Quality Improvement Essay

Quality Improvement Essay

Quality Improvement Essay

Health care organizations should be dedicated to providing care that addresses patient needs comprehensively. As they do so, they must have a limitless desire to provide quality, safe, and efficient care in the most cost-effective way possible. Through their mission, vision, and core values, health care organizations show commitment to providing the best care that patients deserve. However, such statements are mainly theoretical and only practical work can ascertain that they address patient care according to patient needs. As a result, accreditation is crucial. The purpose of this paper is to describe the most appropriate accrediting body for my organization. The requirements for accreditation will also be summarized besides quality metrics of focus and the financial impact of quality performance on the organization.

Most Appropriate Accrediting Body

Different health care organizations seek accreditation from different accrediting bodies depending on their scope of practice and specialization. The most appropriate body for my health care organization is The Joint Commission (TJC/JC). Founded in 1951, TJC serves as the nation’s largest accrediting body in health practice (TJC, 2022). Its mission is to continuously improve health care for the public by ensuring that health care organizations’ performance adheres to the commission’s standards. It is also the oldest accrediting body specializing in performance evaluation and inspiring health care organizations to excel in safe and effective health care delivery (TJC, 2022). TJC’s standards are centered on achieving the highest quality and value.

TJC uses standards to accredit an organization, developed through a rigorous process to ensure that health care quality remains at the highest optimal level possible. To develop these standards, TJC combines input from health care professionals, experts in the health sector, and government agencies (TJC, 2022). As needs arise, TJC also adds new standards provided that they relate to patient safety and care quality. As Jha (2018) posited, the guiding principle is to impact health care outcomes positively. This ensures that patients are adequately and professionally served and public health stays at the best level possible.


Requirements to Obtain Accreditation

Struggling to meet your deadline ?

Get assistance on

Quality Improvement Essay

done on time by medical experts. Don’t wait – ORDER NOW!

TJC must visit an organization to ascertain that it can provide safe and quality care. As a result, TJC only awards accreditation after successfully completing an on-site survey. The reference standards focus on crucial patient care and organizational functions for providing safe, high-quality care (Jha, 2018). A specially trained commission surveyor conducts the survey. If that is not the case, a team of surveyors conducts the on-site survey to assess the level of compliance with the commission’s standards.

To obtain the required information regarding an organization’s capacity to provide care that meets TJC’s standards, the on-site surveyors assess patients, medical records, and health care staff. They usually select patients randomly and evaluate the organization’s compliance with standards using patients’ medical records (TJC, 2022). Surveyors also focus on patient experience with the health care process. To assess this area, the commission’s surveyors talk to the health care staff interacting with patients in everyday practice. They further observe the health care staff providing care and talk to patients where necessary (TJC, 2022). Given that the survey is never announced, health care organizations must always provide safe, quality care.

Regardless of their size, the scope of practice, and specialization areas, health care organizations should seek accreditation. Achieving accreditation implies benefitting from its gains such as increased confidence in patient care, a high reputation, and a better chance of donor and government support. When an organization fails to attain accreditation, it gets guidance from the accrediting body on where to improve and the necessary interventions. In any case, it is a beneficial process as health care organizations intensify efforts to provide care that meets the present century’s needs.

Performance or Quality Metrics for a Quality Improvement Project

Quality improvement implies identifying a practice gap and suggesting measures to achieve better outcomes. It is a practice area that relies on clinical expertise and scientific evidence to ensure that patients are better served and health care professionals execute their mandate more professionally. According to Sherwood and Barnsteiner (2021), TJC mainly focuses on care quality and safety. Accordingly, quality improvement projects should be designed to achieve better care quality and ensure that health care processes are safer. The project leader should be explicit about how the proposed interventions will improve care quality or safety. Several proposals can exemplify performance metrics to focus on for a quality improvement project to present to TJC.

Regarding safety, a project to reduce medication errors is a suitable example of safety enhancement in health care delivery. Medication errors threaten patient safety since they lead to wrong medication, health complications, and extended hospital stays (Wondmieneh et al., 2020). A project to enhance safety, such as nurse education, the orientation of new graduate nurses, or using technology to verify medication before administration would be suitable for presentation to the commission. Its central premise is safety enhancement to ensure the health care environment is safe for health care delivery.

