NUR 621 Wk 5 Quality Improvement Essay

March 6, 2022

NUR 621 Wk 5 Quality Improvement Essay

NUR 621 Wk 5 Quality Improvement Essay

Quality Improvement

When patients visit health care organizations for medical assistance, they always look forward to a comprehensive evaluation of their health problems and treatment. As a result, health care organizations must be adequately resourced and committed to delivering quality care. Accreditation stamps an organization’s ability to provide quality care. It demonstrates that a health care organization’s performance meets the required threshold, implying that patients receive health care services in safe settings with qualified health professionals. Various organizations engage in managed care accreditation and regulation, including the National Committee for Quality Insurance (NCQA), Utilization Review Accreditation Commission (URAC), and The Joint Commission (TJC/JC). The purpose of this paper is to evaluate the body appropriate for my health care organization, accreditation requirements, relevant performance metrics, and the impact of quality performance on the organization.

Accrediting Body: The Joint Commission

TJC would be the most appropriate accrediting body for my health care organization. The independent, not-for-profit organization dominates standards-setting and accreditation in the United States. According to Wadhwa and Huynh (2021), TJC was established in 1951 and accredits over 20,000 health care plans and organizations seeking to optimize care outcomes. Besides quality assurance for patients, TJC also ensures that health care organizations prevent harm and improve patient advocacy.

TJC suits my organization since it emphasizes more on patient safety. Approximately 70-80% of TJC responsibilities and everyday activities address patient safety (Wadhwa & Huynh, 2021). TJC’s mission also aligns with my organization’s mission. TJC strives to continuously improve public health through collaboration with stakeholders and evaluating performance standards for health care programs and organizations. Based on the performance, TJC inspires health care facilities to provide safe and effective care. Beik and Pepper (2021) noted that TJC’s visits are unannounced, considering that TJC visits the organization the day a visit is announced. As a result, an organization must observe the entire TJC’s standards to pass the accreditation test.

Requirements to Obtain Accreditation

Accreditation is a rigorous process whose outcomes depend on the standards that an accreditation body has set. TJC standards are based on an objective evaluation process that primarily seeks to empower health care facilities to measure, assess, and enhance performance (The Joint Commission, 2021). The primary focus is on the critical individual, system, and program-specific functions. Beik and Pepper (2021) explained that TJC standards are based on the reported adverse events in health care facilities with a high potential of harming the patients. Such events include miscommunication and medication errors. Quality measures that guide the assessment focus on population-focused commonalities such as readmissions and hospital-acquired infections (Wadhwa & Huynh, 2021). Irrespective of the standard, health care facilities must be committed to delivering quality care to satisfy TJC requirements.

The basic requirement of TJC accreditation is the successful completion of an on-site survey. To meet the necessary validity and reliability threshold, trained TJC surveyors conduct the survey. Alternatively, it can be conducted by a team of trained surveyors. During the survey, medical records from randomly selected patients are used to assess an organization’s compliance with the commission’s standards (The Joint Commission, 2022). As the survey progresses, the trained surveyors interact with health care providers who interact with the patient. They further observe how care is provided.

Broadly, TJC accreditation focuses on the safety aspect. The commission uses a tracer methodology to assess an organization’s compliance with safety. During the on-site survey process, TJC identifies performance issues using the individual, system, and program-specific tracers. As Finkelman (2020) posited, individual tracer focuses on a patient’s experience when obtaining care in a health care facility. In this case, it traces the patient’s experience while utilizing a health care facility’s treatment and services. A suitable illustration is tracing a patient after arriving in the emergency department through admission, triage, and screening.

System-focused tracing is more extensive than individual tracing. Although it traces a patient’s experience while obtaining care, it focuses more on care coordination, communication, medication management, and other elements affecting the outcome and quality of patient-provider interaction (Wadhwa & Huynh, 2021). For instance, the tracing can start when a patient arrives for surgery and survey how care providers within and across the departments communicate and coordinate. System tracing can also focus on the discharge process and how the patient is transferred across units.

Besides individual and system-focused tracing, TJC also relies on program-specific tracing. According to Wadhwa and Huynh (2021), program-specific tracing primarily involves a detailed evaluation of a program’s risks and safety concerns. Particular attention is on high-risk services or programs dealing with high-volume patient populations. A suitable example is a comprehensive cardiac care program since it is high-risk.

A suitable example of a TJC standard that guides evaluation is the performance improvement accreditation standard. TJC has established a performance improvement standard for various health programs and organizations, including nursing care centers, ambulatory care, hospitals, and home care centers. Complying with this standard requires the facility’s leaders to establish performance improvement priorities in a written plan (The Joint Commission, 2021). The plan must contain five essential elements. The first element is the defined processes requiring improvement. The second element is the method that a facility uses to measure performance. The other three elements include analysis methods, interventions implemented to address deficiencies, and methods for processes monitoring and sustenance (The Joint Commission, 2021). The requirements vary depending on the standard.

