DOCSLIB.ORG

Light PP Presentation

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Light PP Presentation 1910-1919 The Joint Commission: 1920-1929 1950-1959 1960-1969 Over a century of quality and safety 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 2020 Home 1 © 2020 The Joint Commission. All Rights Reserved. 1910-1913 Ernest Codman, M.D. proposes the “end result system of hospital 1910-1919 ⎻ 1920-1929 standardization.” 1950-1959 American College of Surgeons is 1960-1969 1970-1979 founded. The “end result” system 1980-1989 ⎻ becomes an ACS objective. 1990-1999 2000-2009 2010-2019 2020 Home 2 © 2020 The Joint Commission. All Rights Reserved. 1917-1918 The American College of Surgeons develops the 1910-1919 ⎻ Minimum Standard for 1920-1929 1950-1959 Hospitals. Requirements fill 1960-1969 one page. 1970-1979 1980-1989 The ACS begins on-site 1990-1999 inspections of hospitals. 2000-2009 ⎻ 2010-2019 2020 Home 3 © 2020 The Joint Commission. All Rights Reserved. 1926 The first standards manual is 1910-1919 printed, consisting of 18 pages. 1920-1929 1950-1959 1960-1969 1970-1979 1980-1989 The American College of Surgeons made the three-story 1990-1999 former residence shown opposite, on Chicago’s rapidly growing north side, its headquarters in 1920. 2000-2009 2010-2019 2020 Home 4 © 2020 The Joint Commission. All Rights Reserved. 1950-1951 1910-1919 The American College of Physicians, 1920-1929 the American Hospital Association, 1950-1959 ⎻ the American Medical Association, 1960-1969 1970-1979 and the Canadian Medical 1980-1989 Association join with the ACS as 1990-1999 corporate members to create the 2000-2009 2010-2019 Joint Commission on Accreditation 2020 of Hospitals (JCAH), an Home independent, not-for-profit organization, in Chicago, Illinois, whose primary purpose is to provide voluntary accreditation. 5 © 2020 The Joint Commission. All Rights Reserved. 1952 The American College of Surgeons officially transfers its 1910-1919 ⎻ Hospital Standardization 1920-1929 Program to JCAH, which begins 1950-1959 1960-1969 offering accreditation to 1970-1979 hospitals in January 1953. 1980-1989 1990-1999 Edwin L. Crosby, M.D., 2000-2009 becomes the first director of the 2010-2019 ⎻ Joint Commission on 2020 Home Accreditation of Hospitals. 6 © 2020 The Joint Commission. All Rights Reserved. 1953-1959 – JCAH publishes Standards for 1910-1919 Hospital Accreditation. 1920-1929 – Kenneth Babcock, M.D., becomes 1950-1959 1960-1969 director of JCAH. 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 2020 Home 7 © 2020 The Joint Commission. All Rights Reserved. 1964-1965 The Joint Commission on Accreditation of Hospitals begins 1910-1919 ⎻ charging for surveys. 1920-1929 1950-1959 Congress passes the Social Security 1960-1969 1970-1979 Amendments of 1965 with a provision 1980-1989 ⎻ that hospitals accredited by JCAH are 1990-1999 “deemed” to be in compliance with 2000-2009 2010-2019 most of the Medicare Conditions of 2020 Participation for hospitals and, thus, Home able to participate in the Medicare and Medicaid programs. John D. Porterfield III, M.D., becomes director of the JCAH. ⎻ 8 © 2020 The Joint Commission. All Rights Reserved. 1966-1969 Long term care accreditation begins. 1910-1919 JCAH establishes four accreditation 1920-1929 ⎻ 1950-1959 councils to develop standards and survey 1960-1969 ⎻ accreditation procedures. 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 2020 Home 9 © 2020 The Joint Commission. All Rights Reserved. 1970 The Accreditation Council for 1910-1919 Psychiatric Facilities is established and 1920-1929 1950-1959 ⎻ accreditation for psychiatric facilities, 1960-1969 substance abuse programs and 1970-1979 community mental health programs 1980-1989 1990-1999 begins. 2000-2009 2010-2019 Accreditation for hospitals and long 2020 term care facilities is reduced to a Home ⎻ maximum of two years from three years. 