Joint Commission defends its infection control record

Concedes significant’ number of citations

In defending itself against a critical article in the Chicago Tribune, the Joint Commission on Accreditation of Healthcare Organizations issued a statement that includes the following points:

More than 33 million individuals are admitted to America’s hospitals and are later discharged in healthier states. A number of these represent spectacular saves. The care responsible for these positive outcomes is provided in the framework described by Joint Com-mission standards and implemented by conscientious provider organizations, often in the face of severe financial constraints and staffing shortages.

Although the Joint Commission’s on-site evaluations are announced in advance, organizations are expected to demonstrate standards compliance track records of at least one year.

In point of fact, more than 90% of hospitals surveyed receive citations for performance deficiencies. In the infection control area alone, for which there are 175 references in Joint Commission hospital standards, a significant number of the hospitals surveyed in 2002 have been cited for deficiencies. All deficiencies must be remedied satisfactorily by a certain date for the hospital to maintain its accreditation.

The Joint Commission also conducts random unannounced surveys on a 5% sample of its accredited organizations every year. Infection control issues usually are addressed during these evaluations.

Finally, the Joint Commission conducts surprise for-cause surveys whenever it determines that there is substantial concern about patient safety or health care quality in an accredited organization. Those determinations necessarily involve judgments that will subsequently prove to be valid or invalid. For example, in up to 40% of surprise for-cause visits, no standards compliance deficiencies can be identified. Unfortunately, there are instances where the determination not to conduct a surprise visit proves to be erroneous, as illustrated in the Tribune article. Notwithstanding the variety of on-site evaluation activities conducted by the Joint Commission and by federal and state agencies, quality oversight bodies cannot maintain a continuing presence inside health care organizations, nor should they. But the fact that organizations, which have been accredited for many years, continue to be found out of compliance with long-established standards in areas such as infection control and credentialing suggests the need for major changes in the quality oversight process. That indeed is the principal focus of the new accreditation process that the Joint Commission will unveil in January 2004.

The Joint Commission would like to take issue with or clarify certain points raised in the Tribune article:

The Joint Commission works with regulatory agencies, but is not itself a regulatory agency. It can neither fine nor close a hospital.

Almost one-quarter (six) of the members of the Joint Commission’s Board of Commissioners are public members. They are currently drawn from the diverse realms of philanthropy, bioethics, labor, insurance, public policy, and academia. These individuals are, in fact, strong advocates of public perspectives in board policy discussions.

The Joint Commission does not have a monopoly. It has able accrediting-body competitors in virtually every field in which it provides accreditation services, including the hospital field.

As part of its private/public sector partnership, the Joint Commission is regularly subjected to validation ("look behind") surveys in organizations that it has recently evaluated. The Centers for Medicare & Medicaid Services provides an annual report to the Congress, which reports on the validation survey findings and assesses the performance of the Joint Commission.

The Joint Commission relies on information from the public to strengthen its oversight activities and operates a toll-free complaint hotline, (800) 994-6610. The Joint Commission follows up on every complaint it receives. During 2002, more than 7,500 complaints have been reviewed.

The fact that hospitals only rarely report nosocomial infections to the Joint Commission’s Sentinel Event Database relates primarily to the fact that the Centers for Disease Control and Prevention maintains a separate voluntary reporting data-base for such occurrences. The Joint Commission plans to advise accredited organizations in the near future that nosocomial infections resulting in death or serious injury also should be reported to the Joint Commission’s database.