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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT

Running Head: A Reflection on Health Care Quality Management

A Reflection on Health Care Quality Management

Karan P. Singh

August 11, 2010

HADM 605: Healthcare Quality Management

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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
Hospital Accreditation: A Reflection on Health Care Quality Management

Ever since doctors began washing their hands before surgeries in the late 19th century,

quality management has been an important aspect of health care (Wachter, 2007). The Joint

Commission is a private, not-for-profit organization that accredits and certifies more than 17,000

hospitals and medical centers in the United States. The Commission began its operations nearly

100 years ago with a goal to standardize hospital operations. Presently, the Commission

provides high performance standards against which hospital can measure their individual policies

and practice.

The main mission behind this organization’s work is to improve health care that is

offered to the public. Hospital accreditation is an especially lengthy process that examines

performance and quality (Wachter, 2007). Performance is examined through such criteria as

environment of care, infection prevention and control, medication safety, and patient safety

(Wachter, 2007). These criteria are often studied by panels made of recognized professionals

such as doctors, nurses, pharmacists, risk managers, and other professionals who are health care

quality management experts (Wachter, 2007). Once they have reviewed the latest in research,

the panel makes recommendations on best practice policies for each criterion.

Two current criteria that are used by the Joint Commission are National Patient Safety

Goals (NPSG) and National Quality Improvement Goals (NQIG) (The Joint Commission

Accreditation, 2009). NQIG provides standards on concrete goals such as providing the best

care for heart attack patients (The Joint Commission Accreditation, 2009). For instance, if

NQIG standards dictate that patients are administered Aspirin therapy as soon as they enter the

hospital, the standard of care judges how quickly (in hours) the hospital has complied. A

hospital is likely to fail a standard if it shows that this therapy is not administered in time
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
consistently or not complied with the standards (The Joint Commission Accreditation, 2009).

NPSG also sets concrete goals for introducing and maintaining high standards of patient safety

such as improving the accuracy of patient identification.

The Joint Commission’s hospital accreditation process often ends with a final report that

details how well the hospital has complied with regulatory standards (The Joint Commission

Accreditation, 2009). The accreditation cycle lasts three years and given to those who have

complied with most or all of the standards. The following four hospitals are accredited by the

Commission at present (The Joint Commission Accreditation, 2009):

1. Dana-Farber Cancer Institute

2. The University of Texas MD Anderson Cancer Center

3. Memorial Hospital for Cancer and Allied Diseases

4. Cleveland Clinic

The Dana-Farber Cancer Institute (“Dana-Farber”) was founded in 1947 and has been

providing cancer care for adult and child populations for over 60 years. Dana-Farber’s mission

is to provide compassionate care while being a leader in cancer research and therapy. According

to The Joint Commission (2010), Dana-Farber has reached the target value expected for both the

2010 NPSG goals. Specifically, Dana-Farber has shown that it has reached the target value on

the following criteria:

 Improve the accuracy of patient identification

 Improve communication effectiveness among health care providers

 Improve the safety of using medication

 Reduce the risk of health care-associated infections.

 Accurately and completely reconcile medications across the continuum of care.

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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
 Identify safety risks inherent in its patient population.

 Adhere to the universal protocol.

The goal of these criteria is to provide standards that can be accurately and concretely

self-reported by hospitals in a survey. A criterion such as improving the accuracy of patient

identification asks whether the hospital has successfully implemented a 2-identifier policy (by

giving patients two identification pieces). Eliminating transfusion errors is another component

of patient identification accuracy that Dana-Farber has implemented successfully (The Joint

Commission, 2010). Dana-Farber has also achieved target values for NQIG in pneumonia care.

Pneumonia is a common ailment in the elderly and those who are institutionalized with long-

term illness. This disease claimed numerous lives in the past when the quality of health care

offered sufferers was not standardized. Quality management, through the work of specialist

panels, has improved the standard of care for pneumonia patients. Dana-Farber patients have

especially benefitted from their stringent adherence to NQIG standards of pneumonia care (The

Joint Commission, 2010).

The University of Texas MD Anderson Cancer Center (“MD Anderson”) is another

world class hospital that specializes in the treatment of cancer. MD Anderson’s, which is based

in Houston, TX, mission is to eliminate cancer through an investment in research in addition to

offering their patients cutting edge treatments. It also invests heavily in the education of the

public and the prevention of cancer. According to The Joint Commission accreditation report

(2007), MD Anderson has achieved the 2007 seven NPSG goals. Specifically, the hospital has

implemented the use of at least two patient identifiers when providing treatment.

The hospital has also sought and succeeded in improving communication among health

care staff through such measures as the “hand off” technique (The Joint Commission, 2007). In
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
this technique, when a physician gives a nurse instructions, for instance, the goal is to offer a

chance for them to exchange questions, if necessary. This helps clear misunderstanding which

may happen if instructions are simply passed on without a chance for discussion. MD Anderson

has also implemented a fall reduction program successfully (The Joint Commission, 2007). This

program reduces the number of falls that hospitalized patients suffer while they recuperate. The

hospital has also sought to reduce procedural errors by implementing a program of pre-

verification (The Joint Commission, 2007). This extensive checking and re-checking of patient

information helps reduce the incidence of the wrong procedure or medication being given to a

patient.