10 © 2020 The Joint Commission. All Rights Reserved. 1971-1972 The Accreditation Council for Long Term Care is established. 1910-1919 ⎻ 1920-1929 The Social Security Act is amended to 1950-1959 require that the Secretary of the U.S. 1960-1969 ⎻ Department of Health and Human 1970-1979 1980-1989 Services (DHHS) validate JCAH 1990-1999 findings. 2000-2009 2010-2019 The first issue of Perspectives on 2020 Accreditation is published. Home ⎻ 11 © 2020 The Joint Commission. All Rights Reserved. 1975-1977 The Accreditation Council for Ambulatory Health Care is 1910-1919 ⎻ 1920-1929 established and accreditation for 1950-1959 ambulatory health care facilities 1960-1969 begins. 1970-1979 1980-1989 John E. Affeldt, M.D., becomes 1990-1999 president of the JCAH. 2000-2009 ⎻ 2010-2019 2020 Home 12 © 2020 The Joint Commission. All Rights Reserved. 1978-1979 JCAH establishes an agreement with the College of American Pathologists to 1910-1919 ⎻ 1920-1929 recognize CAP accreditation of a laboratory 1950-1959 in a JCAH-accredited hospital in lieu of the 1960-1969 Commission’s accreditation of the 1970-1979 1980-1989 laboratory. 1990-1999 The American Dental Association (ADA) 2000-2009 2010-2019 becomes a JCAH corporate member. 2020 ⎻ A Professional and Technical Advisory Home Committee is established for each ⎻ accreditation program, and the Accreditation Councils are disbanded. 13 © 2020 The Joint Commission. All Rights Reserved. 1982-1983 The accreditation cycle is changed from two 1910-1919 years to three years for hospitals, psychiatric 1920-1929 ⎻ facilities, alcoholism and substance abuse 1950-1959 1960-1969 programs, community mental health centers, 1970-1979 and long term care organizations. 1980-1989 1990-1999 Accreditation for hospice care organizations 2000-2009 begins. (Folded into the Home Care 2010-2019 ⎻ Accreditation program in 1990.) 2020 Home 14 © 2020 The Joint Commission. All Rights Reserved. 1986 Quality Healthcare Resources® (QHR), Inc. is 1910-1919 ⎻ 1920-1929 formed as a not-for-profit 1950-1959 consulting subsidiary of 1960-1969 JCAH. (QHR later becomes 1970-1979 1980-1989 Joint Commission 1990-1999 Resources.) 2000-2009 2010-2019 Dennis S. O’Leary, M.D., 2020 becomes president of the Home ⎻ JCAH. 15 © 2020 The Joint Commission. All Rights Reserved. 1987-1989 The organization name changes to the Joint Commission on Accreditation of Healthcare Organizations to reflect an 1910-1919 ⎻ expanded scope of activities. 1920-1929 1950-1959 The Agenda for Change is launched, placing the primary 1960-1969 emphasis of the accreditation process on actual 1970-1979 ⎻ organization performance. 1980-1989 1990-1999 Development begins on the Indicator Measurement 2000-2009 System® (IMSystem®), an indicator-based performance 2010-2019 2020 ⎻ monitoring system. Home Accreditation for home care organizations and managed care begins. (Managed care is folded into the Ambulatory ⎻ Care Accreditation program in 1990). 16 © 2020 The Joint Commission. All Rights Reserved. 1990 The Joint Commission Headquarters and 1910-1919 Conference Center opens in Oakbrook Terrace, 1920-1929 Illinois, about 20 miles west of downtown Chicago. 1950-1959 1960-1969 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 2020 Home 17 © 2020 The Joint Commission. All Rights Reserved. 1992-1993 The Joint Commission issues a standard requiring all accredited hospitals to have a 1910-1919 ⎻ policy prohibiting smoking in the hospital. 1920-1929 1950-1959 The number and nature of confirmed 1960-1969 substantive complaints filed against 1970-1979 ⎻ accredited facilities and the existence of 1980-1989 1990-1999 type I recommendations becomes public 2000-2009 information. 