Regulatory Agency Paper Essay

Custom Student Mr. Teacher ENG 1001-04 18 May 2016

Regulatory Agency Paper

The industry in healthcare requires that its foundation in leadership is to follow procedures, rules, and regulations, which will help an organization, succeed in their leadership role in healthcare. This paper will identify important aspects of governmental or other agency such as Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) that governs the health care industry or a particular segment of the industry.

In addition, this paper will also identify the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) role, the impact it has on healthcare, the examples how they carry out their duties in regards to healthcare, the regulatory authority does JCAHO have in relation to health care, and what is their process for accreditation, certification, and authorization.

Moreover, The Joint Commission was known as the Joint Commission on the Accreditation of Healthcare Organization. According to Feigenbaum (2013), “the Joint Commission, issues one of the most prestigious accreditations in the health care industry. This nonprofit organization sets high standards for hospital, skilled nursing home health and health-care staffing company operations and performs regular reviews, checks and audits to ensure accredited organizations comply” (ehow, 2013, para. 1).

As a result, the Center for Medicare and Medicaid Services (CMS) has come to trust the judgment of the Joint Commission because of their reputation they have on certifying many medical facilities as “Medicare compliant” (ehow, 2013, para. 3).

More than 15, 000 health care programs and organization throughout the United States are evaluated by The Joint Commission, which is not-for-profit organization that works independently since 1951 to maintain top of the line standards that promote on how to improve the safety and quality of care that many health care organization provides. Agency’s Structure

The structure of The Joint Commission is “governed by a 29-member Board of Commissioners that includes physicians, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicists, a consumer advocate and educators. The Board of Commissioners brings to The Joint Commission diverse experience in health care, business and public policy. The Joint Commission’s corporate members are the American College of Physicians, the American College of Surgeons, the American Dental Association, the American Hospital Association, and the American Medical Association” (The Joint Commission, 2013).

In addition, The Joint Commission have approximately 1,000 surveyors that are employed to survey health care facilities throughout the United States. “It central office office in Oakbrook Terrace, Illinois, and at a satellite office in Washington, D.C. The Washington office is The Joint Commission’s primary interface with government agencies and with Congress, seeking and maintaining partnerships with the government that will improve the quality of health care for all Americans, and working with Congress on legislation involving the quality and safety of health care” (The Joint Commission, 2013). Organization’s Effect on Health Care

The effect that The Joint Commission has on health care is that each hospital or health care facility that need to meet the The Joint Commission standards. For example, “patient rights, patient treatment, and infection control are standards that need to meet the expectation of the Joint Commission. The standards focus not simply on an organization’s ability to provide safe, high quality care, but on its actual performance as well” (The Joint Commission, 2013). Values that are set for performance expectations of activities that concerns and affect the safety of patients as well as the quality of care they receive.

Otherwise if hospitals do not meet The Joint Commission standards they will not get accredited and that can have an effect in Medicaid/Medicare payments in that health care facility. However, if the organization provide high standard in patient care and they perform them well then the patient will have good experience in the outcome of patient care. Moreover, The Joint Commission creates standards in collaboration with experts in healthcare, measurement experts, providers, consumers and purchasers. Example of the Agency Carrying Out Its Duties

Examples that The Joint Commission has when carry out their duties is that they provide assessment of the health care facility or organization that are in compliance with the standards and how they perform. As a result, The Joint Commission will assess the organization compliance with values and their fundamental of performance. “The Joint Commission assess the organization’s compliance with standards based on: Patient and staff interviews about actual practice, Performance improvement data/trends, verbal information provided to the Joint Commission by key organizational leaders, and , On-site observations by Joint Commission surveyors” (The Joint Commission, 2013).

