BHA-FPX 4006 Assessment 4: Voluntary Accreditation

Voluntary Accreditation

The Healthcare industry is one of the largest sectors due to the fact that matters related to people’s health and disease management fall into this industry. It is, therefore, not surprising that over the years, there have been calls from various quarters for the healthcare services offered to the public to be better and better and be fulfilling. In response, the health care leaders and managers have embarked on using various strategies to improve the healthcare services offered. The implication is that such services and actions need to be regulated and must comply with the requirements of the regulatory bodies (Hussein et al., 2021). Therefore, it is imperative that the health care leaders and managers have a knowledge of the best practice, such as compliance practices, to meet specific standards of the industry and know the best approaches to regulatory compliance. Therefore, the purpose of this summary brief is to explore how the Joint Commission accreditation assists organizations in adhering to the regulatory requirements, meeting stakeholders’ needs, and improving quality. Besides, the write-up will formulate a recommendation regarding other accrediting bodies that can be of benefit to the organization.

Accreditation in Health Care

Accreditation in health care entails an external review showing that a particular healthcare provider is meeting the standards and regulations that have been set by the external accreditation organization. Accreditation in healthcare is one of the responses which came in place to help regulate the quality of health care both externally and internally. Accreditation started in the 20th century by the American College of the surgeon (Barghouthi & Imam, 2018). Since then, accreditation in healthcare has been practiced throughout the world with the major aim of improving healthcare quality.

Accreditation Requirements

Hospitals need to meet various eligibility requirements for them to be considered for accreditation. In the US, the healthcare organization has to be within the USA territories, or, in the case that it is outside the US, then to be operated under the US Congress charter or by the US government. The organization also has to meet the parameters for the minimum volume of service or number of in patients needed for the organization to seek accreditation (Bogossian, F., & Craven, 2020). For example, the facility must have an average daily census of twenty-one or offer an inpatient record for at least ten percent of the average daily census.

Accreditation and Regulatory Compliance

Accreditation and regulations are two of the strategies used in improving the services offered by healthcare facilities to help improve patient outcomes. However, the two are not identical, even though there are various similarities between them. Regulation refers to rules that have been set aside and have to be followed by the organizations; on the other hand, accreditation is the seal of approval as obtained from an independent accrediting body (Braithwaite et al., 2017). Such accrediting body certifies that the particular organization or facility has met some send standards. It is worth noting that as far as the health care sector is concerned, accreditation is usually essential such that most of such requirements bear the same weight as regulations.

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In most cases, much of what individuals referred to as regulation is accreditation. The major reason is that it happens in a setting where lack of accreditation has impacts close to non-adherence to the regulations. In terms of potency, regulation tops accreditation since compliance with the healthcare rules is mandatory (Braithwaite et al., 2017). In other words, no healthcare professional or hospital has to be accredited, even though many prefer it. However, failing to adhere to the set rules usually result in penalties.

In addition, while regulations have to be followed as failure to comply usually attracts penalties of varied weight, the accreditation process is voluntary. Therefore, during accreditation, the organization demonstrates that all the operations and programs have been implemented according to the relevant standards through a thorough process undertaken by a third-party entity. Nonetheless, the regulating agencies usually need accreditation if they are to certify or license an organization (Braithwaite et al., 2017). Based on the accrediting body, the accreditation process is a repetitive process, usually happening after every two to four years.

Accreditation plays a critical role in helping healthcare organizations meet the regulatory requirements. For healthcare organizations to achieve the accreditation status, the staff have to hold high standards of patient care hence improving the overall quality of patient care in this healthcare facility. In some cases, the accreditation programs play a vital role in improving patient outcomes. In an effort to adjust their operations and meet the accreditation requirements, the healthcare organizations meet the regulatory requirements (Braithwaite et al., 2017). When a healthcare facility has obtained an accreditation status, the organization gets access to numerous partnerships and resources on how to meet regulations. In addition, the accreditation entities offer resources and useful tips that are key in helping the organizations to keep up with the current regulations and adhere to them.

Joint Commission Standards

Even though there are various accreditation institutions known in healthcare, the Joint Commission accreditation is the most well-known and the most common. Over the years, the Joint Commission has played a critical role in accrediting numerous health care organizations. The implication is that the entity uses specific standards for accreditation to help these organizations comply with the regulations set aside by the practice regulation bodies (Baker, 2017). The Joint Commission standards form the basis of the objective evaluation process, which assists the health care facilities in measuring, assessing, and improving their performance. These standards are concerned about the particular resident, individual, or patient care and various organizational functions key to offering high-quality and safe patient care.

For a long time now, the Joint Commission standards have been used as the foundation for gauging and enhancing the performance of most healthcare organizations. Such standards are majorly on patient safety and quality care (“Joint Commission,” 2020). These standards are formulated using the feedback obtained from the interactions with the government agencies, healthcare professionals, and consumers. It is worth mentioning that the development of standards is a comprehensive process that involves consultations with various entities before they get published on their website for public participation and comments before final approval. These standards are key in helping the hospitals to formulate strategies key to address complicated situations and identify vulnerabilities in operations. Therefore, the Joint Commission standards relevant to this organization are those touching on the patient care process.

In reference to hospitals, there are various standards that apply. One of them is the patient-centered standards. These entail activities and strategies focusing on improving patient outcomes. Among them is the international patient safety goals, which prompt organizations to ensure that they meet the safety goals set regarding the treatment and management of patients. The other aspects of the patient-centered standards are access to care and continuity of care which entails the organizations’ requirement of ensuring that the patients can access the care they offer and that the care can be offered continuously for better outcomes (“Joint Commission,” 2020). Other aspects include patient and family education, medication management and use, anesthesia and surgical care, care of patients, assessment of patients, and patient and family rights.

The next standard entails health care organization management standards. This standard ensures that the healthcare organizations are managed according to levels that ensure efficient operations for better outcomes. In support of this standard, various aspects include management of information which entails managing patient information with the confidentiality and privacy it deserves, staff qualification and education, which ensures that the employed staff has the required levels of education and that programs are in place for continuous professional development and education (“Joint Commission,” 2020). The next aspect is facility safety and management, which entails managing the organization at the required levels that enhance safety. The next is governance, leadership, and direction. In addition, health care organizations are expected to undertake prevention and control of infections which entails efforts to reduce the rates of infections in the facilities. The last aspect under these standards is quality improvement and patient safety.

The other Joint commission relevant to this facility is the leadership support which entails supporting the stakeholders and the senior leadership to focus on getting solutions that can help reduce hospital readmissions. This standard is meant to help hospitals reduce the rates of hospital readmissions in various departments as much as possible. The next standard concerns multidisciplinary collaboration (“Joint Commission,” 2020). Under multidisciplinary collaborations, healthcare professionals are expected to collaborate through various approaches, such as interprofessional approaches to help obtain the best outcomes at reasonable costs.

The Accreditation Best Practices

As earlier pointed out, accreditation is key in ensuring that healthcare organizations meet specific standards. Therefore, there are particular industry best practices that healthcare organizations must undertake to meet the accreditation requirements. From the earlier discussions, it was evident that accreditation happens after every two to five years. Hence healthcare organizations should always be alert. In addition, no healthcare organization can have knowledge in advance on when the accreditation survey by the Joint Commission will take place (Mosadeghrad, 2021). Therefore, healthcare organizations have to be prepared all year through. However, there are various accreditation best practices that can help organizations to achieve accreditation.

One of the best practices is keeping up to date with the accreditation bodies’ current hot topics. On most of the accreditation bodies’ websites, such as the Joint Commission’s, there are blogs that are usually revised and contain the most current and hot topics. Such topics can be indicative of what is to be included in the next surveys. For example, if among the hot topics there is the protection of staff from unfavorable working conditions and enhancing patient safety and services, then there are high chances that employee and patient well-being would form the future standards (Mosadeghrad, 2021).

Another best practice is eliminating the corridor clutter. Corridor clutter can be a huge hindrance whenever there is an emergency situation. For example, when they exist, it can be difficult for those responding to an emergency to appropriately respond and hinder the staff from efficiently moving the patient in the case of emergencies (Mosadeghrad, 2021). Even though the accreditation bodies such as the Joint Commission advise that the medical equipment in the facilities should be permanently accessible, there are so many occasions when the inspectors find various items which block the corridors for several hours.

Making a good first impression when inspectors visit can also be key. The organization’s team should be well equipped on how to identify the inspector, greet them and even accommodate them. As such, the organization has to be aware of the current recommendations on interactions with the inspectors and offer enough office space where the inspectors can work when they visit the organization. The organization should therefore ensure to give a good first impression.

Another best practice is making efforts to learn from other organizations’ failings. Yearly, the accreditation institutions such as Joint Commission usually publish aspects where most of the organizations fail. Such information is contained in the perspectives newsletter. By carefully studying such information, the organization can successfully identify possible and the most common pitfalls and correct them to enable them to obtain accreditation (Mosadeghrad, 2021). In most cases, such failings are connected to the care environment and not the care standards offered by healthcare facilities. Therefore, they can easily be ignored, leading to failure.

It is also important for the healthcare organization to identify the possible discrepancies that exist between the current practices and the guide. Reading the whole survey guide can be time-consuming and challenging. However, the organization can focus on what is applicable and identify the discrepancies (Mosadeghrad, 2021). The facility leaders can then take the necessary steps, such as forming teams that can help in remedying the discrepancies prior to the Joint Commission accreditation survey. Such a step will increase the chances of obtaining accreditation.

Other Accrediting Organizations

Accreditation is key in helping healthcare organizations comply with various healthcare standards and regulations. Therefore, apart from the Joint Commission, there are various other accreditation organizations or entities which can benefit the healthcare facility in terms of helping the facility to comply with various healthcare standards. One of such accreditation organizations is the National Committee for Quality Assurance. This is a non-profit and private firm focusing on health care quality improvement. The organization accredits and certifies several health care organizations. The National Committee for Quality assurance uses the Healthcare Effectiveness Data and Information Set as a tool to measure performance in health care.

The National Committee for Quality Assurance has regularly updated quality standards which are applied by the health insurance as a gauge of improvement and quality ongoing levels. Over the years, the organization has been operating on the measure, analysis, and improve the strategy to help formulate consensus in the healthcare industry by working with health plans, patients, doctors, employers, and policy makers (Papp, 2018). The organization has a national committee responsible for quality assurance and manages voluntary accreditation activities. This is done to the medical groups, health plans, and individual healthcare professionals. The organization also gives various programs which target compliance auditing, software certification, and vendor certification.

The accreditation offered by National Committee for Quality Assurance has various benefits. The organization encourages enhanced accountability for patient care by focusing on the matter of health care quality. It then ensures that the issue of health care quality is brought to the national dialogues. As such, getting accredited by National Committee for Quality Assurance ensures that the organizations offer quality care. Through a consensus, the organizations use the central formula of measuring, analyzing, improving, and repeating to improve healthcare (Papp, 2018). As such, the new standards, measures, and tools developed by the organization become a central component in helping the accredited organization raise their standards and comply. Indeed, accredited organizations can use the developed measures, tools, and standards to evaluate their effectiveness and efficiency in terms of offering patient care and making necessary improvements.

The organization also focuses on a model of care known as Patient-Centered Medical Home, which focuses on helping the healthcare professionals working in the healthcare facilities to enhance comprehensive care through effective communication and coordination of the practitioners. The model is critical in cost management both at individual patient levels and hospital-wide levels. It also helps in improving the provider and patient experiences, better access to care, and patient, provider relationships (Papp, 2018). The implication is that the healthcare organizations accredited by National Committee for Quality Assurance are capable of meeting various standards related to patient care, providing safety and patient relationships, and access to patient care.