2010-2019 2020 The federal government announces that Home home health agencies accredited by the ⎻ Joint Commission after an unannounced survey will be “deemed” to meet the Medicare Conditions of Participation. 18 © 2020 The Joint Commission. All Rights Reserved. 1994 The first organization-specific performance reports are released to the public. 1910-1919 ⎻ 1920-1929 A new survey process is implemented that 1950-1959 uses a systemwide, cross-department 1960-1969 ⎻ orientation. 1970-1979 1980-1989 Quality Healthcare Resources, Inc.® and the 1990-1999 Joint Commission form Joint Commission 2000-2009 2010-2019 ⎻ International to provide education and 2020 consulting services to international clients. Home 19 © 2020 The Joint Commission. All Rights Reserved. 1995 The federal government recognizes Joint Commission laboratory accreditation 1910-1919 1920-1929 ⎻ services as meeting the requirements for 1950-1959 Clinical Laboratory Amendments of 1988 1960-1969 (CLIA) certification. 1970-1979 1980-1989 As part of an Action Plan, the Joint 1990-1999 2000-2009 Commission launches the Orion Project in 2010-2019 ⎻ Pennsylvania and Arizona as a series of 2020 experiments designed to test innovations to Home improve the delivery of accreditation services. Accreditation for freestanding laboratories begins. ⎻ 20 © 2020 The Joint Commission. All Rights Reserved. 1996 The Centers for Medicare & Medicaid Services announces that ambulatory 1910-1919 ⎻ surgical centers accredited by the Joint 1920-1929 1950-1959 Commission will be “deemed” as 1960-1969 meeting or exceeding Medicare 1970-1979 certification requirements. 1980-1989 1990-1999 The Sentinel Event Policy is 2000-2009 2010-2019 established. 2020 ⎻ The Joint Commission launches its Home website at www.jcaho.org (now ⎻ www.jointcommission.org). 21 © 2020 The Joint Commission. All Rights Reserved. 1997 The Joint Commission launches ORYX®: The Next Evolution in 1910-1919 ⎻ Accreditation™. 1920-1929 1950-1959 Quality Check® becomes available 1960-1969 1970-1979 on the Joint Commission website. 1980-1989 ⎻ 1990-1999 2000-2009 2010-2019 2020 Home 22 © 2020
Load more

Recommended publications
  • Association Between Patient Outcomes and Accreditation in US Hospitals
    RESEARCH Association between patient outcomes and accreditation in US BMJ: first published as 10.1136/bmj.k4011 on 18 October 2018. Downloaded from hospitals: observational study Miranda B Lam,1,2 Jose F Figueroa,3,4 Yevgeniy Feyman,2 Kimberly E Reimold,2 E John Orav,5 Ashish K Jha2,3,4 1Department of Radiation ABSTRACT RESULTS Oncology, Brigham and OBJECTIVES Patients treated at accredited hospitals had lower Women’s Hospital/Dana Farber 30 day mortality rates (although not statistically Cancer Institute, Boston, MA, To determine whether patients admitted to US USA hospitals that are accredited have better outcomes significant lower rates, based on the prespecified P 2Department of Health Policy than those admitted to hospitals reviewed through value threshold) than those at hospitals that were and Management, Harvard T H state surveys, and whether accreditation by The reviewed by a state survey agency (10.2% v 10.6%, Chan School of Public Health, Boston, MA 02115, USA Joint Commission (the largest and most well known difference 0.4% (95% confidence interval 0.1% to 3Department of Medicine, accrediting body with an international presence) 0.8%), P=0.03), but nearly identical rates of mortality Harvard Medical School, confers any additional benefits for patients for the six surgical conditions (2.4% v 2.4%, 0.0% Boston, MA, USA 4Department of Medicine, compared with other independent accrediting (−0.3% to 0.3%), P=0.99). Readmissions for the Division of General Internal organizations. 15 medical conditions at 30 days were significantly Medicine, Brigham and lower at accredited hospitals than at state survey Women’s Hospital, Boston, DESIGN MA, USA Observational study.
