The following assignment from NURS 308 provides an excellent example of how I have met VCU Nursing School’s Program Outcome 5 this semester. Program Outcome 5 indicates that the student shall have knowledge of health care, financial and regulatory policies that influence the nature and functioning of the health care system. This reflection essay discusses the nature and important role accrediting bodies in healthcare. Four important accrediting bodies are considering, including the Joint Commission and the Magnet program. Similarities and differences among these accrediting bodies are brought to light by evaluating them from different perspectives, such as the perspective of the patient versus the perspective of nursing staff.


Accreditation Reflection


Hospitals seeking high quality, safe care with excellent patient outcomes and a healthy work environment for their employees may seek to pursue accreditation. Accreditation allows hospitals to identify their strengths and weakness, improve their managerial process, catalyze quality improvement projects, promote transparency, and be competitive to obtain funding from the government or other opportunities (Centers for Disease Control and Prevention, 2018). There are many different types of accrediting organizations that have different focuses. A hospital may choose one accrediting organization over another, depending on its goals.

Perhaps the most well known is the Joint Commission, which is responsible for accrediting 78 percent of hospitals in the United States (R1, 2016). One reason the Joint Commission is so popular with hospitals is that if a hospital achieves accreditation with the Joint Commission, then they are considered compliant with federal requirements associated with Medicare and Medicaid (R1, 2016). Because the Joint Commission is heavily focused on safety and quality care, obtaining accreditation by this group indicates that a hospital is meeting national safety standards, and is known to provide quality care (R1, 2016). Beyond improve patient care and safety, this can also decrease costs by improving risk management strategies (R1, 2016).

Another well known accrediting organization is the Magnet Recognition Program, which focuses on nurse empowerment and quality nursing care (American Nurses Credentialing Center [ANCC], n.d.). This type of accreditation would be important for hospitals seeking to employ quality nurses, reduce nurse burnout and turnover (ANCC, n.d.). Magnet recognition also benefits the patient, because higher quality nursing care leads to better patient outcomes, such as lower infection rates, lower rates of hospital acquired pressure injuries, and higher patient experience ratings (ANCC, n.d.-a).

The Pathway to Excellence is another accreditation process associated with the ANCC (ANCC, n.d.-b). This accreditation process specifically focuses on healthy work environments, in several domains including professional development, safety, quality, shared decision making, and leadership (ANCC, n.d.-b). The benefits of the Pathway program are similar to the Magnet program, in that they strive to reduce burnout and turnover while improving nurse-driven quality indicators like decreasing infections and lowering hospital acquired pressure injuries (ANCC, n.d.-b).

A fourth accrediting organization a hospital might select is the Baldrige Performance Excellence Program, which focuses on a hospitals performance in the business realm (National Institute of Standards and Technology, 2021). Some of the core standards for the Baldrige Performance Excellent Program include financial results, product and process results, customer service, and business ethics (National Institute of Standards and Technology, 2021).

Each of these organizations has a unique perspective and offers hospitals a path to improve their organization on a number of fronts. For a hospital who lacks any type of accreditation such as the new 100-bed facility for High Tide Health System, seeking accreditation by the Joint Commission seems like an important first step, because this is necessary for compliance with federal regulations. Furthermore, the Joint Commission focus on quality and safety seem like a vital framework from which a hospital can grow and learn. It could also attract patients to that hospital. Other hospitals who already have Joint Commission accreditation might seek Magnet or Pathway accreditation if they are trying to recruit higher quality nursing staff and further their goals of patient safety and quality care. A hospital might aim for Baldrige accreditation if they are a for-profit hospital who is more focused on the business side of the health care industry.

From a patient’s perspective, all of these accrediting organizations offer something important. Accreditation by the Joint Commission tells patients that the hospital meets safety standards, delivers high quality patient care, and is continually improving itself to meet and exceed the Joint Commission standards. The Magnet and Pathway accreditations tell a patient that the nurses working with them are supported and have safe patient ratios. This benefits the patient, because when nurses are supported and have appropriate resources, they can provide the best possible care for their patients. The Baldrige accreditation might tell a patient that a particular hospital is a good value, because they have sound and ethical business practices.

From the perspective of the staff, the Magnet and Pathway accreditation pathways are mostly focused on the work environment. Magnet is specifically focused on nurses, so nurses are more likely to value the standards set forth by Magnet. Pathway seems more inclusive, but the benefits are similar—staff are more likely to want to work somewhere with a healthy working environment. Accreditation by the Joint Commission would be important to staff because health care workers want to provide safe and quality care for their patients, and want to work somewhere committed to those same values.





American Nurses Credentialing Center. (n.d.-a). Why become Magnet?

American Nurses Credentialing Center. (n.d.-b). About Pathway.

Centers for Disease Control and Prevention. (2018). Benefits and impacts of accreditation.

National Institute of Standards and Technology. (2021). Core values and concepts.

R1. (2016). Why do hospitals get accredited by the Joint Commission?