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Long-Term Care Facility Accreditation: Action Plan Essay

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Updated: Dec 2nd, 2020

Healthcare facilities in the United States are keen on getting Joint Commission accreditation because of various reasons. According to Bowie and Green (2016), and accreditation by this commission is considered the gold standard in the field of healthcare. The accreditation focuses on continuous quality improvement of services that a healthcare institution offers and the safety of patients and the medical staff (Lambert, 2016).

Getting accreditation is a sign of quality services that a healthcare facility offers. Most of the state governments in the country recognize the institution’s accreditation when defining conditions for receipt of Medicare and Medicaid reimbursements (Burns, Bradley, Weiner, Shortell, & Kaluzny, 2012). As the executive director of ABC Healthcare Center, the researcher has to find ways of pursuing the Joint Commission accreditation.

It will help this institution to convince its clients that its services meet the criteria set by the government and other relevant institutions. The achievement will also enable this institution to get financial benefits from the government in the form of Medicaid reimbursements. In this essay, the focus is to review what it takes for this institution to achieve the accreditation and challenges that the team should expect.

The Management of Challenges of Delivering Value in Healthcare

When striving to deliver value in the healthcare sector, especially when the focus is to get the Joint Commission accreditation, a firm should be ready to overcome various challenges. One of the biggest challenges, according to Bowie and Green (2016), is bureaucracy. Many institutions in the United States are keen on embracing the open-door policy where employees can easily engage their superiors when they feel such an action is necessary.

However, Goldsmith (2014) claims that most of the systems embraced in this country are bureaucratic, making it difficult for top managers to engage junior employees as frequently as would be desirable. As the director of this organization, one of the steps that will be taken would be to eliminate all bureaucratic systems and structures within ABC Healthcare Center as a way of improving communication.

Human relation is another major issue that affects the quality of service that a healthcare facility delivers. Nurses, doctors, and other medical staff should have a good working relationship where there is mutual respect. Such a kind of environment is often created by the management approaches that an institution embraces. The director and other senior managers should not be seen to favor a section of employees, such as doctors, at the expense of other staff members. Such preferences often create a rift among workers. The process of making critical decisions that affect the workforce should be as inclusive as possible. The management should avoid making arbitrary decisions that may be rejected by the medical staff because such actions may affect the quality of services that the facility offers.

The institution should not ignore socio-economic disadvantages in its quest to achieve the accreditation. It is common to have cases where some of the patients who come to the facility lack healthcare insurance cover and the financial ability to pay for services they need. Burns et al. (2012) argue that an institution that constantly rejects patients on the basis that they cannot pay for the services may receive criticism in society, limiting its ability to get Joint Commission accreditation. As such, it would be prudent to have a contingency plan that can enable the hospital to fund services offered to patients who cannot pay.

Leadership and Management: A Framework for Action

ABC Healthcare Center can only get the Joint Commission accreditation if it embraces specific leadership and management principles. According to Bowie and Green (2016), management entails defining responsibilities, assigning roles, and supervising how workers undertake their duties while leadership entails guiding and motivating employees towards a given vision. Administrative leadership brings together the principles of leadership and management.

Goldsmith (2014) defines administrative leadership as orchestrating tasks, which involves hiring, assigning responsibilities, and managing output, and motivating the workforce to develop and sustain development. This approach of leadership will be critical in ensuring that various medical staff understand their responsibilities and remain committed to the delivery of quality services.

Transformational leadership is another concept that the director will embrace in this institution as a way of improving the quality of service delivery. This theory of leadership emphasizes the need for the manager to encourage, motivate, and inspire workers to be creative and innovative as ways of creating change and enhancing organizational success (Burns et al., 2012). It also encourages the management to embrace the concept of followership. One can only be a good leader if they understand the concept of leadership. It means that a manager should be willing to cooperate with junior employees, understand their needs, and design ways of meeting them. Developing SMART (specific, measurable, attainable, relevant, and timely) objectives when undertaking every project would also help this facility to get the accreditation. The team will know what needs to be achieved within a specific period using specific resources.

Organizational Design and Coordination

In an organizational setting, one of the most important factors that define the ability to realize the set goals is the management design and coordination strategies embraced. Every stakeholder should understand their role within the system and how they need to coordinate with others. The chain of command should be defined to avoid cases of insubordination and overlapping of tasks. Figure 1 below shows the proposed organizational structure that should be embraced at ABC Healthcare Center.

