NR 544 Week 6 Collaboration Cafe

Student Name

Chamberlain University

NR-544: Quality & Safety in Healthcare

Prof. Name:

Date

Regulatory Agencies in Healthcare

Healthcare organizations must comply with various regulatory agencies to ensure quality care and patient safety. Two primary agencies in the United States are The Joint Commission (TJC) and The Centers for Medicare and Medicaid Services (CMS), both of which have distinct survey processes. According to TJC (2021), their surveyors engage interactively with hospital staff, reviewing policies and procedures while comparing them to actual practices. The tracer methodology is used to assess compliance by analyzing patient care from admission to discharge. This approach helps surveyors evaluate how effectively a healthcare facility provides treatment and services. My Children’s Colorado (2021) emphasizes staff education to prepare for TJC visits, including identifying practice areas that lack full compliance, developing and implementing improvement plans, and maintaining at least one year’s worth of documentation as evidence of compliance.

CMS surveys differ in their approach, as they are usually conducted by the state department of health. These surveys focus more on reviewing medical records, policies, and procedures rather than patient care interactions (CMS, 2020). Instances of noncompliance within medical records can lead to further staff interviews, with a primary emphasis on documentation accuracy and policy adherence. To help staff prepare for CMS visits, My Children’s Colorado (2021) provides resources through its intranet, where the Compliance Department gathers data from incident reports, complaints, infection surveillance, satisfaction surveys, and performance measures. These data points are analyzed for patterns and trends, allowing leadership teams to design and implement improvement plans. Despite their differences, TJC and CMS share similar goals, and accreditation by TJC often ensures that a healthcare facility also meets CMS standards (TJC, 2021).

When reviewing the Medicare.gov Hospital Compare site, the goal was to compare Children’s Hospital Colorado (CHCO) with other facilities. However, no data was available for CHCO, so the comparison was made with Aurora South Hospital and Medical Center. Medicare (2021) reported that this hospital received an overall rating of 5 out of 5 stars, reflecting strong performance in quality measures such as treating heart attacks and pneumonia, readmission rates, and overall patient safety. The facility scored above the national average in safety, timeliness, and readmissions, while achieving national average scores in mortality, effectiveness of care, and medical imaging efficiency. However, patient experience was rated below average, with a 3 out of 5-star score, primarily due to deficiencies in communication regarding medication use, discharge instructions, and overall diagnosis. Additionally, concerns were noted in cleanliness, staff friendliness, and nighttime quietness. Notably, patient ratings for nursing staff were higher than for other areas, potentially due to the high annual patient volume at Aurora South Hospital and Medical Center (Medicare, 2021).

Comparison of TJC and CMS Survey Processes

Aspect	The Joint Commission (TJC)	The Centers for Medicare and Medicaid Services (CMS)
Survey Focus	Interactive review of policies, procedures, and patient care using the tracer methodology (TJC, 2021).	Emphasis on medical records, policy compliance, and documentation accuracy (CMS, 2020).
Survey Process	Evaluates care delivery from patient admission to discharge to ensure compliance (TJC, 2021).	Reviews medical records for noncompliance, leading to staff interviews if necessary (CMS, 2020).
Preparation Strategy	Staff training, identifying noncompliance, implementing improvement plans, and maintaining records for at least a year (My Children’s Colorado, 2021).	Compliance departments analyze trends, develop corrective plans, and train staff (My Children’s Colorado, 2021).

Hospital Performance Ratings

Category	Aurora South Hospital and Medical Center Rating	National Average
Overall Rating	5 out of 5 stars (Medicare, 2021).	Varies by facility.
Patient Safety	Above national average (Medicare, 2021).	Standard benchmark.
Timeliness & Readmissions	Above national average (Medicare, 2021).	Standard benchmark.
Mortality & Care Effectiveness	At national average (Medicare, 2021).	Standard benchmark.
Medical Imaging Efficiency	At national average (Medicare, 2021).	Standard benchmark.
Patient Experience	Below national average (Medicare, 2021).	Standard benchmark.
Nursing Staff Ratings	Higher than other departments (Medicare, 2021).	Standard benchmark.

References

The Centers for Medicare and Medicaid Services. (2020). Quality standards, accreditation & licensing. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSCompetitiveBid/Quality_Standards_and_Accreditation

The Joint Commission. (2021). Prepare for hospital accreditation. https://www.jointcommission.org/accreditation-and-certification/health-care-settings/hospital/prepare/