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Case study

Building a stronger patient safety and quality improvement system

Ana Pujols-Mckee and Mark G. Pelletier
Management in Healthcare: A Peer-Reviewed Journal, 6 (3), 262-270 (2022)
https://doi.org/10.69554/FZPC7445

Abstract

All people should always experience the safest, highest-quality, best-value healthcare across all settings. This paper analyses how, in keeping with its vision, The Joint Commission works with healthcare organisations to continuously improve healthcare quality and patient safety. It holds its accredited organisations to the highest standards by inspiring them to excel and achieve zero harm. To effectively help healthcare organisations positively transform, The Joint Commission shares with them its high-reliability framework for achieving zero harm. In addition, it provides strategies on how to reorganise healthcare organisations’ structures to integrate all improvement efforts, including performance improvement, infection control, regulatory, accreditation, patient safety and environmental services. The Joint Commission survey is designed to assess risk and identify potential harm that an identified risk poses to a healthcare organisation’s patients, staff and visitors. Healthcare leaders are provided with valuable tools and data analytics that prioritise risk and identify those areas that are most likely to lead to serious harm. Although all identified areas of risk must be addressed, these tools and analytics allow leaders to prioritise their resources and focus their initial efforts on areas that matter most. These electronic tools are available to healthcare systems regardless of size, and are of benefit to leaders in assessing those organisations that may need greater support and/or more resources to perform better. The Joint Commission has positioned itself as a leader in quality improvement and patient safety solely in order to partner with healthcare organisations to help them advance their improvement efforts while at the same time inspiring organisations to aim to eliminate all forms of harm.

Keywords: patient safety; accreditation; quality improvement; survey readiness; data driven

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Author's Biography

Ana Pujols-Mckee , MD, is the executive vice president and chief medical officer, chief diversity, equity and inclusion officer of The Joint Commission. In this role, she represents The Joint Commission enterprise as she focuses on and develops policies and strategies for promoting patient safety and quality improvement in healthcare and leads The Joint Commission enterprise in meeting its goals of increasing diversity and inclusivity. Her responsibilities include providing support to The Joint Commission’s Patient Safety Advisory Group; overseeing work related to the development of the sentinel event policy and sentinel event alerts; supervising the sentinel event database; and overseeing the functions of the standards interpretation group and the office of quality and patient safety. Dr McKee also provides clinical guidance and support to The Joint Commission Center for Transforming Healthcare, Joint Commission Resources and Joint Commission International. In addition, she leads The Joint Commission’s efforts in supporting physician leaders through the annual physician leader forums, corporate CMO Council, and serves as founding leader of the National Patient Safety Collaborative. Dr McKee earlier served as chief medical officer and associate executive director at Penn Presbyterian Medical Center, University of Pennsylvania Health System, and Associate Professor of Medicine at the University of Pennsylvania School of Medicine. She also served as medical director of the Philadelphia Health Department’s ambulatory network. She is a former board member of the American Cancer Society, the Pennsylvania Health Care Cost Containment Council, Philadelphia AIDS Consortium and former board chair for the Pennsylvania Safety Authority. She has also served on the Food and Drug Administration’s Advisory Committee and several committees of the National Institutes of Health. Dr McKee holds a bachelor’s degree in psychology from the State University of New York at Binghamton and a medical degree from Hahnemann Medical College and Hospital in Philadelphia.

Mark G. Pelletier , RN, MS, is the Chief Operating Officer, Accreditation and Certification Operations, and Chief Nursing Executive for The Joint Commission. His responsibilities include executive leadership for the accreditation and certification of more than 21,000 healthcare organisations and programmes and all activities related to surveys, eligibility and application processes, customer account management and federal deeming compliance requirements. Mr Pelletier also administers accreditation and certification policy development, surveyor education and development, survey technology and the ongoing development and refinement of the accreditation process. He earlier served as the Executive Director for the Hospital Accreditation Program and was also responsible for business development in the Hospital, Critical Access Hospital and Laboratory accreditation programmes. Mr Pelletier has more than 30 years of experience in hospital operations, performance and quality improvement, process redesign and programme development. Previously, he was the Senior Vice President and Chief Operating Officer of Condell Medical Center, Libertyville, Illinois. He has also served in executive positions for several hospitals in the Chicago area, including Resurrection Health Care, Northwestern Memorial Hospital, Children’s Memorial Medical Center and Mercy Hospital Medical Center. Mr Pelletier earned a bachelor of science in nursing and a master of science in administration from DePaul University, Chicago, Illinois. He received his diploma in nursing from Mennonite College of Nursing at Illinois State University.

Citation

Pujols-Mckee, Ana and Pelletier, Mark G. (2022, March 1). Building a stronger patient safety and quality improvement system. In the Management in Healthcare: A Peer-Reviewed Journal, Volume 6, Issue 3. https://doi.org/10.69554/FZPC7445.

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cover image, Management in Healthcare: A Peer-Reviewed Journal
Management in Healthcare: A Peer-Reviewed Journal
Volume 6 / Issue 3
© Henry Stewart
Publications LLP

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