At the helm is the executive director who will be responsible for managing daily operations at the firm. The director will work closely with the chief fiscal officer who will offer advice on the financial capacity of the institutions and areas that should be given priority based on the financial position of the firm. The facility will have four vice presidents who are reporting directly to the chief executive officer. They include the human resource director, patient care services director, support services director, and medical affairs director.

Leadership design at ABC Healthcare Center
Figure 1. Leadership design at ABC Healthcare Center (Burns et al., 2012, p. 78).

These directors must ensure that their activities are closely coordinated to enhance the ability of the institution to achieve its vision.

Motivating People

Hiring and retaining a group of talented employees is just one of the steps needed to ensure that a firm achieves its vision. Motivation is another important aspect that encourages employees to deliver the best output in the workplace environment. Bowie and Green (2016) explain that many institutions often use monetary strategies to ensure that workers are motivated. However, Burns et al. (2012) believe that motivating employees goes beyond giving them financial benefits.

Employees get inspired when they work in an environment where they feel respected, cherished, and allowed to participate in decision-making processes within the firm. The human resource director and supervisors within the department have the responsibility of understanding personal and work-related issues that affect employees. When such issues are identified, the department should device proper ways of addressing them to improve the output of workers. The framework shown in figure 2 below can help in diagnosing issues within a firm and finding ways of addressing them.

Framework for managing employees’ needs
Figure 2: Framework for managing employees’ needs (Burns et al., 2012, p. 95)

As shown above, the first step is to identify need deficiency. The management should understand fears, concerns, and issues that may trouble the medical and non-medical staff within the institution. The next step is to search for ways of meeting the identified needs. The team can develop alternative ways of addressing each issue and then evaluate each of them to select the most appropriate alternative.

When the need has been addressed, a plan should be developed to address a similar need should it arise in the future. Goldsmith (2014) argues that Maslow’s hierarchy of needs may also help in motivating employees in the workplace. When using this model, one needs to define the position of the employee within the hierarchy of needs. The classification helps the management to determine the most appropriate way of meeting these needs.

Figure 3 below shows the model. Most of the medical staff have psychological needs, which include esteem needs and a sense of belongingness and love. When defining ways of motivating these employees, their position in the pyramid below should define the path that needs to be taken. The assumption made is that their current jobs make it easy for them to achieve basic needs.

Maslow’s hierarchy of needs
Figure 3. Maslow’s hierarchy of needs (Bowie & Green, 2016).

Teams and Team Effectiveness in Healthcare Services Organization

The management of ABC Healthcare Center should define teams responsible for undertaking various tasks that would help the institution to get the Joint Commission accreditation. In this strategy, the director will go beyond a given department to the unit level where different teams of medical staff work closely to offer services to customers. Given that service delivery in a healthcare setting involves close coordination of different experts, the management must remind doctors, nurses, and clinical officers that they form a team and that their success depends on their ability to coordinate their activities.

Types of Teams in a Healthcare Setting

One such team is the intensive care unit. The unit is crucial as it handles patients in critical condition. When defining SMART goals for this unit, the focus should be on the number of patients who come out of the ICU alive despite their delicate condition. The surgical unit team is responsible for operating on patients with varying conditions. Burns et al. (2012) state that this unit is also very sensitive and its success is often determined by the number of successful operations per given number.

Surgeons, anesthesiologists, nurses, and medical specialists such as cardiologists often form a team in the surgical unit. Within this team, the responsibility of every expert remains clear to avoid any confusion. Some surgical processes are so sensitive and demanding that team members must work in a coordinated manner. Any mistake or unnecessary delay may cost the life of a patient. Other important teams include emergency response unit, medical wards units, delivery units, primary care units, and multidisciplinary teams,

Appropriate Model of Improving Teams’ Effectiveness

The appropriateness of each of the teams identified is based on their size, diversity, and composition. For instance, an ICU unit should have the right number of nurses, medical doctors, and other experts needed to make the process a success. The size of the team may vary depending on the complexity of the assignment and the type of medical experts needed. The composition of the team should be right.