    [Show full text]
  • Appendix I: Methodology and Origin of External Quality Review (Eqr) Protocol Development
    2012 EXTERNAL QUALITY REVIEW (EQR) PROTOCOLS APPENDIX I: METHODOLOGY AND ORIGIN OF EXTERNAL QUALITY REVIEW (EQR) PROTOCOL DEVELOPMENT TABLE OF CONTENTS PURPOSE OF THE APPENDIX .......................................................................................................................................... 1 PERFORMANCE IMPROVEMENT PROTOCOLS DEVELOPMENT .............................................................. 2 PERFORMANCE MEASUREMENT PROTOCOLS DEVELOPMENT ............................................................. 6 INFORMATION SYSTEM CAPABILITIES ASSESSMENT DEVELOPMENT ................................................ 7 ADDITIONAL REFERENCES ................................................................................................................................. 9 PURPOSE OF THE APPENDIX The purpose of this Appendix is to describe how the protocols were developed and to document the references applied to them. As described in the introduction to the protocols, the original protocols were developed in 2001 by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), working with consultants and representatives of private accrediting organizations, quality measurement experts, State Medicaid agencies, and advocates for Medicaid beneficiaries, under the direction of the Centers for Medicare & Medicaid Services (CMS). In 2010, CMS contracted with Provider Resources, Inc. (PRI) and their subcontractor, the National Committee for Quality Assurance (NCQA), to work with EQR stakeholders, including States,
    [Show full text]
  • Preventing Central Line-Associated Bloodstream Infections
    Preventing Central Line–Associated Bloodstream Infections A Global Challenge, A Global Perspective Preventing Central Line–Associated Bloodstream Infections: A Global Challenge, A Global Perspective The use of central venous catheters (CVCs) is an integral part of modern health care throughout the world, allowing for the administration of intravenous fluids, blood products, medications, and parenteral nutrition, as well as providing access for hemodialysis and hemodynamic monitoring. However, their use is associated with the risk of bloodstream infection caused by microorganisms that colonize the external surface of the device or the fluid pathway when the device is inserted or manipulated after insertion. These serious infections, termed central line–associated bloodstream infections, or CLABSIs, are associated with increased morbidity, mortality, and health care costs. It is now recognized that CLABSIs are largely preventable when evidence- based guidelines are followed for the insertion and maintenance of CVCs. This monograph includes information about the following: • The types of central venous catheters and risk factors for and pathogenesis of CLABSIs • The evidence-based guidelines, position papers, patient safety initiatives, and published literature on CLABSI and its prevention • CLABSI prevention strategies, techniques and technologies, and barriers to best practices • CLABSI surveillance, benchmarking, and public reporting • The economic aspects of CLABSIs and their prevention, including the current approaches to developing
    [Show full text]
  • Over a Century of Quality and Safety 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 Home
    1910-1919 The Joint Commission: 1920-1929 1950-1959 1960-1969 Over a century of quality and safety 1970-1979 1980-1989 1990-1999 2000-2009 2010-2019 Home 1 © 2020 The Joint Commission. All Rights Reserved. 1910-1913 Ernest Codman, M.D. proposes the “end result system of hospital 1910-1919 ⎻ 1920-1929 standardization.” 1950-1959 American College of Surgeons is 1960-1969 1970-1979 founded. The “end result” system 1980-1989 ⎻ becomes an ACS objective. 1990-1999 2000-2009 2010-2019 Home 2 © 2020 The Joint Commission. All Rights Reserved. 1917-1918 The American College of Surgeons develops the 1910-1919 ⎻ Minimum Standard for 1920-1929 1950-1959 Hospitals. Requirements fill 1960-1969 one page. 1970-1979 1980-1989 The ACS begins on-site 1990-1999 inspections of hospitals. 2000-2009 ⎻ 2010-2019 Home 3 © 2020 The Joint Commission. All Rights Reserved. 1926 The first standards manual is 1910-1919 printed, consisting of 18 pages. 1920-1929 1950-1959 1960-1969 1970-1979 1980-1989 The American College of Surgeons made the three-story 1990-1999 former residence shown opposite, on Chicago’s rapidly growing north side, its headquarters in 1920. 2000-2009 2010-2019 Home 4 © 2020 The Joint Commission. All Rights Reserved. 1950-1951 1910-1919 The American College of Physicians, 1920-1929 the American Hospital Association, 1950-1959 ⎻ the American Medical Association, 1960-1969 1970-1979 and the Canadian Medical 1980-1989 Association join with the ACS as 1990-1999 corporate members to create the 2000-2009 2010-2019 Joint Commission on Accreditation Home of Hospitals (JCAH), an independent, not-for-profit organization, in Chicago, Illinois, whose primary purpose is to provide voluntary accreditation.