NUR 621 Wk 5 Quality Improvement Essay

Assessment Description

Write a 1,250-1,500-word essay about quality improvement. Include the following points in your essay:

  1. Evaluate which accrediting body would be most appropriate for your health care organization.
  2. Summarize the requirements to obtain accreditation.
  3. Based on your research and experience, what performance or quality metrics could you focus on for a quality improvement project to present to the accrediting body?
  4. How does the quality performance financially impact the organization?

Include at least three references, including the textbook.

Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center.

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Resources

A Mixed-Methods Study to Explore the Impact of Hospital Accreditation

Read “A Mixed-Methods Study to Explore the Impact of Hospital Accreditation,” by Al-Alawy et al., from Inquiry: A Journa

… 


Promoting Patients’ Rights Through Hospital Accreditation

Read “Promoting Patients’ Rights Through Hospital Accreditation,” by Sperling and Pikkel, from Israel Journal of H

… 


In the New Healthcare, Payers and Providers Look to Redefine Quality

Read “In the New Healthcare, Payers and Providers Look to Redefine Quality,” by Leventhal, from Healthcare Informatics (

… 


Towards a Triadic Quality Measurement Framework for U.S. Healthcare

Read “Towards a Triadic Quality Measurement Framework for U.S. Healthcare,” by Chakraborty, from Quality Management Jour

… 


Economics and Financial Management for Nurses and Nurse Leaders

Read Chapter 3 in Economics and Financial Management for Nurses and Nurse Leaders and review Chapter 2.

Quality Improvement Essay – Rubric

Appropriate Accrediting Body

Criteria Description

Appropriate Accrediting Body

5. Target

16.2 points

The essay skillfully describes in a well-researched manner what accrediting body would be most appropriate for the selected health care organization.

4. Acceptable

14.9 points

The essay soundly describes in a well-researched manner what accrediting body would be most appropriate for the selected health care organization.

3. Approaching

14.26 points

The essay clearly describes what accrediting body would be most appropriate for the selected health care organization. Some relevant and supportive research is included.

2. Insufficient

12.96 points

The essay vaguely describes what accrediting body would be most appropriate for the selected health care organization. Little relevant or supportive research is included.

1. Unsatisfactory

0 points

The essay does not adequately describe what accrediting body would be most appropriate for the selected health care organization. No relevant or supportive research is included.

Obtaining Accreditation

Criteria Description

Obtaining Accreditation

5. Target

16.2 points

The essay substantially summarizes the requirements to obtain accreditation.

4. Acceptable

14.9 points

The essay soundly summarizes the requirements to obtain accreditation.

3. Approaching

14.26 points

The essay clearly summarizes the requirements to obtain accreditation.

2. Insufficient

12.96 points

The essay does not clearly summarize the requirements to obtain accreditation.

1. Unsatisfactory

0 points

The essay does not adequately summarize the requirements to obtain accreditation.

Quality Improvement

Criteria Description

Quality Improvement

5. Target

15.3 points

The essay thoroughly and skillfully identifies what performance or quality metrics could result in a quality improvement project to present to the accrediting body.

4. Acceptable

14.08 points

The essay thoroughly identifies what performance or quality metrics could result in a quality improvement project to present to the accrediting body.

3. Approaching

13.46 points

The essay clearly identifies what performance or quality metrics could result in a quality improvement project to present to the accrediting body.

2. Insufficient

12.24 points

The essay does not clearly identify what performance or quality metrics could result in a quality improvement project to present to the accrediting body.

1. Unsatisfactory

0 points

The essay does not sufficiently identify what performance or quality metrics could result in a quality improvement project to present to the accrediting body.

Financial Impact

Criteria Description

Financial Impact

5. Target

15.3 points

The essay comprehensively describes how the quality performance can financially impact the organization.

4. Acceptable

14.08 points

The essay soundly describes how the quality performance can financially impact the organization.

3. Approaching

13.46 points

The essay clearly describes how the quality performance can financially impact the organization.

2. Insufficient

12.24 points

The essay does not clearly describe how the quality performance can financially impact the organization.

1. Unsatisfactory

0 points

The essay does not sufficiently describe how the quality performance can financially impact the organization.

Thesis, Position, or Purpose

Criteria Description

Communicates reason for writing and demonstrates awareness of audience.

5. Target

6.3 points

The thesis, position, or purpose is persuasively developed throughout and skillfully directed to a specific audience.

4. Acceptable

5.8 points

The thesis, position, or purpose is clearly communicated throughout and clearly directed to a specific audience.

3. Approaching

5.54 points

The thesis, position, or purpose is adequately developed. An awareness of the appropriate audience is demonstrated.

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2. Insufficient

5.04 points

The thesis, position, or purpose is discernable in most aspects but is occasionally weak or unclear. There is limited awareness of the

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