Week 4: Licensure and Accreditation

The number of malpractice claims at your facility has doubled in the last quarter. Discuss a strategic plan to reduce the number of claims. Be specific with your example and explanation.

Question 2

Identify a patient-safety issue at your current or previous organization. Share your plan to prevent or eliminate the issue.

Scholarly references to support your response are required.

Week 4: Introduction

Table of Contents

Welcome to Week 4!

The focus for this week will be on aspects of licensure and accreditation; specifically, risk management and patient safety as they relate to the role of the nurse leader. Let’s get started!


Organize legal and regulatory components of healthcare strategies to promote safety and quality care. (PO1 & PO4)

Weekly Objectives

  • Examine licensure and accreditation.


Week 4: Reading

  • Points None

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). China: Wolters Kluwer Health.

  • Chapter 23: Quality Control
    • Introduction
    • Defining Quality Health Care
    • Quality Control as a Process
    • The Development of Standards
    • Audits as a Quality Control Tool (all sections)
    • Standardized Nursing Languages
    • Quality Improvement Models
    • Who Should be Involved in Quality Control?
    • Quality Measurement as an Organizational Mandate
    • Professional Standards Review Organizations
    • The Joint Commission (all sections)
    • Centers for Medicaid & Medicare Services (all sections)
    • National Committee for Quality Assurance
    • National Database of Nursing Quality Indicators
    • Report Cards
    • Medical Errors: An Ongoing Threat to Quality of Care
    • The Leapfrog Group
    • Six Sigma Approach and Lean Manufacturing
    • Reforming the Medical Liability System
    • Integrating Leadership Roles and Management Functions with Quality Control

Roussel, L., Thomas, P., & Harris, J. (2016). Management and leadership for nurse administrators (7th ed.). Burlington, MA: Jones & Bartlett Learning.

  • Chapter 12: Laws, Regulations, and Healthcare Policy Shaping Administrative Practice
  • Chapter 13: Anticipating and Managing Risk in a Culture of Quality, Safety and Value
  • Chapter 14: Leaders Achieving Sustainable Outcomes

Recommended Article

Pulaski, G. (2013, July). Achieving regulatory goals through strategic planning. Journal of Nursing Regulation, 4(2), 49–56.

Week 4: Lesson

Table of Contents

Licensure and Accreditation

As we begin this week’s lesson, it is important to realize the importance of licensure and accreditation for an organization and the influence of the nurse leader related to this area. There may be variations in licensure and accreditation requirements and other influences, such as the government, depending upon the state in which the organization is located or what specific body an organization has chosen to partner with in the licensure-and-accreditation process. Nurse leaders must be aware of changing licensing and other regulations that may affect quality controls and standards for your area or organization.

Quality control describes the activities used to evaluate, monitor, or regulate services provided (Marquis & Huston, 2017). Quality control within an organization is an ongoing process that must have support from senior administration and the resources (human resources and fiscal) to commit to the process. The quality-control goals should focus on high standards, rather than just meeting the minimum requirements.

Most organizations utilize several quality-control and benchmarking outcome measures; some required by select licensure and accreditation bodies, some based on internal requirements. Benchmarking is a process of measuring practices, services, and products against other organizations of a similar nature (Marquis & Huston 2017). Many states have a best-practice program that invites healthcare organizations to share select outcome measures related to quality-improvement areas.

Some selected external influences to organizations include The Joint Commission, the Centers for Medicare and Medicaid Services (CMS), state report cards, the Leapfrog Group, and the National Committee for Quality Assurance (NCQA), which is a voluntary accreditation organization (Marquis & Huston, 2017). The Institute of Medicine (IOM) has conducted much research on the topic of quality outcomes and published the To Err Is Human report, which enhanced the awareness of these issues (Institute of Medicine, 1999). However, most organizations are aware that measuring and reporting various outcome measures can influence the financial viability of their organizations. Consumers are savvy and can research organizations to view the scores and rating of various outcome measures.