The Memorial Sloan-Kettering Cancer Center (“Memorial”) is also a world-renowned

cancer care hospital that is based in New York City, NY. Memorial was built in 1884 and was

initially called the New York Cancer Hospital. Memorial prides itself on prides itself on being a

center of biomedical research that engages in both basic and clinical sciences. The hospital’s

mission is to advance the treatment of cancer through the research of scientists and physicians

working side by side. Memorial tackles cancer cases that are considered late stage and extremely

challenging with a goal of raising the survival rates of traditionally difficult to treat cancers such

as pancreatic an ovarian cancers. These cancers tend to be discovered fairly late in development

so the prognosis for many patients tends to be grave. Similar to Dana-Farber and MD Anderson,

Memorial has reached the target levels of the 2007 NPSG criteria successfully (The Joint

Commission, 2007).

Finally, the Cleveland Clinic (“Clinic”) is another hospital that is known throughout the

world for a high standard of both research and clinical services. However, unlike the other three

hospitals, the Clinic does not concentrate on cancer (or allied diseases) treatment although it
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
offers first class cancer treatment. The Clinic is known as one of the top four hospitals in the

United States and its Taussig Cancer Institute provides specialized cancer care while adhering to

the high standards of the larger hospital. According to The Joint Commission accreditation

report (2007), the Clinic has reached the target levels of the 2007 NPSG criteria successfully. In

addition to this successful implementation and accreditation, the Clinic has reached target levels

of the 2007 NQIG in both heart failure and pneumonia care (The Joint Commission, 2007).

Furthermore, the Clinic has performed above target levels in heart attack care and infection care

in open heart surgery and coronary artery bypass graft (The Joint Commission, 2007).

While all four hospitals are accredited by The Joint Commission and are known to offer

high standards of treatment, as a cancer patient, I would seek treatment at Memorial. The main

reason for my choice is that the physicians and scientists at the hospital have gained a great deal

of experience in the treatment of difficult cancer cases. The accumulated experience of their

health care providers combined with the hospital’s commitment to patient safety are indicators

that they would provide excellent care. Furthermore, a hospital that tackles difficult cases is

more likely to offer greater access to new and experimental drugs since many of their patients are

facing grave prognoses. My greatest concern in managing illness is finding out the latest

available treatment and therapies. To receive those, it is important to me that the physicians who

are treating me are familiar with those new therapies and even experimental ones.

As a physician, however, I would choose to work at MD Anderson. The main reason for

this choice is their dedication to the prevention of cancer. Many cancers, like some of today’s

illnesses, are related to environmental and lifestyle issues. From smoking to pollution to largely

sedentary lifestyles, cancers have begun to affect many people (Verma, 2008). It is expected that

up to one in three people would develop cancer in their lifetime. To me, there is a cause to
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
concentrate equally on prevention and treatment. Through public health education and

awareness, the message should be advanced that some cancers can be prevented if people make

better choices. Furthermore, the recurrence of cancer can be prevented in patients through both

therapy and lifestyle modifications (Verma, 2008). As a physician, I would like to work in a

hospital that values and funds research and practice into the prevention of cancer.
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
References

Cleveland Clinic. (n.d.). Cleveland Clinic. Retrieved August 1, 2010, from

http://www.clevelandclinic.org

Dana-Farber Cancer Institute. (n.d.). Dana-Farber Cancer Institute. Retrieved August 1, 2010,

from http://www.dana-farber.org

MD Anderson (n.d.). Cancer Treatment and Cancer Research - MD Anderson Cancer Center.

Retrieved August 1, 2010, from http://www.mdanderson.org

Sloan-Kettering - Memorial Sloan-Kettering Cancer Center. (n.d.). Sloan-Kettering - Memorial

Sloan-Kettering Cancer Center. Retrieved August 1, 2010, from http://www.mskcc.org

The Joint Commission. (2010, February). Quality Report – Dana-Farber Cancer Institute.

Retrieved July 16, 2010, http://www.qualitycheck.org/qualityreport.aspx?hcoid=4842

The Joint Commission. (2007, November). Quality Report – Memorial Sloan-Kettering Cancer

Center. Retrieved July 16, 2010, http://www.qualitycheck.org/qualityreport.aspx?

hcoid=5826

The Joint Commission. (2007, October). Quality Report – The Cleveland Clinic. Retrieved

July 16, 2010, http://www.qualitycheck.org/qualityreport.aspx?hcoid=9087

The Joint Commission. (2007, December). Quality Report – The University of Texas MD

Anderson Cancer Center. Retrieved July 16, 2010,

http://www.qualitycheck.org/qualityreport.aspx?hcoid=9087

The Joint Commission Accreditation (2009). 2009 Hospital Accreditation Standards (HAS):

Accreditation Policies, Standards, Elements of Performance, Scoring. The Joint

Commission.
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HOSPITAL ACCREDITATION: A REFLECTION ON HEALTH CARE QUALITY MANAGEMENT
Verma, M. (2008). Cancer Epidemiology: Volume 1, Host Susceptibility Factors. Totowa, NJ:

Humana Press.

Wachter, R.M. (2007). Understanding patient safety. New York City, NY: The McGraw-Hill

Companies.