JCAHO Update for Infection Control

JCAHO hails hospital quality care gains

A quality improvement method using standardized measures to track hospital performance for pneumonia care and other conditions was strongly validated in a study by researchers at the Joint Commission on Accreditation of Healthcare Organizations.

Published in the New England Journal of Medicine, the authors "observed consistent improvement in measures reflecting the process of care for acute myocardial infarction, heart failure, and pneumonia."1 Interestingly, the researchers could not definitely say how the project resulted in the improvements, but noted that they attempted to "stimulate continuous improvement through quarterly feedback about results." As veteran epidemiologist Robert Haley, MD, has frequently noted, infection rates and other quality measures will improve if data are collected and reported back to the clinicians directly involved in the care.

"Although the impetus for the improvement cannot be pinpointed, the improvement in measures reflecting the quality of care for acute myocardial infarction, heart failure, and pneumonia remains very encouraging," the authors added. "If the current rates of change were to be maintained — which is by no means a certainty — the mean performance for hospitals that began the study in the lowest performance quartile would be expected to reach rates of 90% for 11 of the 14 rate-based process measures by the first quarter of 2006."

Given the success of the project, infection control professionals may see such JCAHO improvement efforts applied to a broader range of quality outcomes — including others related to preventing infections. The authors said data were largely collected before the widespread public reporting of hospital data or the implementation of pay-for-performance initiatives. "As the JCAHO’s database of performance measures expands with each passing quarter, it will offer an opportunity to track the effect of national public reporting and pay-for-performance initiatives to a degree that once was not possible," they added.


  1. Williams SC. Schmaltz SP, Morton DJ. Quality of care in U.S. hospitals as reflected by standardized measures, 2002–2004.New Engl J Med 2005: 353:255-264.