Without a JCAHO score, where are the distinctions?

We want to stop the billboard war’

One of the key ways in which the Oakbrook Terrace, IL-based Joint Commission for the Accreditation of Healthcare Organizations’ (JCAHO) new accreditation model "really blows up the old paradigm," says Joe Cappiello, vice president for accreditation field operations, is that there is no score.

"We want to stop the billboard war in some cities, where one hospital puts up [on a sign] that it got a 94 and another hospital didn’t," he adds. "The score is irrelevant."

Under the existing model, Cappiello notes, a Type 1 designation meant a hospital was "accredited with recommendations for improvement." After a series of events, he adds, the hospital was required to clear the items in question and then would be just accredited.

If the score was low enough, Cappiello says, it could lead to conditional accreditation or even preliminary denial of accreditation.

Beginning in 2004, a hospital surveyed by the Joint Commission won’t receive a 92 or 86, he points out. "So how do we make a distinction between those that are doing great, those that need some help, and those that need a lot of help?"

The new process

"We are going to count the number of recommendations that are made on site, and then look at the average number of recommendations made the year before, in 2003, for all hospitals," he says. "Then we will go two standard deviations, and that will be the cut line for conditional accreditation. We will go three [deviations] from that and that will be preliminary denial of accreditation."

The process "will be driven by a statistically valid methodology that distinguishes one from another," Cappiello says. "The bottom line is that when the surveyor leaves, the facility will have the final report — not the final decision, but the final report."

The surveyed hospital may review that report, he continues, and respond that it does not believe the JCAHO’s recommendation is valid. The facility might contend, for example, that the surveyor did not sample enough records, Cappiello says. To back up its contention, he adds, the hospital may submit evidence of standards compliance, which the JCAHO will review.

"It won’t be a box full of forms or policies, but you must tell us why you believe you are in compliance, based on activity, not policy," Cappiello says. "For example, if the policy is that a history and physical must be performed, and [surveyors] found one of 10 charts in which this wasn’t done, [the hospital] could say, You found the only chart out of thousands where that didn’t occur.’"

The hospital then could show that it had sampled 250 charts and found only one case in which the procedure was not followed, he explains.

"We hold you accountable to your own policies," Cappiello says. If the hospital policy says certain things must be done to ensure a safe and thorough admission and review of the patient, "we’re going to cite you" if those things are not done.

However, if an access employee fails to provide a patient with a privacy notice or ask about advance directives because that person was new to the job, or unnerved by the presence of the surveyor, he adds, the hospital could argue that point.

"[The hospital] might say to us, We can demonstrate that by pulling 25 other records from the same day in which all the requirements were met,’" Cappiello says. "We would take that into account and probably amend the recommendation."

When standards are found out of compliance, he notes, a hospital has one month "to fix them, to provide us a plan and evidence of how they will come into compliance, and how they will measure that they’re in compliance."

After the hospital has provided measurable criteria to demonstrate its compliance, JCAHO will review the evidence, Cappiello says. "If we accept it, you are accredited. If you submit something and we don’t believe it’s on the mark, then you will be provisionally accredited."

This provisional status is subject to being publicly disclosed until JCAHO and the hospital agree on how the recommendations will be addressed, or if the two parties can’t agree on a methodology, for the hospital to come into compliance, he adds.