regulatory and accreditation influence on institutional priorities

Regulatory and Accreditation Influence on Institutional Priorities

When discussing the regulatory and accreditation influence on institutional priorities, it’s important to understand some background information. There are many different regulatory agencies that exist and include federal, state, and private regulators.  They oversee different aspects of the health care system, ranging from individual providers to entire hospitals. The overall goal of these agencies is to improve patient safety, and this is done in several ways including measuring events, assisting with the design of interventions, holding hospitals accountable for reporting measures and outcomes and establishing norms for metrics. As such, this leads to organizations focusing their efforts on these measures and thus improving outcomes. Examples of federal regulatory agencies include the Department of Health and Human Services, the Agency for Healthcare Research and Quality, the Centers for Medicare and Medicaid Services (CMS), and the Centers for Disease Control and Prevention.  Boards of Medicine and Nursing represent state agencies. Examples of private organizations include the Joint Commission on Accreditation of Healthcare Organizations (JC) and the National Board of Medical Examiners.

The JC is a private regulator and the oldest accrediting organization within the country.  It accredits hospitals and other types of health care facilities. JC accreditation is voluntary, however, in order to receive payment from federally funded Medicare and Medicaid programs it is required.  Accreditation involves the organization performing an on-site evaluation on a regular basis in which specific indicators are met in the areas of patient safety, treatment, and care quality.  Achievement of accreditation demonstrates an organization’s commitment to safety and quality and has other benefits including decreased insurance costs and access to best practice resources.

Hospitals must comply with regulatory and accreditation requirements.  In the perinatal world, the Joint Commission requires hospitals with a minimum of 300 births per year to publicly report the Perinatal Care Core measures, which encourages hospitals to focus quality work in these areas. See the table below for a list of current and retired Perinatal Care Core Measures:

Metric  Description
PC-01: Elective Delivery Rate of deliveries between 37w0d- 38w6d that are NOT medically indicated (excluded: patients in labor or with PROM)
PC-02: Cesarean Delivery Primary Cesarean Delivery Rate for Nulliparous, Term, Singleton patients with vertex presentation and no contraindication to vaginal delivery
PC-05: Exclusive breast milk feeding Rate of newborns fed only with breast milk since birth
PC-06 Unexpected Complications in Term Newborns Rate of term, normally grown newborns that experience complications
PC-03: Antenatal Steroids

(retired 1/1/20)

Rate of steroid administration in patients delivering between 24w0d-31w6d
PC-04 Healthcare-associated bloodstream infections in newborns (retired 1/1/20) Rate of septicemia or bacteremia in newborns

Certain metrics are publicly displayed on a government Care Compare website including PC-01, helping to educate consumers and enabling them to make better decisions about their care.  This also helps to drive improvement in these areas at both hospital and clinician levels.

In addition to public reporting, medicare reimbursement through CMS is impacted by hospitals reporting designated quality measures including PC-01 and PC-05 (required for the fiscal year 2021). Reduced reimbursement applies if hospitals don’t meet these reporting requirements; this is part of the Hospital Inpatient Quality Reporting Program.

Thus, both regulatory and accrediting agencies help to drive quality improvement and safety by providing organizations with areas of focus and for some, linking financial implications.

*If this article interests you, you may also enjoy my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide


Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of patient safety and quality improvement. Wolters Kluwer.

Hospital Inpatient Quality Reporting Program. (n.d.). Retrieved from

2 thoughts on “Regulatory and Accreditation Influence on Institutional Priorities”

  1. It might be helpful in this section to include other organizations that accredit hospitals. The hospital system I work for has not utilized JCAHO in many years and utilizes DNV for accreditation. Perinatal Quality Measures are also publicly reported through the LeapFrog Group.

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