    [Show full text]
  • • Pioneers in Quality™ Is a Collaborative Program to Improve
    • Pioneers in Quality™ is a collaborative program to improve health care quality and patient safety through education, innovation, and recognition of pioneering practices for Joint Commission stakeholders. The Pioneers in Quality™ program started in 2016 to assist Joint Commission- Read more accredited hospitals on their electronic clinical quality measure (eCQM) journey to improve eCQM data use for quality improvement. It has expanded over time to • Pioneers in Quality™ include additional key components related to eCQM and chart-abstracted data. web portal Hospitals collect performance measurement data and submit the data to The Joint • Proven Practices ® Commission as part of its ORYX performance measurement requirements, and Program webpage as applicable to the Centers for Medicare & Medicaid Services (CMS) for quality reporting programs. The Joint Commission continues to work to align measures as • Expert to Expert Series closely as possible with CMS. site Key components of the Pioneers in Quality™ program include: • Educational content, such as webinars for continuing education (CE) units: o Pioneers in Quality™ general session webinars (i.e., ORYX reporting requirements, on-boarding for Direct Data Submission platform). o Expert to Expert webinar series to connect hospitals with technical expertise on eCQMs, clinical quality language (CQL) and measure specifications. o Proven Practices webinar series to share peer-to-peer successes, tips, and guidance regarding health IT and performance measure use of eCQM and chart-abstracted data. • An online resource portal is offered to health care organizations collecting and submitting data. • Recognition for eCQM pioneering practices. • Proven Practices Collection describes eCQM data utilization and optimization success stories. • Outreach is available through the Joint Commission’s speaker’s bureau.
    [Show full text]
  • Medicare and the Joint Commission on Accreditation of Healthcare Organizations: a Healthy Relationship?
    MEDICARE AND THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS: A HEALTHY RELATIONSHIP? TIMOTHY STOLTZFUS JOST* I INTRODUCTION Country-wide, more than 5000 hospitals are permitted to provide Medicare- financed services solely because they are accredited by the Joint Commission on Accreditation of Healthcare Organizations (the "JCAHO" or the "Joint Commission"). With JCAHO accreditation, a health care institution is deemed to meet the Medicare conditions of participation. This "deemed status" program is the oldest and most substantial regulatory use of health care accreditation in the United States. This article will critically consider the economic and political forces driving the program and will examine why the federal government has relied on private accreditation in health care and whether this reliance is in the public interest. This article will first describe the JCAHO and its accreditation programs, then review the history of the Medicare-JCAHO relationship, next examine why the federal Medicare program has relied on accreditation as an indicator of the quality of participating hospitals, and finally consider, in theory and practice, the extent to which accreditation status serves as an adequate substitute for direct public regulation of the quality of health care institutions. II THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS The JCAHO is a private, nonprofit corporation that currently accredits more than 9000 health care institutions, including about 5400 hospitals.' Its twenty- six member board includes twenty-one commissioners appointed by the American Medical Association (seven commissioners), the American Hospital Association (seven), the American College of Physicians (three), the American Copyright © 1995 by Law and Contemporary Problems * Newton C.
    [Show full text]
  • United States of America Region of Americas Updated: February 2017
    United States of America Region of Americas Updated: February 2017 This document contains links to websites where you can find national legislation and health laws. We link to official government legal sources wherever possible. Where we link to unofficial sources this is noted and users should take this into account before relying on these materials. We recommend checking with the relevant national government if you have questions about the currency or validity of any unofficial source of law. Legal system Common law National law database Language: English Link: www.loc.gov/law/ Nature: Official site of the law library of the congress of the United States of America Organisation responsible Library of the congress of the United States of America for the website: Legal UHC start date 2014 Source: http://www.nytimes.com/2010/03/22/health/policy/22health.html?hp The health system and policy monitor: regulation (PDF) As part of its Health Systems in Transition (HiT) series the European Observatory on Health Systems and Policies systematically describes the functioning of health systems in countries as well as reform and policy initiatives in progress or under development. The HiT health system reviews cover the countries of the WHO European Region as well as some additional OECD countries. This PDF includes information about the country’s regulation. To see the complete HiT report of this country go to: http://www.euro.who.int/en/about-us/partners/observatory/publications/health-system-reviews-hits Search list of contents: Regulation Overview and publication details 2 Regulation United States Of America 3 Page 1/11 Regulation United States Of America HIT: 2013 - Rice T, Rosenau Lynn Y Unruh P, Barnes A J.
