Look out: Joint Commission could come every 18 months
Look out: Joint Commission could come every 18 months
Reviews will focus on performance improvement
A new white paper released by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO) outlines a set of prospective changes to its accreditation processes that could dramatically affect how hospitals prepare for Joint Commission surveys.
The JCAHO is suggesting a more frequent review process of roughly every 18 months, which, according to a white paper issued by the organization, is intended to "enhance the evaluation of critical patient safety and patient care functions and to achieve an accreditation process that remains consultative and focused on performance improvement."
According to Donna Larkin, a spokeswoman for the Joint Commission, "the goal is to make the accreditation process more relevant while reducing costs. But nothing is set in stone," she insists.
Consultant Marjorie Alderson, MPH, MSN, RN, CPHQ, president of the New York Association for Healthcare Quality in Brooklyn, says she shudders at the idea. "It could serve a certain purpose," she concedes, "because it does require you to revise, review, and change a lot of things you might let go if [the Joint Commission] were not overseeing your operation.
"However," she adds quickly, "it’s labor-intensive and extremely expensive. You have your entire top administrative team in the hospital day and night and over the weekends working on this. I find it to be extremely burdensome, particularly for academic medical centers. They have narrow profit margins to being with. They’re expected to have a balanced budget, and there is increased pressure from third-party payers. All of this makes it increasingly difficult to provide quality care for patients."
The JCAHO’s white paper claims that "the implementation options must preserve or enhance all the gains in rigor and credibility derived from our recent product redesign efforts." But the paper allows that the Joint Commission must address growing concerns by accredited organizations regarding the value of JCAHO accreditation.
Part of the proposal includes hospital self-assessment, reduced on-site survey time by approximately one day per 36 months, and a revised survey with consolidated group interview activity. The proposal also indicates that the Joint Commission wants to "maximize the use of the Internet and other technologies to enhance customer satisfaction and further reduce costs."
"But we want to actively engage the field in the accreditation process," says Larkin. "We’re looking for feedback from hospitals on what future accreditation should be. This is an opening for thought-provoking discussion."
"I believe it’s overkill," says Alderson. "The three-year cycle that they’ve done for years is fine, plus they do a number of unannounced checks. This seems to me to be more effective than reducing the cycle. To me, this looks like more of a revenue-generating plan for the Joint Commission. They’re in trouble financially, and in order to recoup, they’ll place more of a burden on hospitals."
Don Nielsen, MD, senior vice president for quality leadership at the American Hospital Association (AHA) in Chicago, sees it differently. "The JCAHO is setting up a model here with an action plan in which they go to the field to get feedback. We look at it as a positive step on the part of the Joint Commission that recognizes the value of the process re: the cost for some hospitals."
The white paper also addresses the skills and styles of the surveyors. According to the paper, the JCAHO would make an effort to provide "an infrastructure for surveyor development and management in the field" — a construct currently lacking in the survey process. Surveyors would be subject to certification and recertification. Survey teams might be created that combine generalist surveyors, analyst surveyors, and survey mentors or team leaders.
In addition, the Joint Commission envisions changes such as market research, town hall meetings, frequent written communications, advisory and focus groups, and pilot testing of the proposed elemental changes to the process. These factors all would be part of a concerted effort to improve communications.
Russ Massaro, the Joint Commission’s vice president of accreditation operations, told the AHA that changes discussed in the paper have been suggested by professionals in the field. The goal is to give health care institutions an incentive to comply with standards continuously, reducing the need to ramp up for surveys a year in advance. Massaro said that the more frequent surveys, combined with other suggested changes, like self-assessments prior to surveys and the use of outcomes data and the Internet, won’t cost hospitals more.
"But we don’t need more regulations," argues Alderson. "People and time are very expensive. Hospitals can do this on their own without paying these outrageous fees to be surveyed."
"Actually, expense would vary from institution to institution," says Nielsen. "Some maintain an ongoing state of compliance, which means they have minimal expense involved in preparing. Others need to ramp up every three years to be sure they’re on track."
The JCAHO white paper emphasizes that the new approach would lead to more in-depth assessment of critical patient care and safety issues. This could ultimately lead to higher productivity if it includes such things as ORYX performance measures and a self-assessment process for hospitals before they are surveyed. Posting data on the Internet to encourage constant attention to JCAHO standards will also help hospitals to maintain compliance.
The JCAHO guidelines for implementation suggest the accreditation process should:
• increase the real and perceived value to accredited organizations;
• cause the public to have greater confidence that organizations are in compliance with standards at all times;
• be acceptable to deeming authorities and purchasers;
• decrease costs to accredited organizations;
• decrease costs to the Joint Commission;
• increase customer and staff satisfaction;
• support the perception among accredited organizations that accreditation is more of a service than a commodity.
The JCAHO acknowledges that accredited organizations have been increasingly vocal about the costs of accreditation and the issue of value vs. expense. Without using numbers, the Joint Commission performs a cost/benefit analysis of the proposed changes by noting the major elements of cost and benefit.
Cost elements include the fee; ramp-up costs related to staff time consumption and diversion; consultants, if used; opportunity costs; ORYX-related costs; and the cost of meeting the standards per se. Benefit elements include: template and driver for good operations; template and driver for integration of departments and services; risk reduction for patients; lever for performance improvement; public trust and validation; financial benefits (Medicare, contracts, etc.); market differentiation; and a general "raising of the bar" nationally.
Ongoing compliance means no costly ramp-up
The Joint Commission claims that the system would expect organizations to be in compliance at all times and be able to demonstrate that compliance at any time. It looks at perceived advantages — less intensive consultation, less ramp-up, only the usual, ongoing ORYX costs — and describes them as an "investment" rather than a "cost." It suggests the Joint Commission savings from the model could "control prices in a competitive environment." Thus, the Joint Commission would become "more a service than a commodity."
"We’re actually trying to determine what the future accreditation system should be," says Larkin.
Nielsen sees the proposed changes as a good thing. "It offers a lot more mechanisms for helping institutions to comply — the self-assessment, the ORYX performance measures, use of outcome data," he says.
The changes could lead to a significant overhaul of the accreditation process. Hospitals will be encouraged to provide input and feedback over the coming months.
Still, the JCAHO claims it’s all a concept waiting to be developed. No rules are in place. "We’re looking for feedback," insists Larkin. "Absolutely nothing has been decided yet."
"It’s very early in the game," agrees Nielsen. "But it has many possibilities."
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