QI professionals take harder look at alternatives to JCAHO accreditation
Burdensome costs, questionable link between surveys and quality
It may be that at one time the desire to seek accreditation from the Joint Commission on the Accreditation of Health Care Organizations was a given among hospital quality professionals, but a growing number of them no longer consider the decision a no-brainer. This is not to say that quality managers are rejecting the Joint Commission in large numbers, but some are thinking longer and harder before taking the plunge.
For one thing, a number of alternatives are available today, including using the Centers for Medicare & Medicaid Services (CMS) survey alone, ISO 9000, the Accreditation Association for Ambulatory Health Care Inc., and the American Osteopathic Association’s (AOA) Healthcare Facilities Accreditation Program, to name just a few. In addition, recent Joint Commission survey changes have drawn out both supporters and critics.
"With the upcoming changes in the JCAHO survey process, I’m seeing more questions about alternatives to JCAHO accreditation coming from hospitals," notes Patrice L. Spath, a consultant with Brown-Spath & Associates in Forest Grove, OR.
"I think it’s more of a discussion point than it used to be, and a small number of hospitals have ceased using JCAHO," adds Lisa A. Mead, RN, MS, director of quality at Scottsdale (AZ) Healthcare. "There are alternatives, and there’s enough on the table to have people at least reconsider the value."
However, she adds, "I’m looking forward to the new changes they’re putting in place."
Still, there seem to be enough concerns about the JCAHO accreditation process to require careful thought and analysis on the part of quality professionals. Not the least of these is cost; sources tell Healthcare Benchmarks and Quality Improvement that for a 500-bed system, for example, the cost can be about $80,000 to $100,000.
Still, according to Mead, the list on both sides of the ledger is fairly comprehensive. For example, she notes, the plus side includes the following:
- JCAHO has good prescribed methods for achieving standards and for utilizing guidelines, standards, and policies.
- JCAHO encourages greater focus on quality of care than the normal licensing processes.
- You can compare your facility to other hospitals, so the public can make some determination as to which hospital to use.
- It offers solid education programs.
- JCAHO recently responded to public concerns about quality of care and patient safety and has taken the issue quite seriously with its patient safety goals.
On the minus side, Mead says, are these considerations:
- The cost of accreditation is high, not only through direct survey fees but also through the internal costs of gearing up for the survey. The latter should decrease with unannounced surveys, she notes, although she hopes preparation doesn’t vanish altogether.
- It’s hard to quantify the correlation between the process and how it improves patient care.
- Because JCAHO has a lot of stakeholders, there is some question as to whether it is strictly a provider-friendly service.
- Duplication of surveys is frustrating. "We also have to do state licensing surveys, and they are really very similar," Mead says.
- You can’t pick the areas to be surveyed.
"A lot of this depends on how your organization views the accreditation process," adds Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Metamora, MI.
"If the leaders have a commitment to quality and they have well-running systems and processes, accreditation almost becomes a by-product. On the other hand, in some organizations, you can tell that clearly they do a lot of these activities just to get ready for the Joint Commission, and there is not a true commitment to change long term; these organizations might consider other accreditation processes," she explains.
"Most of the reasons [for seeking alternatives] have something to do with the cost of accreditation and the perceived value received," Spath says.
"Some complain that many JCAHO standards are not relevant to quality patient care, and yet resources must be expended to meet these standards. Others complain about mandatory participation in the ORYX database. The organization must expend a significant amount of money for technical support and data input and analysis, and yet few patient care improvements can be attributed directly to ORYX participation," she points out. "Some organizations are fed up with the complexity and constant revisions of the standards. A large amount of money must be spent on JCAHO training workshops and publications. And in some facilities, outside consultants must be hired to help the organization meet the intent of the standards."
Weighing the options
In considering whether to stay with the Joint Commission, it’s becoming clear that for a number of the benefits it offers, there is an alternative process that purports to provide the same benefit.
For example, Spath notes, "One of the most frequently cited reasons for participating in the JCAHO accreditation program has been to achieve deemed status for Medicare/Medicaid participation. However, health care organizations can elect to undergo state surveys; JCAHO accreditation is not mandatory."
By the same token, while accreditation may be useful for marketing purposes, a less costly alternative might be the Healthcare Facilities Accreditation Program (HFAP) of the AOA, which has deeming authority to survey hospitals under the Medicare Conditions of Participation. (Go to: www.aoa-net.org/Accreditation/HFAP/HFAP.htm.) HFAP is designed to service allopathic (MD) and osteopathic (DO) facilities alike.
"Aside from a small number of AOA standards articulating a commitment to osteopathic principles, in large part, JCAHO and AOA address the same issues with somewhat different semantics," says Spath.
"I’m working right now with someone who is HFAP-accredited," Homa-Lowry adds. "My opinion is that they have more mandatory requirements to meet. For example, AOA has mortality reviews, while the Joint Commission does not."
While the AOA does have deemed status, she continues, different problems may arise from within the medical staff.
"Years ago, there were sharp differences between DOs and MDs, but now I see some of the osteopathic hospitals going with the Joint Commission. However, I don’t think you could ever convince an MD hospital to go with an osteopathic accreditation," Homa-Lowry asserts.