In an ICU, the surgeon, the anesthesiologist, nurses, and cardiologists have very specific responsibilities. It is not possible to complete the process when one of the needed experts is not available. The team cannot replace the cardiologist with a general physician because the skill and experience needed are specific. Diversity may sometimes help the team. A woman would feel comfortable when nurses handling her are female officers. A diversified team makes it easy for the patient to feel comfortable and protected if he or she can identify with some of the medical staff.


Communication is one of the most important factors that define the ability of an institution to achieve its vision. ABC Healthcare Center is not only focused on improving its service delivery but also getting the Joint Commission accreditation. It means that its services must meet certain standards set by the commission. When the commission sends its experts for a site review, they should not only find an environment where set specifications are met but also a team of employees who can communicate effectively when asked specific questions. As shown in figure 4 below, the entire process of communication starts with the sender who encodes a message through a given channel.

The recipient then decodes the message to get the intended meaning before giving feedback (Burns et al., 2012). Communication can break down because of wrong encoding, barriers associated with the channel used, or mistakes during the decoding stage. Such challenges should be addressed to ensure that different teams could coordinate their activities and communicate with the top management unit to address concerns that may exist.

Communication process
Figure 4. Communication process (Perley, 2016, P. 68).

Doctors, nurses, and clinical officers should have effective ways of communication within this institution. When a doctor evaluates a patient and believes a nurse should administer a given medicine, the information should be communicated in simple and clear terms. When the condition of the patient is not yet clear and further laboratory tests are needed, the message should be sent to the relevant clinical officers.

Using an integrated internal digital communication platform may help in posting the progress made on a patient and stages that remain in administering the right medication. The digital platform is effective when handing over a patient at the end of a doctor or a nurse’s shift. The new team will understand what has been done and what should be done on the patient. During the site visit, officers from the Joint Commission should find an effective digital communication platform that makes it easy for the staff to pass and receive relevant information about their patients.

Power, Politics, and Conflict Management

Power and politics within ABC Healthcare Center may have a significant impact on its ability to get accreditation from the Joint Commission. Unions of employees such as The Union of American Physicians and Dentists (UAPD) or National Nurses United have the power to define activities of their members in various healthcare institutions in the country (Sui & Rui, 2016). They can call for a strike among their members or go-slows when they feel their needs are not met.

This healthcare facility may not restrict its members from joining the unions. However, the management can create a conducive work environment that makes nurses, doctors, and clinical officers that they do not need to join these institutions to fight for their rights. Their salaries should be within or above the market average and occupational health and safety rules observed in the best way possible. Goldsmith (2014) advises that it is important for management to avoid power politics in the workplace.

Conflicts would arise frequently among different stakeholders in the workplace. Finding effective ways of resolving conflicts would improve the quality of services delivered to patients. Burns et al. (2012) believe that dialogue is one of the best ways of managing conflicts. Whenever there is an issue affecting a team of employees or an individual staff member against the other, the management should encourage the affected parties to embrace dialogue. It may also be necessary to have mediation teams within the firm to address concerns that cannot be managed through dialogue.


ABC Healthcare Center needs Joint Commission Accreditation to ensure that it can get various financial benefits from the government. The accreditation is also an assurance to clients that this institution offers high-quality services. In this plan, the researcher has identified various steps that the management must take to achieve the intended goals. The plan has also identified challenges that the team should expect as they strive to achieve the intended goal. If the management implements this plan, the institution would be able to get the accreditation.


Bowie, M. J., & Green, M. A. (2016). Essentials of health information management: Principles and practices. Clinton Park, NY: Delmar Cengage Learning.

Burns, L. R., Bradley, E. H., Weiner, B. J., Shortell, S. M., & Kaluzny, A. D. (2012). Shortell and Kaluzny’s healthcare management (6th ed.). Clifton Park, N.Y: Delmar.

Goldsmith, S. B. (2014). Understanding health care management: A case study approach. Burlington, MA: Jones & Bartlett Learning.

Lambert, P. D. (Ed.). (2016). Managing arts programs in healthcare. New York, NY: Routledge.

Perley, R. (Ed.). (2016). Managing the long-term care facility: Practical approaches to providing quality care. San Francisco, CA: Jossey-Bass.

Sui, P. L., & Rui, Z. (2016). Service quality for facilities management in hospitals. Singapore, Singapore: Springer Singapore.

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