Health care quality can be improved by timely delivery of care, reducing patient delays, and improving interprofessional collaboration. As a result, timeliness of care would be a suitable performance metric for a project to present to TJC. An example of a project to improve timeliness is using patient portals to book appointments such that health care professionals prepare in advance depending on a patient’s condition. Booking appointments via patient portals also gives nurses and doctors ample time to go through the patient’s history and design measures for care coordination.

The other suitable performance metrics include care effectiveness and patient engagement in personal care management. They are key components of care quality, achieved by creating an informed patient population, creating communications for patient-provider communication, and promoting preventive health. Statistics show that more than 50% of Americans with hypertension are untreated (CMS.gov, 2021). A quality improvement project to avoid the consequences of this problem is to advocate for mandatory blood pressure measurement for all patients given that a third of Americans have hypertension (CMS.gov, 2021). Mandatory measuring would help patients and health care professionals to adopt proactive measures for disease management. This would further prevent health complications or the development of the disease to unmanageable levels.


Financial Implications of Quality Performance

Health care organizations should be highly innovative and apply strategies that prevent wastage and enable them to serve patients cost-effectively. According to Penner (2017), efficient systems are cost-effective and do not financially burden health care organizations. From an operation and management dimension, high-quality performance is highly beneficial, and low-quality performance is regrettable and affects the organization negatively. Financially, organizational performance is directly proportional to its performance.

When the organization excels in performance, it gains from a high reputation and increased trust in health care professionals. When this happens, patients are more comfortable seeking health care services from the organization, implying continuous revenue. Increased and reliable revenue enables the health care organization to invest in current technologies, research, and evidence-based projects to improve patient outcomes. The increased ability to serve patients better is critical to patient retention as the main customers. Patients also refer their friends and family members to the same facility to seek health care services.

The financial implications are far-reaching when the organization fails to achieve excellence in quality performance. Besides not gaining from patient visits and referrals, patient dissatisfaction is usually associated with a low reputation and legal and ethical issues. For instance, patients can sue the organization for issues, such as medication errors and damages within the premises. Legal accusations are costly to settle and consume finances that could have been used in quality improvement projects.


Health care organizations’ primary mandate is serving patients and addressing their needs comprehensively. Accreditation ascertains that a health care organization is capacitated to satisfy patients and provide safe and quality care. TJC is the oldest and largest accrediting body in the United States. As discussed in this paper, TJC primarily evaluates the organization’s ability to provide quality care in safe environments. Surveyors assess patient records and interact with patients and health care professionals during on-site surveys.


CMS.gov. (2021).What is a quality measure?https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/NTM-What-is-a-Quality-Measure-SubPage#:~:text=Quality%20measures%20are%20standards%20for,effectiveness%2C%20timeliness%2C%20and%20fairness.

Jha, A. K. (2018). Accreditation, quality, and making hospital care better. Jama320(23), 2410-2411. doi:10.1001/jama.2018.18810

Penner, S. J. (2017).Economics and financial management for nurses and nurse leaders (3rd ed.).Springer Publishing.

Sherwood, G., &Barnsteiner, J. (Eds.). (2021). Quality and safety in nursing: A competency approach to improving outcomes. John Wiley & Sons.

TJC. (2022). About our standards. https://www.jointcommission.org/standards/about-our-standards/

TJC. (2022). What is accreditation?https://www.jointcommission.org/accreditation-and-certification/become-accredited/what-is-accreditation/

Wondmieneh, A., Alemu, W., Tadele, N., &Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC Nursing19(1), 1-9. https://doi.org/10.1186/s12912-020-0397-0


Write a 1,250-1,500-word essay about quality improvement. Include the following points in your essay:

Evaluate which accrediting body would be most appropriate for your health care organization. (PLEASE USE “THE JOINT COMMISSION” AS THE ACCREDITING BODY!)
Summarize the requirements to obtain accreditation.
Based on your research and experience, what performance or quality metrics could you focus on for a quality improvement project to present to the accrediting body?
How does the quality performance financially impact the organization?
Include at least three references, including the textbook.

Textbook for reference: Penner, S. J. (2017). Economics and financial management for nurses and nurse leaders (3rd ed.). New York, NY: Springer Publishing. ISBN-13: 9780826160010


Open chat
WhatsApp chat +1 908-954-5454
We are online
Our papers are plagiarism-free, and our service is private and confidential. Do you need any writing help?