The grass isn't always greener

What brought some organizations back to TJC?

Editor's Note: Last month, Hospital Peer Review looked at some of the differences between the two largest hospital accreditation organizations, The Joint Commission (TJC) and DNV, and asked several DNV clients to talk about what made them choose DNV. This month, we look at some organizations that thought about leaving TJC and either came back after trying out DNV, or changed their minds. What brought them back?

It was the acquisition-fueled growth of the organization that brought ProMedica to the point of having to choose what company to use for accreditation. When the integrated delivery system reached 12 hospitals in Ohio and Michigan (as well as a multispecialty practice, a payer, and other ancillary services), it was using all three major accreditation organizations — The Joint Commission, DNV and HFAP, says David James, MD, JD, CPE, chief medical officer and senior vice president, medical operations for the Toledo-based organization.

"As we move towards the accountable care organization model, we felt we needed to have a systemwide standard in terms of accreditation," he says. One facility used DNV, and ProMedica executives were struck by the combination of ISO certification and Conditions of Participation-based evaluation.

They were open to dropping TJC in part because so many people felt that it was an adversarial accreditation process and lacked collaboration with the organizations being surveyed. But James says he wanted more information and so asked all three bodies to provide detailed answers to a series of questions. Nursing and physician leadership, quality directors from each facility, and systemwide staff including James, best practice, performance improvement, analytics, and nursing excellence representatives, all got together as an accreditation team.

They created a list of questions and asked each of the organizations to approach ProMedica as if they were approaching a completely new business that did not know what they had to offer (for a sampling of the questions they developed, below).

Questions for potential accreditors

Source: ProMedica, Toledo, OH

  • Aside from checking our compliance with the conditions of participation, what do you offer that gives us a strategic business advantage?
  • Describe your key products and services.
  • What are your learning and development systems?
  • Tell us about your performance improvement systems.
  • How do you sustain our continuing ongoing readiness?
  • What accreditation services do you offer across the continuum of care?
  • What business opportunities do you offer for integrated delivery networks?
  • How are you moving toward an ACO environment?
  • How might you partner in development of high-reliability organizations?
  • Share your view of the future of healthcare.
  • What's your ability to share best practices with us?
  • What is your partnering approach to performance improvement — collaborative vs. consultative — and how do you walk the line between collaboration and evaluation?
  • What's your relationship with the Baldrige criteria?
  • Describe your alignment or movement toward aligning standards with CMS and the National Quality Forum.
  • What are the competitive advantages you offer?
  • What is your relationship with CMS and influence on healthcare policy?

HFAP, which got its start with osteopathic hospitals, was considered too small, with a narrow focus that did not relate to an integrated system, James says. "They were heads down to the Conditions of Participation and nothing else. If I was a small hospital, they might be a great choice. They are cheap, effective, and offer nothing but accreditation. But they aren't made for us."

DNV and TJC seemed more appropriate. The former offered an entire quality management system through the ISO 9001 certification. "What was appealing about them is they have a broad cross-industry thinking. They work with so many industries, and they have within themselves, in 9001, a well-thought-out total quality management system. We at ProMedica were looking around at ways to achieve system standards. We have pieces and parts, but not a total systemwide package."

But pursuing certification in some systemwide standard isn't something that the team felt was necessary. "I do not think that certification and awards move markets," he says. "But internally, being ISO compliant, being certifiable, that has value. And DNV is an expert in that regard."

The Joint Commission had done some restructuring, though, and was showing itself to be nimble and interested in moving in a much more collaborative direction, James says. "They are retooling, reinvigorating their relationships with clients in a real customer service approach." It was apparent during the face-to-face interview that the talk about restructure was more than talk: They were serious about change. "They saw that they had to do something different. CMS had indicated that it wanted a movement toward organization-wide quality management strategies, so they were moving that way. They also have a huge capacity for benchmarking across the country, and the most integrated delivery system experience."

TJC also has accreditation capability for many kinds of entities, and a large compendium of resources it can make available to client organizations. "Combine that with a strong effort at customer service, and the only thing really missing was an integrated approach to accreditation with a total quality management system," he says.

But The Joint Commission had an answer for that: a pilot program for ISO certification. "It all just fell into place," James says.

