1. Ridge, Richard A. RN, CNAA, PhD

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Healthcare's regulatory environment includes the following five major areas. Each category has its own focus, priorities, and different administrative implications.

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1. Accreditation: The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) focuses primarily on performance improvement and emphasizes evaluation rather than inspection. Accreditation targets what a health-care organization is doing right to achieve standards and what it can do to improve systems, processes, and outcomes. The primary intent of JCAHO's new accreditation process, Shared Visions-New Pathways, is to ensure that healthcare organizations provide a continuum of safe, high-quality care.


The increasingly prescriptive approach of JCAHO, best represented by the National Patient Safety Goals, provides many examples of standards that will only be met through extensive, comprehensive, and sometimes significant investment of time, personnel, and effort. Medication reconciliation, introduced in 2005, may be the most complex and challenging standard yet. Compliance will occur only when fundamental nursing, physician, and pharmacy work practices are redesigned.


JCAHO has also introduced disease-specific certification that's currently optional but certain to grow; some of these programs will significantly impact reimbursement if required for Medicare participation.


2. Licensure/certification: Unlike accreditation, state licensure and certification inspections focus on what an organization is doing wrong, and what it needs to do to meet minimal expectations, address deficiencies, and avoid sanctions and fines. Compliance with key standards must be built into regular routine work components. Observance of environmental standards, for example, is everyone's responsibility. If managers and staff members routinely ignore unlocked medication cabinets, stretchers in the hallway, and food at the nursing stations, then the culture is created for a reactive and ineffective stance when the inspections occur.


3. Awards/recognition: Although not strictly regulatory, awards and recognition have become more important due to competition. The American Nurses Credentialing Center's Magnet Recognition Program now has almost 200 health-care organizations recognized for meeting the quality indicators and standards of nursing practice. Strictly voluntary, but becoming increasingly crucial as a marketing tool within the nursing labor market, Magnet status serves to validate patient care and nursing excellence, and to elevate the overall reputation and standards of our profession.


The U.S. Commerce Department's Baldrige Award and JCAHO's Codman Award are two examples of programs that hospitals can use to achieve recognition for high levels of safety and quality performance. By pursuing these voluntary awards, organizations elevate their performance in the key areas, and external recognition is an added benefit and reward.


4. State labor and other laws: Safe staffing requirements, prohibition of mandatory overtime, and safe patient movement and handling laws are examples of state-level initiatives with potential regulatory and/or reporting impact on facilities. Mandatory staffing ratios have the highest visibility of the state-level measures and possibly make the greatest impact on nurse leader regulatory requirements, although the other labor-related laws could also impact administrative practice. A total of 10 states now have nurse staffing legislation passed into law and another 19 states have bills pending. Legislation may either mandate specific nurse-to-patient ratios or hold healthcare organizations accountable for developing and implementing nurse staffing plans.


5. Public report cards and pay for performance: These initiatives, relative newcomers to the regulatory scene, warrant some attention. JCAHO and a wide variety of other organizations, including The Leapfrog Group, have developed publicly accessible "report card" systems that collect, analyze, benchmark, and publish quality and outcome data. Financial and patient outcome data is used to influence hospital participation in health plans, patient and provider selection of facilities, and to improve the overall functioning of facilities.


Successful preparation for accreditation surveys, licensure inspections, award and recognition programs, compliance with labor statutes, and public reporting of outcomes requires a shift away from preparing for the event to a continuous and ongoing effort to ensure compliance with the vast and growing set of standards.