cared for by the organization.  Elaborate on this standard by explaining and provide examples to support your explanation

Individual assessments are also relevant in the survey carried by JCI agencies as they address the preparedness and the measure of how health care institutions are prepared to address the needs of the particular population, and the patients’ needs are prioritized based on their needs.

6. 6.1 Diagnostic imaging services are provided by the organization or are readily available through arrangements with outside sources.

The JCI examines whether the hospital has the necessary equipment to carry out the various laboratory tests and provide the tests within the allocated time for diagnosis and treatment of the patient.  This addresses the ability of the hospital to offer readily available services to patients at all times.