Name
Chamberlain University
NR-544: Quality & Safety in Healthcare
Prof. Name
Date
Hello Dr. White and Class,
This week’s discussion focuses on the roles and differences between The Joint Commission (TJC) and The Centers for Medicare and Medicaid Services (CMS) in regulating healthcare facilities. Both agencies serve as critical overseers of healthcare quality, but they differ in their approaches, methods, and areas of emphasis.
The Joint Commission conducts surveys with a strong focus on collaboration and engagement with hospital staff. According to The Joint Commission (2021), surveyors utilize the tracer methodology, which follows a patient’s care journey to identify possible noncompliance with standards. This approach allows them to directly compare written policies with actual clinical practices.
Healthcare facilities often prepare for TJC visits through ongoing staff education. For instance, My Children’s Colorado (2021) recommends training staff to recognize areas of partial or full noncompliance and developing action plans to address these gaps. Implementation involves executing the plan, evaluating results, and embedding changes into daily operations. To remain compliant, facilities must also maintain at least one year’s worth of documented evidence of adherence to standards (My Children’s Colorado, 2021).
Unlike TJC, CMS surveys are usually conducted through state health departments. Their reviews emphasize medical records, policies, and documentation rather than direct patient care. CMS surveyors aim to detect deficiencies within medical records, and interviews with hospital staff are often used to validate findings (The Centers for Medicare and Medicaid Services [CMS], 2020).
To prepare for CMS inspections, hospitals rely on compliance data. My Children’s Colorado (2021) notes that incident reports, complaints, infection control data, performance measures, and mock surveys are systematically analyzed to detect trends. Leadership then creates targeted improvement strategies and provides education to staff, ensuring readiness for CMS evaluations.
Even though TJC and CMS operate independently, their requirements often overlap. Meeting TJC accreditation standards frequently ensures compliance with CMS regulations as well (TJC, 2021). However, their methods differ, as summarized in the table below:
Comparison Between TJC and CMS Survey Processes
| Aspect | The Joint Commission (TJC) | Centers for Medicare & Medicaid Services (CMS) |
|---|---|---|
| Survey Approach | Interactive and collaborative with staff; tracer methodology | Focuses primarily on medical records and documentation |
| Focus Area | Patient care processes, treatment, and service delivery | Policies, compliance documentation, and record accuracy |
| Preparation Required | Ongoing staff education, action plans, and maintaining at least one year of evidence | Data analysis (incidents, complaints, infection control), leadership-driven plans |
| Outcome | Accreditation demonstrates compliance with CMS standards | Regulatory approval for Medicare and Medicaid participation |
When reviewing hospital quality ratings, the Medicare.gov Care Compare tool provides a comprehensive evaluation across multiple domains. While data for Children’s Hospital Colorado (CHCO) was not available, Aurora South Hospital and Medical Center served as a point of comparison.
According to Medicare (2021), Aurora South Hospital received an overall 5 out of 5-star rating, excelling in areas such as safety, timeliness, and reduced readmissions. They scored at the national average in mortality, efficiency of care, and imaging use, but underperformed in patient experience, with a 3 out of 5-star rating.
Aurora South Hospital and Medical Center – Quality Ratings Compared to National Average
| Quality Measure | Rating Compared to National Average | Notes |
|---|---|---|
| Safety of Care | Above average | Strong adherence to safety protocols |
| Timeliness of Care | Above average | Faster service delivery than peers |
| Readmissions | Above average | Effective discharge planning and follow-up |
| Mortality | Same as average | Comparable patient outcomes |
| Effectiveness of Care | Same as average | Meets national care standards |
| Efficient Use of Medical Imaging | Same as average | Imaging use appropriate and within guidelines |
| Patient Experience | Below average | Issues in communication, medication education, discharge planning, and staff friendliness |
The lower patient experience rating was primarily due to communication gaps regarding medications, discharge instructions, and diagnosis explanations (Medicare, 2021). Patients also noted concerns with cleanliness, staff courtesy, and noise levels at night. Interestingly, nursing staff interactions received higher ratings, suggesting that the facility’s high patient volume may contribute to inconsistencies in non-nursing services (Medicare, 2021).
Question: What did you notice about the survey findings and hospital comparison?
Answer: I observed that despite high ratings in clinical quality and safety measures, patient experience remains a critical challenge. This indicates that while technical standards of care are being met, the human experience of care (communication, comfort, and education) is falling behind. Hospitals must balance regulatory compliance with patient-centered care to achieve excellence in all domains.
In summary, both TJC and CMS play vital roles in ensuring healthcare organizations meet quality and safety standards. TJC emphasizes patient care practices and staff engagement, while CMS prioritizes documentation and compliance with regulations. Facilities that align with TJC standards typically meet CMS requirements as well, underscoring the interconnection between the two.
Comparisons of hospital ratings, such as those for Aurora South Hospital, reveal that achieving top marks in safety and effectiveness does not guarantee positive patient experiences. Thus, healthcare organizations must adopt a dual focus: maintaining compliance with regulatory expectations while simultaneously enhancing the patient experience.
The Centers for Medicare and Medicaid Services. (2020). Quality standards, accreditation & licensing. https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/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/
Medicare. (2021). Aurora South Hospital and Medical Center. U.S. Centers for Medicare and Medicaid Services. https://www.medicare.gov/care-compare/details/hospital/060100?city=Aurora&state=CO&zipcode=80013
My Children’s Colorado. (2021). Accreditation and regulatory compliance. https://childrenscolorado.sharepoint.com/sites/dept/accrc/Pages/default.aspx
