This Week You Will Scrutinize Your Reading Assignment And Cr

This Week You Will Scrutinize Your Reading Assignment And Create A 1 P

This week you will scrutinize your reading assignment and create a 1 page memo to answer the following question(s): Your department will be audited by the Joint Commission and the Center for Medicare and Medicaid (CMS). You must inform your staff of the audit and what steps they need to take in order to prepare for the audit. To complete this assignment you will go to site and research what these organizations look for in order to complete a quality audit. Your memo, at a minimum, should name at least 3 measures that CMS and the Joint Commission will be reviewing. Explain why the measures being reviewed are important How can your staff help to ensure this information is available and the measures are current?

Paper For Above instruction

The upcoming audit by the Joint Commission and the Center for Medicare and Medicaid Services (CMS) necessitates thorough preparation from our department. These organizations focus on specific quality measures to ensure healthcare facilities meet established standards of care. To assist our staff in understanding and preparing for this evaluation, it is essential to highlight key measures that will be reviewed, their significance, and how staff can contribute to a successful audit process.

Firstly, one critical measure is the Hospital readmission rates, particularly within 30 days of discharge. CMS emphasizes this metric because high readmission rates can indicate issues with discharge planning, continuity of care, or quality of in-hospital treatment. Monitoring and reducing readmissions not only improve patient outcomes but also demonstrate efficiency and quality in the care provided. To ensure this measure is current and available, staff should meticulously document discharge instructions, coordinate follow-up care, and accurately record patient statuses at discharge.

Secondly, the accuracy and timeliness of vaccination records, especially for influenza and pneumococcal vaccines, are scrutinized. These immunizations are vital in preventing infections and reducing hospital-acquired complications. The Joint Commission assesses compliance with immunization protocols to ensure patient safety. Staff can assist by verifying patient vaccination statuses, updating records promptly, and educating patients about the importance of vaccinations.

Thirdly, medication reconciliation accuracy is a key focus. CMS and the Joint Commission review this measure to prevent medication errors, which are a significant cause of adverse events in healthcare settings. Proper reconciliation on admission, transfer, and discharge minimizes discrepancies between what medications patients are supposed to be on and what they are actually taking. Staff should double-check medication lists, update records meticulously, and communicate changes clearly across care teams.

The importance of these measures lies in their direct impact on patient safety, care quality, and operational efficiency. Accurate documentation and ongoing staff education are crucial in ensuring these measures are current and reflective of actual practice. Regular audits, staff training, and adherence to protocols will help maintain compliance and readiness for the survey. Encouraging a culture of continuous improvement and accountability will also enhance the accuracy and completeness of our documentation.

In conclusion, preparing for the Joint Commission and CMS audits involves understanding the key measures they prioritize. By focusing on reducing readmissions, maintaining vaccination records, and ensuring medication reconciliation accuracy, our staff can significantly influence the outcome of the audit. Proactive engagement, attention to detail, and ongoing education are essential to demonstrate our commitment to high-quality, patient-centered care.

References

• Centers for Medicare & Medicaid Services. (2022). Hospital Quality Accountability Measures. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Hospital-Quality-Reporting-Data
• The Joint Commission. (2023). Standards for Hospital Accreditation. https://www.jointcommission.org/standards/
• Levinson, W., & Roter, D. (2017). The role of communication in medication errors. Journal of Patient Safety, 13(3), 154-160.
• O’Connor, P. (2020). Reducing hospital readmissions through effective discharge planning. American Journal of Managed Care, 26(5), 209–212.
• CDC. (2021). Immunization Schedules. https://www.cdc.gov/vaccines/schedules/index.html
• Bond, C. M., et al. (2016). The essential role of medication reconciliation in reducing adverse drug events. BMJ Quality & Safety, 25(5), 369-377.
• Jencks, S. F., et al. (2009). Rehospitalizations among patients in Medicare fee-for-service. New England Journal of Medicine, 360(14), 1418-1428.
• National Institute of Standards and Technology. (2019). Improving healthcare quality through data standards. NIST Interagency/Internal Report (NISTIR) 8152.
• Weingarten, S. R., et al. (2017). New approaches to patient engagement in care: implications for quality measures. Journal of Diabetes Science and Technology, 11(4), 819–823.
• Medical Design & Outsourcing. (2018). Ensuring compliance with healthcare regulations: A guide. https://www.medicaldesignandoutsourcing.com/healthcare-compliance-guide/