During the voluntary review process, the performance of a healthcare entity is measured against:

Research BMJ 2022; 377 doi: //doi.org/10.1136/bmj-2020-063064 (Published 23 June 2022) Cite this as: BMJ 2022;377:e063064

Preparing for accreditation can be a long, intensive process. It requires collaborating with administrators and leaders to update policies, procedures, and training materials.

But accreditation is a worthwhile investment. In the end, achieving accreditation in healthcare can have many important benefits for your organization:

Improved quality of care

Achieving accreditation requires holding staff to high standards for patient care. Studies have shown that accreditation improves the overall quality of care in healthcare facilities.

In certain specialty areas, accreditation programs even improve patient outcomes.

In a survey by the Public Health Accreditation Board, 98% of respondents agreed that accreditation prompted their organization to improve quality and performance.

Healthcare accreditation requires organizations to examine processes in every department and section of their facility. This also improves the quality of care by decreasing variations in the ways different staff members and departments care for patients.

The standards ensure that patients will receive consistent, excellent care throughout the facility.

Increased community confidence

In healthcare, patient trust is essential. Patients are putting their personal health – and often their lives – in the hands of healthcare staff.

Accreditation shows your patients that they can trust your organization to take care of them. It also demonstrates to the community that you are seeking to provide the highest quality service possible.

When community members see that your organization is accredited, they know that you have voluntarily undergone the process of meeting rigorous standards.

This increased confidence not only brings in more patients, it also can help your organization build partnerships within your community.

Better operational efficiency and processes

Healthcare organizations face unique challenges when it comes to management and business operations.

Organizations must make sure their operations comply with a complex series of federal and state laws. They also must continually improve processes while also cutting costs.

A survey conducted by the Harvard Business Review found that management issues were the biggest challenges facing healthcare providers.

They interviewed more than 150 healthcare executives at different types of organizations, and found that more than half of them said their operational model needed to change.

Accreditation in healthcare can help organizations make strategic shifts. Most accreditation standards provide a framework to help your organization set up better structures and achieve operational excellence.

In the Public Health Accreditation Board survey, 90% of respondents said accreditation improved the management processes of their leadership team.

Achieve DNV accreditation the easier way. 

See how PowerDMS can help.

Reduced liability insurance

Healthcare is a high-risk and highly regulated industry. Federal healthcare regulations such as HIPAA, the False Claims Act, the Affordable Care Act, and more are complex and ever-changing.

Medical mistakes or compliance violations can cost your organization millions in lawsuits, or even put you out of business.

Preparing for accreditation requires doing a comprehensive review of how your organization functions. This lets you see the areas where you are most at risk.

You may spot a gap in compliance or find that you need to adjust the procedure to make a certain task safer. This proactive approach to risk management will result in safer processes, and therefore, fewer mistakes.

As a result, accreditation may provide you with better access to liability insurance.

Some insurance companies offer a reduced premium to facilities that are accredited. This can bring significant savings for your organization, and may even offset the cost of accreditation.

Gain competitive advantage

Accreditation gives you a leg up on your competition. Potential patients or partners are more likely to choose an accredited healthcare facility over one that is not accredited.

Since accreditation improves the quality of care, it also improves patient satisfaction. And satisfied patients spread the word and come back when they need additional medical help.

Receive shared policies, procedures, and best practices

When your organization gets accredited, you gain access to a whole new world of resources and partnerships.

Often the accreditation organization will offer ongoing tips and resources to help keep you up to date on new regulation, technology, and changes in the industry.

You can also share knowledge with other accredited organizations to improve your policies and procedures and keep up with current best practices.

Obtain insights and transparency through external review

When accreditation surveyors conduct their review of your organization, they do more than just check that your facility meets the standards.

Often, they will give you advice and insights on how to improve your organization above and beyond the standards.

The peer reviewers bring an objective, outside perspective that can help you identify the strengths and weaknesses of your organization. Often, they are leaders from other healthcare organizations, so they can provide concrete examples of strategies that have helped their organization improve.

Since your organization has to go through peer review every few years to maintain accreditation, the process will keep your organization moving forward and constantly improving.

These are just a few of the benefits of accreditation in healthcare. Healthcare accreditation can help your organization improve the quality of care, streamline operations, reduce liability risks, and more.

Achieving and maintaining accreditation gives you a clear picture of how to constantly improve your organization for years to come.

Cards Return to Set Details

Term

Identify the 4 basic elements that must be proven in a malpractice case

Definition

1.  Duty

2.  Breach of Duty

3.  Damages

4.  Cause

Term

The process for ensuring qualifications for medical staff members in healthcare organizations is known as . . .

