Question

You are the executive director of a long-term care facility that has decided to pursue Joint Commission accreditation. Write an Action Plan for preparing the long-term care facility for the accreditation site visit. The length of the Action Plan should be approximately 2,400 words.

Answer 1

Applying case studies are a crucial part of the learning process in any type of health care education course/career. They allow you an opportunity to “encounter” hypothetical situations before you hit real world situations that could impact patients’ lives. This case study will involve me playing the role of the executive director of a long-term care facility that has decided to pursue Joint Commission accreditation. In the Midterm case study scenario, I will draw on, apply, and cite the first seven chapters of the course textbook to write an Action Plan for preparing the long-term care facility for the accreditation site visit. In addition, I will cite various outside sources to support the execution of the Action Plan.

Background Information

The Joint Commission is known for being the golden standard for accreditation with 60+ years of experience within the health care organization. The Joint Commission a non-government/not-for-profit organization that is comprised of the American Hospital Association, the American Medical Association, the American College of Physicians, the American College of Surgeons, and the American Dental Association. “Fueled by the changing nature of health care in America, The Joint Commission has, over the years, broadened its scope to include accreditation of many non-hospital settings, including long term facilities. The Joint Commission established the Long Term Care Accreditation Program in 1966 to support the delivery of safe, high quality care to patients/residents in long term care setting (Zimmerman, n.d.)” According to the Center for Disease Control Nursing Homes and Assisted Living (2017) , a long term care facility is defined as a nursing home, skilled nursing facility, and/or assisted living facilities that can provide a variety of services. These services can include medical or personal care to individuals who cannot manage themselves independently with daily activities. They can provide rehabilitative service, restorative services, and/or on-going nursing care.

Understanding Requirements for Accreditation

The Joint Commission’s Comprehensive Accreditation Manual for Long Term Care (CAMLTC) is the place to begin when preparing for accreditation process whether this is something that we decide to pursue early on or later down the road. This guide will provide all the organizational needs for a continuum of operational improvement in regards to standards, rationales, elements of performance (EPs), Accreditation Participation Requirements, scoring, National Patient Safety Goals, accreditation decision rules, and accreditation policies and procedures.

“The standards stress the importance of managing risks in the environment of care, and are organized around the concepts of planning, implementation, and evaluation of results. Standards call for written plans for managing risks in each of these areas. Organizations may choose to address all required components of the environment in a single management plan or in several different plans (Zimmerman, n.d.).”

The standards require that you have someone in place to manage risks, and intervene when there are potentially threatening situations within the organization. These responsibilities can be held by the same person, if necessary for the convenience of finding a solution. Areas that will be looked at during the accreditation process include:

1. Environment of Care
2. Emergency Management
3. Human Resources
4. Infection Prevention and Control
5. Information Management
6. Leadership
7. Medication Management
8. Provision of Care, Treatment, and Services
9. Record of Care, Treatment, and Services
10. Performance improvement
11. Rights and Responsibilities of the individuals
12. Waived Testing

Written documentation is not a requirement, but it is quite important to document the processes. The primary mission of the accreditation process will be how our organization carries out the functions above. Surveyors will be used in conjunction with “data sources, including interviews with leaders of the organization, staff, patients/residents and family members; visits to patient/resident care settings; and reviews of documentation to arrive at an assessment of your organization’s compliance with the standards (Zimmerman, n.d.).”

Action Plan

Mission

            Developing a mission and vision within the long-term care facility is vital to ensure there is a clear and concise direction for the path forward. We want to optimize the health, safety and quality of life for people within the long-term care facility. We will ensure continuous projects to enforce compliance with all current standard to ensure health and safety of the patients who reside within the facility. In addition, promoting quality of care abiding by the most current clinical procedures with an emphasis on a resident-centered approach.

Long-Term Care Facility Goals

1. Enhance Consumer Awareness
2. Strengthen Survey Processes, Standards, & Training
3. Improvement Enforcement Activities
4. Promote Quality of Care Improvement
5. Create a Strategic Approach through Partnerships

(CMS Survey and Certification Group 2016/2017 Nursing Home Action Plan, n.d.)

Enhance Consumer Awareness

Consumers are a vital piece to the quality of care that is presented forward in a health care system. In addition, without the consumer we would not have a facility to upkeep. We want to ensure that our consumers have the most up to date information that is relevant to their care plan. This information will not only allow for us to stay up to date, but allow the consumer to hold the facility responsible and accountable for the support, quality of care, and services that will be provided to them.