You may see some hybrid setups, she adds, such as a mix of CMS and JCAHO, in the future. "CMS has changed its conditions of participation. It’s more in line with where the Joint Commission is going."
Still, a lot of the CMS surveys are more prescriptive, she says. "They deal with issues like nurses doing care plans, but not necessarily evaluating the effectiveness of those care plans."
As for deemed status, Homa-Lowry says that your location likely will play a role in your decision. "Some facilities continue with JCAHO because of deemed status, or the requirement by various payers that they be accredited. For example, in the state of Michigan, it is a requirement in the Detroit area but not necessarily throughout the state."
Wherever payer contracts, medical school/ health professional training affiliation agreements, or CME provider arrangements require that the health care organization maintain JCAHO accreditation, "All such agreements should be carefully evaluated to determine if such a requirement exists before a judgment can be made about what might be lost if JCAHO accreditation is dropped," Spath says.
The individuality of your facility comes into play as well, Homa-Lowry says. "In the past, I did an evaluation with an organization in terms of whether to stick with JCAHO or go to an ISO model or to CMS.
"It was a small hospital; in terms of actually looking at things that had to do with quality, JCAHO did not particularly address the needs of their organization," she recalls.
"They evaluated the ISO process, and Baldrige, as well as the Joint Commission, and presented an analysis on which model best met their needs. Then, the leaders and the board made the decision," Homa-Lowry explains.
Which brings up another key issue: Who ultimately makes the decision as to whether to stick with JCAHO?
"The organization’s governing board, in consultation with the medical staff and senior leaders, must decide whether the organization is truly better off by being both accredited and Medicare/ Medicaid certified and if the extra cost of accreditation is worth it," Spath says.
"Input should come from the administrative staff or from the quality executive to the full executive team," says Mead. "Then, of course, to the board."
The cost of freedom
Spath notes that deciding to go it alone carries with it an added burden of responsibility. "Often, accreditation standards are the big stick used to get needed improvements in an organization," she observes. "Once an organization drops accreditation, it’s important that the big stick is replaced by a strong and visible commitment from senior leaders to provide high-quality, safe patient care."
But many hospitals already have such a commitment from leaders, she adds. "And it is often these hospitals questioning the value of JCAHO accreditation — they don’t need the big stick of JCAHO standards to get needed improvements. Plus, a hospital that is not JCAHO-accredited has more latitude to choose improvement projects that are important to its patients and other stakeholders. Often, JCAHO standards dictate where improvement activities should be focused; however, hospitals that want to continue as Medicare/Medicaid providers must still comply with the quality and safety requirements in the CMS Conditions of Participation."
JCAHO responding?
Homa-Lowry asserts that the Joint Commis-sion is responding to the individual requirements of facilities through its recent changes to the survey process. "If you set up processes and systems and assess them yourself, you will have a good accreditation process."
"I see the changes in the survey process as positive because they are really going to force organizations to put in place systematic processes that are ongoing; you can’t just rev up for the survey." She concedes, however, that organizations that prefer a more prescriptive process might move away from JCAHO.
"The new survey process changes are an improvement; this is a much more effective way to survey," says Mead, whose hospital just participated in the process.
"We felt very positive," notes Mead, who says her facilities’ preliminary scores were 96 and 97 with only one Type I at one hospital. "The process was educational and rewarding for our staff. They were allowed to share examples of implementation excellence. Supposedly, the process will only get better."
Mead’s organization had gone through an intensive process before deciding to stay with JCAHO accreditation.
"Some of our major concerns included the fact that other hospitals might use our nonaccreditation status for competition purposes," she notes.
"In addition, we might have to go back and re-contract with our bonding agencies and health plans, and there might be some concerns about our staff in terms of quality of care. For years, this has been seen as mandated — everyone does it. If it’s gone, what’s our story?"
However, she stresses, the decision to leave or stay with JCAHO should be revisited continually.
"Once people go through [the consideration of alternatives], I’m not too sure I would ever take it off as a discussion item," she says. "It needs to be looked at like any item in the quality budget: What is the value? Are we getting value? Are we learning? Does it help gain market share? And, are we improving quality of care?"
Need More Information?
For more information, contact:
• Patrice L. Spath, Brown-Spath & Associates, P.O. Box 721, Forest Grove, OR 97116. Telephone: (503) 357-9185. E-mail: [email protected].
• Lisa A. Mead, RN, MS, Director of Quality, Scottsdale (AZ) Healthcare. Telephone: (480) 675-4217. E-mail: [email protected].
• Judy Homa-Lowry, RN, MS, CPHQ, President, Homa-Lowry Healthcare Consulting, 560 W. Sutton, Metamora, MI 48455. Telephone: (810) 245-1535. E-mail: [email protected].
It may be that at one time the desire to seek accreditation from the Joint Commission on the Accreditation of Health Care Organizations was a given among hospital quality professionals, but a growing number of them no longer consider the decision a no-brainer. This is not to say that quality managers are rejecting the Joint Commission in large numbers, but some are thinking longer and harder before taking the plunge.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.