Definition
Term
Peer review and performance improvement discussions, deliberations, records and proceedings of the medical staff committees are considered "discoverable" in a court.
Definition
Term

The Federal Health Care Quality Improvement Act of 1986 confers immunity from civil liability for damages for actions taken by peer review bodies to the following individuals and entities:

Definition
  • The professional body itself

  • Any person acting as a member of a staff to the professional review body

  • Any person under a contract or other formal agreement with the professional review body

Term

A healthcare organization has the responsibility for disclosing these elements of adverse events to the patient or the patient's family.

Definition
  • A factual explanation of the circumstances surrounding the adverse event

  • An explanation of the impact of the adverse event on the patient's treatment, including treatment that may otherwise not have been necessary

  • Steps that will be taken to correct or mitigate any injury

  • An assurance that the physician and/ or other memebers of the patient care team will remain available to discuss any concerns that the patient or family may have

Term

Chapter 22

The Institute of Medicine defined six aims for providing care that health care organizations and professionals should have focused and aligned.  These six aims are:

Definition
  1. safe
  2. effective
  3. patient centered
  4. timely
  5. efficient
  6. equitable
Term

Identify Peter Senge's suite of five disciplines that individuals should master to be able to approach quality from a systems orientation rather than a process orientation.

Definition
  • a shared vision
  • team learning
  • personal mastery
  • mental models
  • systems thinking
Term
A quality functional deployment is a two-step process that helps the concurrent engineering team identify the following:
Definition
1. factors that determine the quality of performance
2. actions that ensure the desired performance
Term
Identify the four groups of systems analysis tools
Definition
Modeling and simulationEnterprise management toolsFinancial engineering and risk management tools

knowledge discovery in database

Term
List five steps required to apply Theory of Constraints
Definition
1. Identify the systems constraint2. Decide how to exploit it.3. Prioritize and synchronize decisions above everything else4. Elevate the systems constraints

5. If in the above steps the constraint has shifted, go back to step one. Do not allow inertia to become the system constraint.

Term
The primary objective in healthcare for both the patient and provider is to
Definition
arrive at the desired outcome
Term
Which of the following statements regarding quality management in healthcare is true?
Definition
Healthcare Quality Improvement Methods have been adopted from the business sector.
Term
Clinical quality management focuses on the evaluation of
Definition
direct care and treatment of patients
Term
The current Joint Commission accreditation standards related to quality emphasize
Definition
measuring process of performance and using the data to improve care.
Term
The current Joint Commission quality initiative is called
Definition
Term
The Institute of Medicine released a report in 2000, that focused attention on medical errors. According to the IOM, reports about errors indicate that
Definition
there is a gap between average care and best care
Term
The role of the health information professional in QM includes all of the following except-
Definition
making judgements about the quality of clinical care.
Term
An organization- wide QI plan in hospitals is required by
Definition
Term
Which landmark legal case established responsibility of the hospital for the quality of care given by its physicians?
Definition
Darling vs Charleston Community Memorial Hospital
Term
Every healthcare organization's risk management plan should address
Definition
focus areas for the current year
Term
Which of the following is not a basic function of the utilization review process?
Definition
Term
In assessing the quality of care given to patients with DM, the CQI group collects data regarding blood sugar levels on admission and discharge. This date is called-
Definition
Term
The Donabedian Quality Assessment Model includes which three measures?
Definition
Structure, Process and Outcome
Term
The Joint Commission currently indentifies five core measures that provide an indication a healthcare facility's performance. The core measures include all of the following except-
Definition
Term
Which of the following provides step-by-step guidance to physicians and others in making decisions related directly to patient care?
Definition
Clinical Practice Guidelines
Term
During the voluntary review process, the performance of a healthcare organization is measured against-
Definition
Term
Which of the following documents the results of care for individual patients as well as for specific types of patients grouped by dx category?
Definition
Term
Under the ORYX system, all hospitals and skilled nursing facilities must report outcome measures on at least - percent of their patients.
Definition
Term
The process of reviewing and validating a physician's education and experience prior to granting medical staff membership is called -
Definition
Term
Dr. Smith, an OBGYN specialist, is granted membership on the Medical Center Hospital medical staff, where she may offer care and treatment related to obstetrics . . . The process of defining what services she may perform is called -
Definition
Term
During a hospital stay the social worker assesses the situtation and determines that LTC placement is necessary upon DC. This process is called-
Definition
Term
A risk manager is called in to evaluate a situation in which a visitor to the hospital slipped on spilled water, fell, and fx'd his femur. This situation was referred to the Risk Manager because it involves a -
Definition
potentially compensable event
Term
The terrorists attacks of 9/11/2001, focused additional attention on which of the following components of Risk Management?
Definition
Term
In 1998, the Joint Commission implemented a QI poicy that requires review of unexpected occurrences that result in death or serious physical or psychological injury. These occurrences are referred to as -
Definition
Term
The systematic investigation of both the clinical and administrative reasons for the occurrences described above is called -
Definition

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