Quality Improvement in the Health Care Organization Accreditation

The mandate for improving the way in which health care is delivered was stimulated by the public outcry over the estimated 98,000 deaths because of medical errors each year, according to the Institute of Medicine in 1999. Since then, health care organizations have sought means by which the public can be reassured that they were meeting quality and safety standards. Accreditation agencies (such as JCAHO) and quality awards (such as the Consumer Choice Award, Reuters 100 Top Hospitals, HealthGrades, National Committee for Quality Assurance, Malcolm Baldridge Award, Magnet Status, and other memberships) provide a means for the public to evaluate where the agency is meeting minimum standards.

You have been assigned by your manager to determine which accrediting agencies or quality improvement programs your hospital will utilize in its upcoming revenue cycle. Your hospital is a magnet hospital in a large urban area that provides multilayered services. You have previously used JCAHO for your accreditation but feel that you might be better served by using another accreditation body. You have three months in which to gather data and present the information to your manager.
•Choose 3 quality improvement/accreditation related programs to consider in replacing JCAHO for your organization, and briefly describe them. Note: Your agency accepts Medicare and Medicaid payments; therefore, you will need to explore, as background, the conditions of participation for Centers for Medicare and Medicaid Services (CMS). This is important information because you will need to compare your list of accrediting agencies and quality improvement programs with the conditions of participation to see if they meet the criteria.
•Analyze the costs and benefits of each quality improvement/accreditation related program by stakeholder group (e.g., patient, provider, and third-party payer).
•Rank order your quality improvement/accreditation related program suggestions with rationale.