Regulatory Authority Relation to Health Care

The regulatory authority that The Joint Commission has in relation to health care is that they maintain a list of agencies throughout the state that will identify accreditation/certification throughout the United States health care facilities. For example, The Joint Commission will monitor legislative and regulatory activities in the state. “The Joint Commission’s various accreditation/certification programs are recognized and relied on by many states in the states’ quality oversight activities. Recognition and reliance refers to the acceptance of, requirement for, or other reference to the use of Joint Commission accreditation, in whole or in part, by one or more governmental agencies in exercising regulatory authority” (The Joint Commission, 2013).

For example, in Texas the Routine inspections of the “The Department of State Health Services (department) may conduct an inspection of each hospital prior to the issuance or renewal of a hospital license. (1) A hospital is not subject to routine inspections subsequent to the issuance of the initial license while the hospital maintains: (A) certification under Title XVIII of the Social Security Act, 42 United States Code (USC), §§ 1395 et seq; or (B) accreditation by a Centers for Medicare and Medicaid Services-approved organization” (The Joint Commission, 2013). Process for Accreditation, Certification, and Authorization

The Joint Commission process for accreditation, certification and authorization is “to earn and maintain accreditation, a hospital must undergo an on-site survey by a Joint Commission survey team. Joint Commission surveys are unannounced and occur 18 to 39 months after the previous unannounced survey. The objective of the survey is not only to evaluate the hospital, but to provide education and guidance that will help staff continue to improve the hospital’s performance. The survey process evaluates actual care processes by tracing patients through the care, treatment and services they received. It also analyzes key operational systems that directly impact the quality and safety of patient care” (The Joint Commission, 2013).

In addition, the surveying team can include a health care professionals such as a nurse, physician, hospital administrator who has senior management level experience, and life safety code specialist. “The Joint Commission has a group of more than 400 surveyors, reviewers and life safety code specialists who are trained and certified, and receive continuing education on advances in quality-related performance evaluation” (The Joint Commission, The Surveyor Process, 2008, para. 5).

The Accreditation process is a continuous; data-motivated that focuses on the overall systems operation which is crucial to the quality and safety of patient care. The following are important aspect of the process which includes: Periodic Performance Review (PPR) an annual review where the health care facility will evaluate their compliance with relevant standards and widen an action plan that can help them identify areas where they are not compliance. The tracer methodology is another process used “On-site evaluation of standards compliance in relation to the care experience of patients using a “tracer” methodology.

Tracer activities permit assessment of operational systems and processes in relation to the actual experiences of selected patients who are under the care of the organization. This activity actively engages all direct caregivers in the accreditation process” (The Joint Commission, 2008). The Priority Focus Process (PFP) is a survey that looks at quality of care of patients and their safety.

The Joint Commission will do unannounced survey to apply the credibility of how they do the accreditation process so the surveyors can look at the performance of the organization under a normal day for the health care facility. If the health care facility being surveyed passes the audits then the hospital can get accredited for another three years and this authority comes from The Joint Commission who has high standards on patient safety and quality of care. Conclusion

The leadership foundation of a health care industry identifies a governmental or other agency, such as JCAHO, that governs the health care industry or a particular segment of the industry in order to provide patient safety and quality of care through their structure, their effect on health care, their duties, their regulatory authority in relation to health care, and their process for accreditation, certification and authorization.


Feigenbaum, E (2013). Ehow. Jcaho Reciprocal Credentialing Regulations. Retrieved on October 13, 2013 from The Joint Commision (2008). Facts about The Joint Commission. Retrieved on October 13, 2013 from The Joint Commission (2013). Inspiring health care excellence. Retrieved on October 13, 2013 from The Joint Commission. Code of Conduct. Retrieved on October 13, 2013 from

Free Regulatory Agency Paper Essay Sample


  • Subject:

  • University/College: University of Chicago

  • Type of paper: Thesis/Dissertation Chapter

  • Date: 18 May 2016

  • Words:

  • Pages:

Let us write you a custom essay sample on Regulatory Agency Paper

for only $16.38 $13.9/page

your testimonials