NUR 621 Quality Improvement Essay

NUR 621 Quality Improvement Essay

Quality Improvement

The priority of the health professional in any health care organization is the safety of the patients. However, patients are exposed to many risks, thus threatening their security. Among other problems in healthcare, medication errors form the most considerable concern (Inomata et al., 2018). Some of the causes of medication errors include distraction of health care professionals in the course of administering a drug, working environment, lack of proper knowledge about the drug being dispensed, wrong patient information, and systemic problems within a hospital setting (Nanji et al., 2017). However, the elimination of all measures that affect the quality of health care delivery increases the value of services offered within health care institutions. Accreditation or approvals from known institutions increases the quality and establish standards of health care delivery in a country. The purpose of this paper is to evaluate accrediting body appropriate for our health care organization, summarize its requirements, and evaluate quality metrics that would enable the organization to fit in the accreditation body. Again, the study would examine how quality performance affects the organization financially.

Accrediting Body

NUR 621 Quality Improvement Essay
NUR 621 Quality Improvement Essay

The most appropriate accreditation body for our organization is joint commission accreditation. Achieving the Joint Commission accreditation signifies that an organization is committed to continuous improvement of patient care (Inomata et al., 2018). The accreditation tells the patients that the organization is committed to offering safe and high-quality services at all times. The safety of the patient is a significant matter of concern in health care systems today. The aspect of accreditation within the care setting has drawn concern among researchers since it forms part of patient safety. The focus of research studies in this area is because it contributes to patient mortality either directly or indirectly (Johnson & Sollecito, 2018). Poor healthcare delivery has been linked to death, injury, and increased medical bills of the patients; hence proper medication process is essential to members of the medical fraternity, including doctors, administrators, nurses, pharmacists, and the patients. Besides, it poses a severe negative impact on health professionals in terms of personal status. These are among the major issues that resulted in the formation of accreditation bodies to ascertain the quality of healthcare delivery and prove the safety that each organization takes on patients.

Requirements to Obtain Joint Commission Accreditation

The accreditation is awarded to an organization upon completion of an on-site survey which is carried out by a skilled and specially

NUR 621 Quality Improvement Essay
NUR 621 Quality Improvement Essay

trained Joint Commission Surveyor. The professional assess how the organization has been complying with health standards over the past. During the survey, the surveyors randomly selected patients and used their medical records in evaluating the compliance standards (Despotou et al., 2020). Besides, the trace patients experience in health care organization by talking to the doctors, nurses, and other staff who are in close interaction with the patients. In essence, adherence to all health care delivery compliance standards would allow an organization to attain this accreditation which would affect its future operation in the health care industry.

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The Performance or Quality Metrics to Focus on for a Quality Improvement Project to Present to the Accrediting Body

Conducting quality measurement before the accreditation survey would allow our organization to understand some of the negative measures that would limit its ability to attain the accreditation process. Measurement is critical when undertaking a quality improvement project. It provides the baseline data on the quality issue to be addressed hence enabling the researchers to determine the current performance of a given healthcare facility on the quality issue. For instance, the measurement tool employed by the committee to collect data on the occurrence of medication errors in our healthcare facility was the use of medication tracking forms (Despotou et al., 2020). The form allows the tracing, assemblage, and systematic arrangement of data on medication errors, thus enabling problem quantification, selection of potential appropriate solutions, and setting preference. This form is usually reviewed by one or two personnel with a good understanding of the medication use process. The individuals could be from relevant departments within the hospital setting, for instance, the pharmacy and therapeutics committee, quality assurance department, or delegation to the department of pharmacy.

After initiating an appropriate quality improvement plan to prevent incidences of medication errors, data collected through medication care tracking forms can be used to measure the impacts of these interventions. Tracking medication errors while a continuous quality improvement initiative is ongoing enables the healthcare organization to monitor the whole process and identify new opportunities where improvements need to be carried out (Inomata et al., 2018). The medication error tracking form may look simple, but it has proved to be a powerful tool for accelerating growth by reducing the incidences of medication errors. Many healthcare organizations have employed its use to improve numerous processes in healthcare and outcomes.