In an effort to have an organizational culture of ongoing improvement, many organizations conduct periodic audits, which may be random, on select outcomes to ensure that the expected outcomes are being met. Various audit tools are available for organizations, or an internal audit tool may be developed. If the nurse leader finds that an audit is missing certain data or an individual is not performing at the level of expectation, an employee counseling session (depending upon policy), may occur. Ongoing monitoring and follow-up are needed to ensure that outcomes are continuing to be met over time.

Risk Management

When an issue or discrepancy in an expected outcome occurs, such as a medication error, often a root cause analysis (RCA) may be conducted within the organization to determine why the incident occurred. This method of evaluation is to help prevent recurrence of a situation. Generally, a committee is involved in reviewing cases that present for an RCA evaluation. Disciplinary action toward the person or persons responsible for a discrepancy or error can vary among organizations. Having set standards for measuring the quality of care and policies and procedures can be helpful in guiding risk situations. Tracking of various data can be helpful to leaders to notice trends that may be occurring and to see where some additional focus may be needed.

Knowledge of various laws can be helpful for the nurse leader, and participation in an RCA can be beneficial to have an awareness of what quality issues are occurring in certain areas. Most organizations have a risk-management department or person to assist with the case and document review of the incident and to help determine what compliance issues need additional attention. In certain situations, specific rounding or documenting may be required to prevent an incident from occurring or recurring (Roussel, Thomas, & Harris, 2016). The risk-management department can also assist and provide education to the nursing staff regarding the use and preparation of incident reports.

Patient Safety

The safety of patients is a priority for healthcare organizations. Continuous quality improvement and monitoring is beneficial, and required measures must be submitted by certain deadlines to selected monitoring and oversight agencies. Many organizations aspire for a continuous-quality-improvement (CQI) model to strive to be better in regard to patient-related outcomes and customer service (Marquis & Huston, 2017).

Empowerment of employees within the organization is a critical component to a CQI culture. When nursing leadership provides positive feedback and reinforces the expected behavior and attitudes to support a culture of CQI, employees feel valued to improve the quality of care and service. Allowing employees input and sharing ideas to enhance the work setting is a common practice within a CQI culture. Deming’s fourteen total-quality-management principles are provided in your readings this week to reflect on these principles and to consider implementing some or all of them in your role as a nurse leader.

Some organizations have adopted a Six Sigma approach for quality improvement (QI) to help create a culture of safety (Marquis & Huston, 2014). Measurement of various outcomes has influenced organizations to embrace a QI culture and has allowed employees to provide creative changes and solutions to organizational issues. Utilizing an evidence-based approach to patient-safety concerns can help support any needed change and buy-in by the staff. Nurse leaders can utilize their vision to inspire their team members to improve quality of care and the healthcare system.

There are several quality awards designed to recognize high-quality patient care, such as the Magnet Recognition Program by the American Nurses Credentialing Center (ANCC), that recognizes healthcare organizations that provide nursing excellence and the Malcolm Baldrige National Quality Award, which recognizes organizations that establish best practices and demonstrate excellence in quality performance (Roussel et al., 2016). Attainment of either of these awards is considered a high honor.


This week, we discussed aspects of licensure and accreditation, specifically the influence of the nurse leader within the healthcare organization. Next week, we will explore human-resource issues in healthcare.


Institute of Medicine (1999, November). To err is human: Building a safer health system. Retrieved from http://www.iom.edu/~/media/Files/Report%20Files/1999/To-Err-is-Human/To%20Err%20is%20Human%201999%20%20report%20brief.pdf.

Marquis, B.L. & Huston, C.J. (2017). Leadership roles and management functions in nursing: Theory and application (9th ed.). Philadelphia: Lippincott Williams & Wilkins.

Roussel, L., Thomas, P., & Harris, J. (2016). Management and leadership for nurse administrators (7th ed.). Burlington, MA: Jones & Bartlett Learning.

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