    [Show full text]
  • And Family-Centered Care: a Roadmap for Hospitals
    Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care A Roadmap for Hospitals Quality Safety Equity A Roadmap for Hospitals Project Staff Amy Wilson-Stronks, M.P.P., Project Director, Health Disparities, Division of Quality Measurement and Research, The Joint Commission. Paul Schyve, M.D., Senior Vice President, The Joint Commission Christina L. Cordero, Ph.D., M.P.H., Associate Project Director, Division of Standards and Survey Methods, The Joint Commission Isa Rodriguez, Project Coordinator, Division of Quality Measurement and Research, The Joint Commission Mara Youdelman, J.D., L.L.M., Senior Attorney, National Health Law Program Project Advisors Maureen Carr, M.B.A., Project Director, Division of Standards and Survey Methods, The Joint Commission Amy Panagopoulos, R.N., M.B.A., Director, Division of Standards and Survey Methods, The Joint Commission Robert Wise, M.D., Vice President, Division of Standards and Survey Methods, The Joint Commission Joint Commission Mission The mission of The Joint Commission is to continuously improve health care for the public, in collaboration with other stake- holders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value. The inclusion of an organization name, product, or service in a Joint Commission publication should not be construed as an en- dorsement of such organization, product, or services, nor is failure to include an organization name, product, or service to be construed as disapproval. © 2010 by The Joint Commission Permission to reproduce this guide for noncommercial, educational purposes with display of attribution is granted. For other requests regarding permission to reprint, please call (630) 792-5954.
    [Show full text]
  • Home – the Best Place for Health Care a Positioning Statement from the Joint Commission on the State of the Home Care Industry Home – the Best Place for Health Care
    Home – The Best Place for Health Care A positioning statement from The Joint Commission on the state of the home care industry Home – The Best Place for Health Care Table of Contents Home Care is the Patient-Preferred Setting . 2 The View from 30,000 Feet – An Overview of Home Health Care . 6 The Opportunities for Home Health Care . 8 Initiatives of Special Interests . 10 The Challenges Facing Home Health Care . 13 Raising the Bar for Home Health Care . 14 References . 17 © 2011 The Joint Commission All rights reserved. No part of this document may be reproduced in any form or by any means without written permission from the publisher. Request for permission to reprint: (630) 792-5631. Home – The Best Place for Health Care Home Care is the Patient-Preferred Setting Just about everyone agrees: the home is the best very high tech and very skilled and we know how setting for providing health care to increasing to provide this service in a less controlled numbers of patients. environment than what you have in any other health care setting.” Not only can care be provided less expensively in the home, evidence suggests that home care is a key Amy Berman, senior program officer at the John A. step toward achieving optimal health outcomes for Hartford Foundation, leads its Integrating and many patients. 1,2,3,4 These studies show that home Improving Services portfolio, which focuses on care interventions can improve quality of care and creating cost-effective care models that improve reduce hospitalizations due to chronic conditions or health outcomes for older adults, by far the largest adverse events.