"They offered the 'both/and' that we need. The depth, breadth, benchmarking, accreditation, collaborative approach, and integration with a total quality management system," he says, noting ProMedica is now one of the ISO 9001 pilot sites for TJC. "It is not a perfected integration with ISO, but they are putting resources behind it and have hired some great, nationally recognized people. We feel we have an opportunity to help TJC develop how they use ISO."

James says he thinks competition has been good for TJC. "We'll always look at what's out there, and I think that all three are here to stay. But I think each will have its niche, and it will depend on the scope and size of the organization which they use. DNV does great work. I like them. But they do not have the size and scope TJC does to work with entire systems."

The Wild West

Down in Arizona, Banner Health experimented with each of its hospitals choosing its own accreditor. "After the 2006 survey, we just questioned the value of The Joint Commission," says Sandy Severson, RN, MBA, CPHQ, senior director of quality management systems. "There was a lot of discontent with them, and we had CMS surveys coming in with lots of problems. They were dictatorial and we thought there was a subjectivity to the surveyors we did not like. They focused a lot on governance."

In 2007, the system let each facility do its own thing. Five decided to move away from The Joint Commission. They opted to use CMS and a state certification system, which worked with the theory that doing things with a local slant was a good thing.

Because every facility was choosing its own path, the system had to set some minimum standards that met the requirements of all the options, says Severson. After the 2009 survey, they did a gap analysis to determine how the hospitals were doing compared to that minimum standard that was set. "There were certain issues of noncompliance, and we found that those who were not Joint Commission-accredited had more opportunities for improvement," she says. "We found that the lack of a systematic approach created duplication of work, so in 2010, we decided to reduce some variation and our reliance on external agencies. We wanted an internal structure for oversight."

The health system has a standardized electronic medical record, standardized clinical practices, and standard service and operations models. "As we moved forward, it became very evident that we couldn't have that variation of each facility doing what it wanted for accreditation," Severson says.

But which company to choose? They looked at DNV, but Severson says that organization did not give any added benefit to them. "We have our own internal management system," she notes. "We did not need another one." Some wanted one thing, some another, but the majority felt that the increasing collaborative style and focus on patient safety made TJC a better pick. "There were some people who just wouldn't have budged from The Joint Commission anyway," she says. Aside from one small critical access hospital for which Banner doesn't have a mandated accreditation body, they are all with The Joint Commission.

For the five that opted out of TJC initially, the return came as a relief. The surveys are shorter, the surveyors are fewer and more knowledgeable, and there is a consistency about them that was lacking under the other regimes, says Severson. "They talk about the huge change in tone of the surveys with The Joint Commission. They are seen as educational opportunities. They aren't as punitive, and they seem very interested in adapting to the change in the healthcare environment, particularly as regards accountable care organizations."

Like ProMedica, Banner will always evaluate its relationship with TJC. But Severson thinks that TJC will also be evaluating itself and looking for ways to improve. "They are always asking us what's working and what's not," says Severson.

That there are people asking clients what's good and what's bad is part of The Joint Commission's master plan, says Ann Scott Blouin, PhD, RN, FACHE, executive vice president for customer relations at The Joint Commission. Her role was created specifically to figure out what customers wanted, and how to ensure that their needs were met by The Joint Commission.

If someone says they are going to change accreditors, Blouin or another senior commission executive will call the client and ask them to explain. "We want to know where their dissatisfaction lies," she says. Sometimes, the problem is a recoverable error that can keep the client with The Joint Commission. Regardless, the issues raised are addressed.

Interestingly, people are happy to talk about their concerns. "Sometimes people say they did not expect anyone to call," Blouin notes. "They are happy to be asked their opinions."

The account executive responsible for the departing client conducts an exit interview, and the data from that are collated and pored over. For Blouin, this is a mission that she takes seriously, and just as hospitals are encouraged to practice based on data and evidence, she mimics that. The Joint Commission team works together to adapt its practice to meet the expectations of its customers.

For more information on this topic, contact:

  • Sandy Severson, RN, MBA, CPHQ, Senior Director Quality Management Services, Banner Health, Phoenix, AZ. Telephone: (602) 747-7562. Email:
  • Ann Scott Blouin, RN, Ph.D., FACHE, Executive Vice President, Customer Relations, TheJoint Commission, Oakbrook Terrace, IL. Email:
  • David James, MD, JD, CPE, Chief Medical Officer, Senior Vice President Medical Operations, ProMedica, Toledo, OH. Email: