Continuous quality monitoring and accreditation and healthcare

Continuous quality monitoring and accreditation and healthcare

In healthcare we are often exposed to accreditation agencies and regulatory compliance standards that we must meet and maintain throughout our operation and interactions with patients. Every system, process, and every program must be continually monitored and maintained in order to protect not only the patient safety but exceed HIPAA and security standards. This is done through a variety of benchmarks tools and review bodies such as Boards of Governors, regulatory agencies and accreditation committees such as Joint Commission. Medicare & Medicaid under CMS also have standards that must be met. Today, as one of the longest-standing Medicare quality reporting initiatives, the Hospital IQR Program includes more than 50 care measures related to process, outcome, structure, and patient experience. The program also focuses on several high-impact conditions, including acute myocardial infarction, heart failure, stroke, and pneumonia (Smith, 2012).

I really don't have any experience with quality and accreditation boards although I know they are important. I have been through numerous quality inspections in my career in healthcare. From the paper medical record to the new electronic health record, rules and requirements in the formats may have been changed but many of the standards have become stricter.  The biggest focus is in detailed information documentation and system processes in order to protect patient’s safety and privacy (Cassidy, 2011). Both Joint Commission and CMS have strict standards that must be met to protect health information and patient safety. Each set of surveyors will review policies, procedures, records in all formats and interview patients and staff. By having an effective health informatics system in place with the necessary safeguards helps make accessing this information easier. Failure to meet or exceed these standards can be cause for fines and loss of accreditation. This can also be tied into lost revenue and reimbursements.  

NAHQ

Health informatics tools are a way of being able to meet regulatory standards as well as a means to continually monitor quality within an organization and provider. This will be an ongoing process, especially when dealing with computers, mobile devises and the internet.There must also be processes in place to measure and monitor the system that is collecting this information. Data collected in the Hospital IQR Program is reported by Medicare and can be found on the Medicare Quality Care Finder website (www.medicare.gov/quality-care-finder/) under “Hospital Compare.” The Hospital IQR program plays an important role in the evolution of the Hospital Value-Based Purchasing (Hospital VBP) Program, as measures included in that program must first have been available under Hospital Compare for at least 1 year (Smith, 2012).   

By continually monitoring our systems and maintaining accreditation status positively affects not only the patient as well as the provider. Staff is trained just what the regulatory standards are that they must meet and exceed as well as what acceptable benchmarks must be met based on processes procedures and  the systems that are in place. Patients benefit with positive clinical outcomes based on safety measures that are in place. As a safeguard, being monitored by the organization itself as well as outside agencies sets a bar we must always obtain to provide quality care.

One area of particular focus for positive clinical outcomes (and is often the starting point for most surveyors) is the electronic medical record as well as CPOE. This type of technology helps to reduce errors and has the capacity to derive reports and data based on the information that is stored in this format (Armitage, Newell & Wright, 2010).  Surveyors review this information for accuracy and any outliers. It is also be benchmarked against other processes. They often wish to know how we are using the information we are able to gather. Everyone is affected when it comes to clinical monitoring and quality especially the patient. This monitoring is beneficial for all involved, just think when you get the age where you may need this type of care, wouldn't you like to know the type of quality care you are receiving?

The major impact on society is that accreditation standards and continuous monitoring processes allows the public to understand who is meeting or exceeds in providing care. It also serves as a means to alerting others what problem areas maybe in place at specific facilities or organizations. With the advent push towards electronic health record adoption transparency is now being provided so patients can review the information easily and quickly ask questions of their healthcare provider. Individuals can access results and surveys on specific website in order to see how their facility organization stands up against its peers, benchmarks and itself. Ultimately the patient is one that is greatly affected by the outcomes that are noted.

Smith, H. L. (2012). Quality Reporting in the Hospital Inpatient Setting. PT In Motion,4(11), 36-39.

Cassidy, B.  (2011).  AHIMA's Code of Ethics. Journal of AHIMA, 82(3), 10.  Retrieved from the ProQuest database.

Armitage, G., Newell, R., & Wright, J. (2010).  Improving the quality of drug error reporting.  Journal of Evaluation in Clinical Practice, 16(6), 1189-1197.  Retrieved from the EBSCOhost database.