    [Show full text]
  • Patient Safety Systems (PS)
    Patient Safety Systems (PS) Introduction The quality of care and the safety of patients are core values of The Joint Commission accreditation process. This is a commitment The Joint Commission has made to patients, families, health care practitioners, staff, and health care organization leaders. This chapter exemplifies that commitment. The intent of this “Patient Safety Systems” (PS) chapter is to provide health care organization leaders with a proactive approach to designing or redesigning a patient- centered system that aims to improve quality of care and patient safety, an approach that aligns with the Joint Commission’s mission and its standards. The Joint Commission partners with accredited health care organizations to improve health care systems to protect patients. The first obligation of health care is to “do no harm.” Therefore, this chapter is focused on the following three guiding principles: 1. Aligning existing Joint Commission standards with daily work in order to engage patients and staff throughout the health care system, at all times, on reducing harm. 2. Assisting health care organizations with advancing knowledge, skills, and com- petence of staff and patients by recommending methods that will improve quality and safety processes. 3. Encouraging and recommending proactive quality and patient safety methods that will increase accountability, trust, and knowledge while reducing the impact of fear and blame. Quality * and safety are inextricably linked. Quality in health care is the degree to which its processes and results meet or exceed the needs and desires of the people it serves.1,2 Those needs and desires include safety. The components of a quality management system should include the following: n Ensuring reliable processes * The Institute of Medicine defines quality as the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.
    [Show full text]
  • Standards for Hospital Accreditation
    1910-1919 The Joint Commission: 1920-1929 1950-1959 1960-1969 Over a century of quality and safety 1970-1979 1980-1989 1990-1999 2000-2009 2010-2018 Home 1 © 2018 The Joint Commission. All Rights Reserved. 1910-1913 1910-1919 Ernest Codman, M.D. proposes the 1920-1929 “end result system of hospital 1950-1959 ⎻ standardization.” 1960-1969 1970-1979 American College of Surgeons is 1980-1989 founded. The “end result” system 1990-1999 ⎻ 2000-2009 becomes an ACS objective. 2010-2018 Home 2 © 2018 The Joint Commission. All Rights Reserved. 1917-1918 1910-1919 The American College of 1920-1929 Surgeons develops the 1950-1959 ⎻ Minimum Standard for 1960-1969 1970-1979 Hospitals. Requirements fill 1980-1989 one page. 1990-1999 2000-2009 The ACS begins on-site 2010-2018 inspections of hospitals. Home ⎻ 3 © 2018 The Joint Commission. All Rights Reserved. 1926 1910-1919 1920-1929 The first standards manual is 1950-1959 printed, consisting of 18 pages. 1960-1969 1970-1979 1980-1989 1990-1999 2000-2009 The American College of Surgeons made the three-story 2010-2018 former residence shown opposite, on Chicago’s rapidly growing north side, its headquarters in 1920. Home 4 © 2018 The Joint Commission. All Rights Reserved. 1910-1919 1950-1951 1920-1929 1950-1959 1960-1969 The American College of Physicians, the 1970-1979 American Hospital Association, the 1980-1989 ⎻ 1990-1999 American Medical Association, and the 2000-2009 Canadian Medical Association join with 2010-2018 the ACS as corporate members to create Home the Joint Commission on Accreditation of Hospitals (JCAH), an independent, not-for-profit organization, in Chicago, Illinois, whose primary purpose is to provide voluntary accreditation.
    [Show full text]
  • Joint Commission Medical Staff Standards
    1/9/2020 Print Chapter Effecve Date: July 1, 2019 Program: Hospital Chapter: Medical Staff Overview: The self-governing organized medical staff provides oversight of the quality of care, treatment, and services delivered by practitioners who are credentialed and privileged through the medical staff process. The organized medical staff is also responsible for the ongoing evaluation of the competency of practitioners who are privileged, delineating the scope of privileges that will be granted to practitioners, and providing leadership in performance improvement activities within the organization. All licensed independent practitioners * are credentialed and privileged by the organized medical staff. Physician assistants (PAs) and advanced practice registered nurses (APRNs) who are not licensed independent practitioners may be privileged through either the medical staff process or a procedure that is equivalent to the medical staff process and criteria set forth in the credentialing and privileging standards contained in this chapter. This procedure must be approved by the governing body and assure communication with and input from the Medical Staff Executive Committee regarding those privileges. The organized medical staff must create and maintain a set of bylaws that define its role within the context of a hospital setting and responsibilities in the oversight of care, treatment, and services. The medical staff bylaws, rules, and regulations create a framework within which medical staff members can act with a reasonable degree of freedom and confidence. The hospital’s governing body has the ultimate authority and responsibility for the oversight and delivery of health care rendered by licensed independent practitioners, and other practitioners credentialed and privileged through the medical staff process or any equivalent process.
    [Show full text]