Accreditation by National Committee for Quality Assurance also helps healthcare organizations to have a completely different and better view of patient care. It makes the hospitals come up with systems that are not reactive, focusing on the patients when they come in but integrating population management and care management at the practitioner level. The implication is that the facilities take more responsibility for ensuring that things are done right throughout the organization for better patient care (Papp, 2018). By enhancing a positive relationship between the practitioners and the patients, there is much participation in patient care by both the patients and the healthcare providers for better outcomes. The organization also helps the accredited healthcare facilities to operationalize primary patient care and integrate care to the level that the organizations are capable of complying with the expected patient care and management standards.

Operationalization of primary patient care is particularly key and helpful for handling complicated patient cases. For example, patients attended to different healthcare professionals, and individuals with chronic conditions may find it difficult to keep their medications, among other things. However, with the aspects of the operationalization of primary care as supported by the National Committee for Quality Assurance, the accredited organization can effectively manage these patients by putting in place effective strategies. Connected to this group of patients is the requirement that enhances access to care for patients (Papp, 2018). There are provisions to ensure that when patients get ill, they can be kept outside the emergency room and out of the hospitals as much as possible by offering adequate access.


Voluntary accreditation is key in ensuring that healthcare organizations participate in activities that make them comply with various set standards and regulations. Therefore, it is important for a healthcare organization to choose a relevant organization and voluntarily get accredited. Even though there could be cost implications, the benefits outweigh the cost. From the discussion explored in this paper, the cost and the required effort to meet the accreditation requirement have value to the organization. Indeed, with accreditation, the organization will be able to meet the set standards of compliance and licensing bodies hence avoiding potential penalties in the long run. Again, through accreditation, the organization stands to gain as most patients would prefer to go to an accredited institution. Therefore, the organization would have financial gains as more patients would seek the facility’s services.


Baker, D. W. (2017). History of The Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. Jama317(11), 1117-1118. doi:10.1001/jama.2017.0935

Barghouthi, E. A. D., & Imam, A. (2018). Patient satisfaction: comparative study between Joint Commission International accredited and non-accredited Palestinian hospitals.

Bogossian, F., & Craven, D. (2021). A review of the requirements for interprofessional education and interprofessional collaboration in accreditation and practice standards for health professionals in Australia. Journal of interprofessional care35(5), 691-700.

Braithwaite, J., Matsuyama, Y., & Johnson, J. (2017). Healthcare reform, quality, and safety: perspectives, participants, partnerships and prospects in 30 countries. CRC Press.

Hussein, M., Pavlova, M., Ghalwash, M., & Groot, W. (2021). The impact of hospital accreditation on the quality of healthcare: a systematic literature review. BMC health services research21(1), 1-12.

Joint Commission International. (2020). Joint Commission International accreditation standards for hospitals: including standards for Academic Medical Center Hospitals. Joint Commission Resources.

Mosadeghrad, A. M. (2021). Hospital accreditation: The good, the bad, and the ugly. International Journal of Healthcare Management14(4), 1597-1601.

Papp, J. (2018). Quality management in the imaging sciences e-book. Elsevier Health Sciences.

Although being accredited is voluntary, many healthcare organizations feel that it is necessary to have(Shaw, 2011). Patients can feel confident that they are receiving the best care when they are seen at a hospital that has been nationally recognized by an accredited agency. The process can be time consuming, however it is beneficial once complete and obtained. Accreditation in Healthcare Healthcare facilities need to be accredited in order to be reimbursed by Federally funded programs, such as Medicare and Medicaid. Showing that you have met federal standards shows the organization has met federal requirements. Hospitals are not the only organizations that can be accredited. An example of other healthcare entities include physician offices, nursing homes, office-based surgery centers, and behavioral health treatment facilities, to name a few. The Joint Commission is one of the accreditation agencies that is responsible for surveying facilities. They accredit more than 4,000 facilities in the United States, this is about 78% of the hospitals (Alkhenizan, 2011). In the United States, 89% of hospitals are accredited, 11% go through other accreditation agencies (Alkhenizan,2011). Other than financial benefits there are other advantages to becoming an accredited hospital. The accreditation helps facilities stay focused on patient safety and quality. This has been a standa…….

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