Tasking to Enhance Consumer Awareness

Task	Responsible Party	Timeline
Obtain guidance/input from consumers, physicians, facilities on website efficiency	Executive Director	TBD
Implement focus groups to provide feedback on facility	Executive Director	TBD
Evaluate quality measures put in place to ensure accountability of staff	Executive Director	TBD
Ensure appropriate staffing is available	Human Resources	TBD

Strengthen Survey Processes, Standards, & Training

            To enforce the standard to enhance consumer awareness we need to have a method in place to measure our initiatives. Through annual consumer/employee survey’s, and investigations due to complaints from patients or family, we can implement a checks and balance process. By ensuring a effective survey process is in place we are able to measure our performance objectives and patient quality of care. This will allow us to see where we need to improve, to implement training methods in place for all employees.

Tasking to Strengthen Survey Processes, Standards, and Training

Task	Responsibility Party	Timelines
Implement a survey analysis group for each section to gather results	Executive Director	TBD
Evaluate results and implement measures to improve services/standards	Executive Director	TBD
Ensure monthly training objectives are met for each section	Clinical & Non-Clinical Administrative Staff	TBD

Improvement Enforcement Activities

            As a long term care facility we want to have a system that is centered around the residents. We want to ensure the health and safety of all patients, while ensuring we are compliant with all federal rules and regulations. To improve enforcement activities we will ensure all we maintain all partnerships, certifications, and checklists required. Without a system of checks and balance there is no reason to strive forward for better quality of care.

Tasking to Improve Enforcement Activities

Task	Responsible Party	Timeline
Conduct quarterly calls/visits within each section to find trends, concerns, and issues	Executive Director	TBD
Check compliance of all certifications required to conduct daily operations	Executive Director	TBD

Promote Quality of Care Improvement

            Quality of care is what the foundation is to ensure our patients are happy and healthy. We will embrace an individualized approach to care in order to promote and provide quality improvement programs in all areas and programs necessary. Our consumers and employees will have good working relationship to ensure retention on both sides to prevent unnecessary turnover within the facility.

Tasking to Promote Quality of Care improvement

Task	Responsible Party	Timeline
Ensure monthly town hall meetings to discuss room for improvement	Executive Director	TBD
Develop consumer material to distribute on a monthly basis	Clinical & Non-Clinical Administrative Staff	TBD
Conduct focus groups with consumers to survey the quality of care provided	Executive Director	TBD

Create a Strategic Approach Through Partnerships

            From a perspective of providing excellent healthcare, there is not one method that can ensure each individual has what they need. We need to look at a combination of tactics through forming strategic partnerships within the community. We can look at government agencies, non-government agencies, and other long-term care facilities. A collaborative effort will help to ensure the facilities are held accountable to the goals set above.

Tasking to Create a Strategic Approach Through Partnerships

Task	Responsible Party	Timeline
Participate in community outreach to form strategic partnerships quarterly	Executive Director	TBD
Communicate monthly with stakeholders	Executive Director	TBD
Attend Annual Leadership Summit	Executive Director	TBD

Strategic Problem Solving

            We want to look ahead for the organization that we are striving to be at all times. We need to thoroughly define the strategic problems related to obtaining our Joint Commission in a very clear and concise manner with deliverables tied to them. This will identify the objectives that we need to accomplish, and focus on each individual problem as set forth. Each of these strategies set forth need to address the cause and potential barriers that could cause for points of vulnerability. In doing so, there must be a timeline set forth for the projects to assignment responsibility, and obtain accountability within the facility for the Joint Commission. The last step is to develop a plan to evaluate the results of the strategic problem solving methods set forth. This will allow for all individuals to see a process that will allow for tracking of progress, and outcomes that can be assessed to obtain a common goals to gain accreditation from the Joint Commission.

Conclusion

Accreditation with The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will always play a vital role within the healthcare organizational community. The JCAHO has a precedent for setting a standard that facilities can only hope to strive for. “Once every three years most hospitals in the United States endure a three-day long inspection by JCAHO. JCAHO is not the only accreditation agency, but it is by far the largest and most prestigious. Anyone who has spent any time in a hospital knows that this visit is highly anticipated and very important (Lighter, 2004).” They are experts within their specific fields set out to survey the programs set forth to evaluate them for accreditation. The Joint Commission is the future of integrated healthcare with standards from various different organizations.