Quality Improvement

The topic in brief Discussion: Quality Improvement
Type of Service coursework
No. of Pages/Wordcount 2 pages
Citation Style APA Style
Detailed Description/Explanation Accreditation/Credentialing Bodies
Accreditation and credentialing are synonymous terms within one arena. Accreditation is a part of the umbrella of credentialing for healthcare organizations. Credentialing is much like a certification which is the minimum standard for a predetermined service provided by healthcare organizations which are met through prior authorization and qualifying parameters. The one-time designation differs from accreditation, which is performed over a specific time period.

What follows are some of the more important healthcare sector accrediting agencies.

Examine: Accreditation Agencies
The Joint Commission (TJC) – Accreditor – Joint Commission (2009)

The Joint Commission provides internationally recognized accreditation and credentialing for healthcare organizations. TJC accredits hospitals, laboratories, nursing care centers, ambulatory care centers, and home care agencies. Each type of organizations has a specialized set of accrediting requirements. Joint Commission accreditation communicates that the organization meets the highest quality standards for patient care.

National Committee on Quality Assurance (NCQA)

NCQA is a national private non-profit that review health care organizations for quality, based on national standards. The entity’s goal is to protect patients and employees. Institutions can voluntarily seek review from the NCQA. Institutions that past the thorough quality review are given a seal, signifying quality care and service. The seal helps to in confidence in the institution from consumers (patients).

Accreditation Commission for Healthcare (ACHA)

ACHA is the accrediting arm of CMS. Similar to the other accreditors presented, ACHA approval signifies healthcare quality. ACHA differs from others in that it also provides a distinction for specialty areas, such as nutrition, hazardous drug handling, HIV, palliative care, behavioral health, and others (ACHA,2018).

Leapfrog Group

The Leapfrog Group refers to themselves as consumer watchdogs. They advocate for patients to promote quality and safety in hospitals. Although Leapfrog does not receive federal or state funded, its power and influence come from its strong advocacy record and data translation efforts to the protection of the public. Hospital systems have seen the impact of this groups effort (Leapfrog, 2009).


Magnet designation/recognition is bestowed by the American Nurses Credentialing Center. The designation signifies high-quality patient care and nursing work environment. The Magnet model focuses on transformational leadership, structural empowerment, evidence-based practice, exemplary professional practice, and innovation and improvements (ANA Enterprise, 2018).

Estimated time to complete: 15 Minutes

Review: ANCC Magnet Recognition – A Magnet for Exceptional Nurses
Review this video as it discusses the hospitals that have ANCC Magnet Recognition program in their hospitals and why it is important.

As you watch the video answer the following questions:

Why is it important for a healthcare organization to be recognized and credentialed by the ANCC?
For hospitals that have the American Nurses Credentialing Center (ANCC) Magnet Recognition what benefits does it provide for nursing professionals? How would these benefits impact a nursing career?
Who benefits from this scenario? Healthcare workers? Patients? Both?
Estimated time to complete: 30 Minutes

Review: Organizational Influence
In addition to accrediting bodies, there are also a number of other organizations that have a direct influence on healthcare and the nursing profession in the United States. Several of these are outlined below.

American Nurses Association (ANA)

The American Nurses Association (ANA) is a combined enterprise of three organizations, the ANA, the American Nurses Credentialing Center (ANCC), and the American Nurses Foundation. These organizations work to promote quality healthcare. The prestigious ANCC reviews and recognizes organizations for their ability to have positive patient outcomes and the highest level of nursing care (ANA Enterprise, 2018).

The National Academy of Medicine is a recognized and respected group of healthcare practitioners who work to inform health organizations nationally and internationally regarding health care trends and needs. They specifically work to influence health policy by highlights key healthcare issues.

IHI is the Institute of Healthcare Improvement. “The Institute for Healthcare Improvement takes a unique approach to work with health systems, countries, and other organizations on improving quality, safety, and value in health care” (IHI, 2018). IHI actively intervenes to develop plans, measures, then implements changes to improve health.

Emergency Care Research Institute (ECRI) “is an independent nonprofit organization whose mission is to benefit patient care by promoting the highest standards of safety, quality, and cost-effectiveness in healthcare. We accomplish our mission through our research, publications, education, and consultation” (ECRI, 2018). They promote safety and quality by assisting with technology purchases, risk control and other services related to evidence-based medicine (ECRI, 2018). Membership for healthcare organizations is not mandatory.

National Patient Safety Foundation, is a nonprofit organization for patient safety, founded in 1997. Of all of the listed organizations here, it is the only organization with a sole focus on patient safety. Their primary intervention is education and the following identified areas needing improvement as NPFS (2018) states on their website:

Helping leaders of health care organizations know how to create and sustain a safety culture.
Advocating for greater transparency at all levels of health care: between physicians and patients, among physicians, between organizations to enhance learning, and with the public.
Promoting patient engagement in all aspects of care, including design of care processes and health care governance; Promoting the safety of the health care workforce and restoring joy and meaning in work for a profession that is currently suffering high levels of burnout.
Advocating for health information technology that promotes safety and does not introduce new risks.
Estimated time to complete: 15 Minutes

Examine: National Patient Safety Foundation Overview
Review this video for an overview of the National Patient Safety Foundation.

As you watch consider the following:

What is the purpose of the National Patient Safety Foundation?
Who are their constituents and how do they serve them?
In what ways is the work of the NPSF critical to the healthcare profession? How in particular is it critical to nursing professionals?
If organizations like the NPSF were not in existence what do you think the outcomes would be for patients? For nursing professionals? The healthcare profession as a whole?

Estimated time to complete: 30 Minutes

Hospitals pay outside companies to collect patient satisfaction data for them. Popular patient satisfaction data collection services are Gallup and Press Ganey. Press Ganey has significance influence over health quality, through the National Database of Nursing Quality Indicators. This database provides evidence to support the value of nursing care by measuring the patient care experience and the degree of nursing workforce engagement in an organization. NDNQI tracks and measures rates of hospital acquirer conditions, injuries and other measures of the relationship between nursing care and patient outcomes. NDNQI is not required, but 95% of hospitals with Magnet designation utilize the NDNQI (Montalvo, 2007).

Estimated time to complete: 15 Minutes

Quality healthcare is everyone’s job. Improve the quality of health care are require government intervention and patient advocacy groups. NDNIQI is the only agency that tracks nursing specific quality indicators. Quality is an ongoing process takes planning, ongoing monitoring, and data analysis. Accreditation and designation are external markers what demonstration excellence in care and increase consumer confidence.



Listed Below are the instructions:

Please complete the following steps for your discussion post and response.

Quality improvement is constantly needed within healthcare organizations and change is inevitable. Education and training can be costly to units, departments, and healthcare organizations as a whole. Think of quality improvement within your organization and address the following:

Select one quality improvement topic discussed in the unit that could be implemented in your organization.
What is the need for improvement? How could it be implemented?
Estimate a budget for the project. Why would this funding be necessary?
Align the QI initiative with an accreditation and/or credentialing body.
Please be sure to validate your opinions and ideas with citations and references in APA format.



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