HIMS 655 UMDC The Gold Seal of Approval Discussion

Hi, Please read and contribute to peer discussion posts for peers 1 & 2 in 100 words minimum with at least 2-3 credible references.

Peer 1:

When it comes to state and federal regulations accreditation is important since all organizations must show they are ok with accrediting voluntarily. This is important is because its needed for all organizations to gain Medicaid and Medicare participation within the government programs. The CMS joint commission has the intention to have the best quality of care possible for all patients. The safety is also a concern, which is done by third party companies showing the quality of care is consistent and keeping the staff safe too. The Joint Commission has specifications that need to be established with the efficiency in terms of the CMS. The joint commission is accredited from the CMS when they exceed on survey method standard. There is also a joint fee in the organizations that need permission from CMS to help with hospital certifications. Hospitals that are licensed through the joint commission there is a fee and they can gain reimbursments from Medicaid and Medicare. Hospitals and all medical institutions part of this must pay their rates for the survey process.

CMS is known for conducting surveys for validation to view all hospitals to be licensed through the joint commission fee. They run investigations that are centered around surveys and the complaints on them. Something to keep in mind would be that to improve the quality of care CMS and the joint commission there are necessities needed by all companies to ensure they are giving the best care.

Facts about Joint Commission Accreditation and Certification. (n.d.). https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/topics-library/accreditation_and_certification_10_09pdf.pdf?db=web&hash=D69C362F1F50C042F4C77C9F129322D6

The Gold Seal of Approval and Guidelines for Use. (n.d.). Www.jointcommission.org. Retrieved June 6, 2021, from https://www.jointcommission.org/accreditation-and-certification/accredited/publicity-kit/the-gold-seal-of-approval-and-guidelines-for-use/

The Joint Commission. (2020). About Our Standards. Jointcommission.org. https://www.jointcommission.org/standards/about-our-standards/

Peer 2:

Healthcare facilities need accreditation to ensure at the very least a basic level of quality. One major agency that accomplishes this accreditation, as well as continuous monitoring of healthcare quality is the Joint Commission (TJC). The TJC assesses specific aspects of hospitals and other healthcare facilities to ensure patients receive the best care possible. Some areas that are assessed are use of EHR and patient communication. The TJC has several requirements when it comes to these two areas. In respect to EHR, the TJC doesn’t have any required format, it simply evaluates EHR for content. Required content consists of information that reflects the patients care, services, and treatments, as well as race, ethnicity, and preferred language (The Joint Commission, 2016). In the event that a facility lacks the documentation required by the TJC, it will be granted some extra time to produce the lacking information in order to comply with TJC standards. One requirement they do set is for a super-user to be present during surveying. For patient communication, TJC Standard PC.02.01.21 states that hospitals must identify and address oral and written communication needs that take into account speech, hearing, visual and cognitive difficulties as well as language and health literacy barriers (Blackstone et al., 2011). The TJC has some new guidelines to help combat poor health literacy, which directly affects communication of health information to patients. The TJC states that patients exhibiting signs of low health literacy may be tested using the Newest Vital Sign (NVS), which involves reading a food label and lets healthcare providers understand the level of understanding the patient gains from it. Additionally, patients exhibiting low health literacy may be shown Photonovelas, which are visual health education items (Cornett, 2009).

The National Committee for Quality Assurance (NCQA) is another accreditation body currently in operation. The NCQA has similar standards for the content of EHR records, but as for certification the NCQA has some more robust requirements. The NCQA has specific requirements for the interoperability of EHR to ensure reliability and share-ability, as well as vendor system validation requirements that typically use over 900 more test cases than other agencies like the TJC (O’Kane, 2019). In respect to patient communication, the NCQA also aims to respect any communication difficulties patients have whether they be oral, visual, or cognitive. They have put forth a specific program aimed at evaluating health literacy and relationships between doctors and patients, the Patient-centered Medical Home (PCMH) Recognition Program (NCQA, 2011). The PCMH is a model designed to improve patient quality of care, improve doctor-patient relationships, and address health literacy by mitigating health information navigation and understandability for each patient (Using Health Literacy Tools to Meet PCMH Standards, n.d.). In my opinion, the NCQA appears to have slightly more in-depth evaluation methods, and more specified programs put in place to address patient communications as compared to the TJC, which has more broad guidelines.


Blackstone, S., Garrett, K., & Hasselkus, A. (2011). New Hospital Standards Will Improve Communication. The ASHA Leader, 16(1), 24–25. https://doi.org/10.1044/leader.otp.16012011.24

Cornett, S. (2009). Assessing and addressing health literacy. Online Journal of Issues in Nursing, 14(3). DOI: 10.3912/OJIN.Vol14No03Man02

NCQA. (2011). Patient-Centered Medical Home (PCMH) – NCQA. NCQA. https://www.ncqa.org/programs/health-care-provider…

O’Kane, M. E. (2019). NCQA Strategy to Reduce EHR Burden Comments. NCQA. https://www.ncqa.org/comment-letter/ncqa-strategy-…

Please respond to Peer 3 & 4 below in 75 words or more.

Peer 3:

Thank you for your very informative post. I decided to look further to additional accreditation agencies and read about the Council on Accreditation (COA). COA certifies a variety of social and human services, including residential and behavioral health care. Any reputable drug and alcohol treatment center will have accreditation from an accreditor like COA.

“The Council on Accreditation (COA), founded in 1977, is an international accreditor that works with social and human service organizations to develop quality standards for care” (Addiction Resource, 2022, p. 1, para 1).

Client exploitation, deceptive advertising, and poor quality of care provided to customers by non-accredited providers puts families and individuals at risk. Accreditation demonstrates that a rehab center has gone above and above to demonstrate that they provide quality care and a safe treatment environment that adheres to basic care standards.


Addiction Resource. (2022, January 5). Addiction Resource. Retrieved from Council On Accreditation (COA) accredited drug and alcohol rehab centers: https://www.addictionresource.net/accreditation/co…

Peer 4:

  • Very interesting post. I also noted with comparison of TJC with NCQA. NCQA has guidelines for medical record documentation. The NCQA considers the core elements significant illnesses and medical conditions listed, allergies and adverse reactions noted, past medical history identified, diagnoses consistent with findings, treatment plans consistent with diagnoses, and no inappropriate risk by diagnostic or therapeutic procedure (NCQA, 2018).TJC and NCQA have similar guidelines on making sure EHR includes the patient’s background and the medical history. The similarities are very sensible as the medical record should include as much information about the patient as possible.National Committee for Quality Assurance. (2018). Guidelines for medical record documentation. Retrieved from https://www.ncqa.org/wp- content/uploads/2018/07/20180110_Guidelines_Medical_Record_Documentation.pdf