The successful collection of data using the medication care tracking forms would prompt proper analysis that should be done using a suitable method to uncover actual root causes for the safety problem. With suitable design and structuring, the process can present steps in a quality improvement process very competently and efficiently. The initiatives would then be recommended by the committee on effective measures that would allow the organization to gain accreditation from the Joint Commission (Inomata et al., 2018). In preparing the organization for the accreditation process, the committee would need to approve the plan of the use of computerized physician order entry. This system eradicates handwritten orders and also helps to reduce errors of prescription. Besides, it ensures fullness and legibility of orders, thus helping to improve quality efficiency in the health system hence a vital tool in ensuring patient safety. Also, computerized physician order entry offers clinical decision support to the clinician; therefore, it is very helpful as far as patient safety is concerned.

Besides, the committee could as well approve increased patient monitoring by initiating electronic surveillance, reminders, and alerts in the wards to prevent likely causes of error as a result of poor patient monitoring. With electronic surveillance in place, patients at risk of adverse drug events can be identified and attended to appropriately, thus enhancing patient safety. Information technology with the primary objective of alerting caregivers on changes in the patient is essential in improving the quality of care as it helps in ensuring patient safety and diminishes the expenditure on care services. One study conducted revealed that computer applications established patients at danger for venous thromboembolism and alarm the physicians, thus offering opportunities for prophylaxis prescription (Johnson, & Sollecito, 2018). It was found that patients who got prophylaxis prescriptions from physicians who were alerted attained reduction of venous thromboembolism by forty-one percent at ninety days. These are the effective measures that would prepare the organization for the attainments of accreditation from the Joint Commission.

Effect of the Quality Performance on the Organization Financially

The use of technology is significant in assessing the quality of an organization as it forms the basis of eliminating errors that affect the health care delivery quality. Easy communication among the health care professionals in an organization would be achieved through the use of modern technology, thus enhancing proper coordination and collaboration during the whole process. Technology allows the organization to use automation which provides a uniform way of reporting the information and makes sorting and analysis of data much easier (Jember et al., 2018). This also enhanced reduction in data entry errors by those sorting out the medication error tracking forms, thus ensuring the accuracy of data collected. Technology also allowed easy spot checking of random data collected to determine discrepancies associated with the data to enable early detection.

Improved quality would have a financial effect on the organization. The increased quality of services would increase the number of patients visiting the organization that would as well translate to increased income within the organization. Besides, additional accreditation from Joint Commission would increase the value and appearance of the organization. The increased value would imply that the hospital will be receiving many patients that would pay for the services at the organization (Despotou et al., 2020). The needed power to advance the organization financially would imply that there would be added value on the general services at the company. The success of the use of the modern practice in care provision will be determined by comparing the number of errors before and after the implementation of the initiative. Success is marked by fewer error incidences compared to before execution.


Our organization needs Joint Commission accreditation to advance its level of operation and ensure that the company depicts an inclining trajectory in terms of finances. Preparation for the attainment of the accreditation would require our health organization to install various measures that would be effective in eliminating the errors and increasing the service delivery at the company.


Despotou, G., Her, J., & Arvanitis, T. N. (2020). Nurses’ perceptions of joint commission international accreditation on patient safety in tertiary care in South Korea: a Pilot Study. Journal of Nursing Regulation10(4), 30-36.

Inomata, T., Mizuno, J., Iwagami, M., Kawasaki, S., Shimada, A., Inada, E., … & Amano, A. (2018). The impact of Joint Commission International accreditation on time periods in the operating room: A retrospective observational study. PloS one13(9), e0204301.

Jember, A., Hailu, M., Messele, A., Demeke, T., & Hassen, M. (2018). Proportion of medication error reporting and associated factors among nurses: a cross sectional study. BMC nursing, 17(1), 9.

Johnson, J. K., & Sollecito, W. A. (2018). McLaughlin & Kaluzny’s Continuous Quality Improvement in Health Care. Jones & Bartlett Learning.,exact,101556953

Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2017). Evaluation of perioperative medication errors and adverse drug events. Anesthesiology: The Journal of the American Society of Anesthesiologists, 124(1), 25-34. DOI: 10.1055/s-0041-1736339