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Can related facility stain reputation?

If you work for a large health care system, you’ve probably asked yourself the following questions: What if one facility within the system loses its accreditation due to falsification? What happens to me? Do JCAHO reprimands trickle down?

"There are many variables involved when considering a system’s member hospitals," says Julia M. Roberts, a spokeswoman for the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. The agency would have to determine at what level the falsification took place. It would also seek to determine whether the infraction was deliberate, and whether it affected the quality of care. "If, for example, the chief surgeon on the review committee falsified minutes of a meeting for the whole system, the entire system would be under investigation and member hospitals could possibly lose their accreditation," Roberts says. "That would be an extraordinary situation, however. The Joint Commission’s legal counsel says the whole situation would have to be examined before a decision like that could be made."

Robert Pollack, MD, director of Professional Quality Analysts in Casselberry, FL, agrees. "If a system had five satellite hospitals and one was found guilty of fraud or improprieties," he says, "JCAHO would probably look at the other four a whole lot more intensely than they would an unrelated facility. The assumption is that another facility within the chain may possibly be guilty as well, and the agency would look for it. JCAHO couldn’t deny accreditation, however, unless it had concrete evidence."

JCAHO’s 1998 Hospital Accreditation Standards clearly state, "Any hospital that fails to participate in good faith by falsifying information presented in the accreditation process may have its accreditation denied or removed by the Joint Commission."

Requirement 9 (p. 43) of the Standards states that a hospital must not misrepresent information in the accreditation process. "Each hospital seeking accreditation must engage in the accreditation process in good faith." Falsification is defined as the fabrication, in whole or part, of any information provided by an applicant: redrafting, reformatting, or content deletion of documents. Information can be provided orally, by direct observation by surveyors, derived from documents supplied to the Joint Commission, or transmitted electronically to the Joint Commission.

Requirement 10 (p. 44) mandates that a "hospital does not publicly misrepresent its accreditation status or the scope of facilities and services to which the accreditation applies."