The Joint Commission of Accreditation of Healthcare
Organizations (JCAHO) is a good organization.
It goes beyond the standards of the Conditions of Participations that an
organization needs for Medicare funding, but does it go too far and what are the
alternatives. I believe that
everyone knows that passing the JCAHO triennial exam with a good score is
important, but why?
Let’s review what is necessary for Medicare funding.
HCFA has stated that in order to receive Medicare or Medicaid monies an
organization must pass certain minimum standards.
These are known as the Conditions of Participation (CoP). This is a
document of patient rights, etc., and is found in the Code of Federal
Regulations at Section 42. The
standards are simple and easy to understand.
Passing the CoP can be accomplished by having HCFA or
its state designee, the Department of Health do a survey or have another private
entity who has applied to HCFA for and been given “deemed status” do that
survey. Two private organizations have also been given the green light to survey
and if the survey is passed HCFA will agree that the organizations have passed
just as if they would have surveyed them themselves (deemed).
These are the Joint Commission of Accreditation of Healthcare
Organizations (JCAHO) and the American Osteopathic Association (AOA).
These private organizations use the Conditions of Participation as the
backbone of their accreditation standards.
Conditions of Participation
These are the conditions that all institutions must meet
to be accredited for receipt of federal (Medicare & Medicaid) funds.
This document gives the base quality standards.
There are different ones for various healthcare entities.
For hospitals they are compliance with laws, patients rights, governance,
quality assurance, medical staff, nursing services, medical records,
pharmaceutical, radiology, laboratory, food, utilization review, physical
environment, infection control, discharge planning and organ donation.
The optional services covered are surgical, anesthesia, nuclear medicine,
outpatient, emergency, rehabilitation, and respiratory.
There is not a lot of regulation in each section.
There is nothing in the CoP about re-credentialing physicians within two
years or other items of minutiae and intrusion that are fostered by a private
accreditation firm. The latest one is doing full soil and engineering testing
prior to building or adding to a building. This
is for patient safety. Somehow, I don’t find that in the CoP.
The Joint Commission grew out of the
The Joint Commission is a private non profit institution
that has applied for and been granted deemed status by HHS.
The Service inspects the Commission on a routine basis and either
continues to grant them deemed status or not.
The only condition is that the private organization use and make sure the
CoPs are being complied with. This
is the baseline. Anything the Joint
Commission does above and beyond this is up to them. There is no requirement for
a score. The Joint Commission’s
recent ruling that any score below a 79 will give a less than full accreditation
is an edict by the Joint Commission and not related to their contract.
Until recently, when there has been more and louder criticism of their methods and costs, the Commission has not done any meaningful self-evaluation or performance improvement. As hospitals know, many Joint Commission standards are not relevant to patient care. The Commission itself realizes this and is attempting to re-evaluate and remove non-relevant standards.
Another of the Joint Commission edicts is if a hospital
has affiliated medical groups or other agencies, they must be part of the
inspection. This magnifies the
complexity of the inspection. As the Joint Commission is paid per inspection the
cost that they command is also magnified tremendously.
They refuse to grant accreditation to a hospital without also looking at
all the affiliated agencies at the same time.
Money is perceived to be a driving motive behind much of what the Joint
Commission does. The Commission states it is because of public perception that
if the hospital is JCAHO approved, all of its component parts are also JCAHO
Due to Joint Commission’s regulatory complexity, many
hospitals hire outside consultants to help them prepare for the triennial
survey. This usually adds many
thousands of dollars to the cost of the survey and by definition takes that
money out of the patient care slice of the pie.
Another relatively new JCAHO requirement is ORYX (Our
Regulation Your eXpense).
This also takes significant money for technical consulting and inputting
the information. I have not seen
much in the way of positive return from this program that could not be done on a
non-individual input basis. I also
wonder how HIPAA will impact this program. Is
JCAHO a business entity and requires a business associate agreement or is it
part of healthcare operations? I
believe that it is a business associate and as such will require about 20,000
business associate agreement contracts. Since it also looks at open and closed
charts that contain personal health identification, the question unanswered as
yet is will the hospital need to obtain authorizations and track disclosures.
I believe that JCAHO stepped over the line with their
sentinel report that has been found discoverable in
It is my contention that if a hospital is truly doing
good patient care every day and paying attention and not just lip-service to the
CoPs and performance improvement, they not only do not need a consultant but
also do not need the required survey. The
survey is most helpful to those institutions that do not on a day in and day out
basis look at their organizational structure and the patient care. I realize
that in order to be paid one must be surveyed by an accrediting agency, but I
wonder if this could not be done on a drop in basis with a one month heads up.
This is especially true with the advent of
Each state’s Department of Health has the authority to
inspect and accredit institutions in lieu of the federal government.
When the Department inspects they use the Conditions of Participation as
their manual. Therefore, most of the regulations of the private firms are not
necessary. The Department will
accredit any institution that requests them to do it.
There are no grades given. It
is a pass/fail test. The cost is
reasonable. There is no cost, it is
free. The problem is if you fail a
private firm’s accreditation, you get a chance to make it right.
That does not hold with a State inspection.
If you fail, you are reported to HHS but retain appeal rights to correct
any CoP deficiencies. If all that is
necessary is a fix on your policies and procedures, these may be mailed to the
State. If the needs are more, then
the state may have to re-inspect. The
other related problem is the lack of significant consultive methods in the
inspection. The private firm’s
surveyors will help you to improve your processes.
Another major downside is the need for yearly inspections and not every
three years as with the private inspecting organizations. This may be a blessing
in disguise since it makes the institution continually aware and updating their
processes. The State looks more at
outcomes and interviews more staff and patients where the private accreditors
seem to be more interested in processes, especially their own.
Recently there has been a trend for more hospitals and
hospital systems switching to the State for their accreditation.
This year a small system and several hospitals in
The American Osteopathic Association (AOA) has been
accrediting hospitals, osteopathic and non-osteopathic, five years longer than
JCAHO. However, they did not have
the backing of the AMA and their subsidiaries so never became a large
accreditation association. They have
all the same powers as the JCAHO but at less cost and have more flexibility.
They also accredit for more than the CoP but do not have all the other
minutiae that plague the JCAHO. They
do not require all components of a hospital to be accredited to accredit the
hospital. They are currently making a strong bid to become more of a competitor
The conclusion is an organization needs to ask itself
why it would want to spend precious resources to pass a required evaluation.
Is it for ego satisfaction to know that your score is 94 and your
competitor is 93? Are you truly any
better? You are both only known as
accredited and deemed Medicare and Medicaid certified.
There is no difference. The health community knows what accreditation is,
the remainder of the world does not. They just assume their hospital is
Why wouldn’t the organization keep their processes up
to date so that they could pass any evaluation regarding the Conditions of
Participation and good performance improvement processes at any time? Doing
things right the first time and doing what is best for the patient is what’s
important, not the score.
I hope this article has opened up some discussion in
your organizations where the alternatives are now known and considered.
It does not matter which organization you decide to use as long as it is
the one that best serves your considered purpose.
Please remember the famous Dan Quayle statement about
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DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.