Will Baldrige or ISO 9000 ever replace JCAHO?
Will Baldrige or ISO 9000 ever replace JCAHO?
QI/TQM discovered a lively debate surrounding the relative merits of two quality programs: The Baldrige Criteria for Performance Excellence, co-administered by the National Institute of Standards and Technology (NIST) in Gaithersburg, MD, and the American Society for Quality in Milwaukee, and the ISO 9000, administered by the American National Standards Institute in New York City.
As you might guess, each has its strengths and limitations, proponents, and skeptics. Consensus upholds accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) as the accepted baseline standard for health care, and that's not likely to change any time soon. Most of our sources see accreditation as a prerequisite to doing business because it's so closely tied to Medicare reimbursement.
Leonard Spears takes exception, however. As vice president and chief operating officer of American Legion Hospital in Crowley, LA, Spears dropped accreditation in 1993. He grew weary of what he deems "perpetual change" in the accreditation requirements. After his bold action, Spears invited Health Care Financing Administration (HCFA) officials to inspect the hospital to determine whether it still qualified for Medicare reimbursement. "Medicare came, and of course, we passed easily," Spears explains. "HCFA said, 'You do more than you have to do,' which didn't surprise us. We had passed their standards for years." (Learn more about the American Legion Hospital's experience and how it ensures quality, even without JCAHO accreditation, from the case profile "Hospital 'fires' JCAHO and stays in business," p. 95.)
ISO 9000 gets mixed appraisals
Mike Rudolf, MBA, director of improvement services at VHA-East Coast in Cranbury, NJ, sees Baldrige self-assessments as challenge to exceed minimum standards rather than a replacement of accreditation. The Baldrige criteria award 45% of the possible points on patient-based outcomes and others on measures such as an organization's community citizenship. (The diagram below illustrates the interplay among the criteria.)
For instance, Rudolph continues, "Accred itation gives you a pass/fail on things like how you handle 'red bag' waste [to dispose of potentially contaminated items]. If you followed Baldrige criteria, you would 'red bag' much more than you are legally responsible for because you would want your community to feel completely safe from any hazardous waste from your institution."
Sharon Donahue Hellwig, EdD, RN, director of Quality Improvement at Easton (PA) Hospital, thinks JCAHO is taking a similar turn. Observing a shift beyond the accreditation standards' earlier patient-centered focus, Hellwig says, "I'm pleased to see that the Joint Commission is moving clearly in the direction of the Baldrige criteria. It's becoming outcomes oriented. I can see a coming together of the programs."
The ISO 9000 has gotten mixed appraisals regarding its applicability as a systemwide quality tool. In Simmons view, it could bridge the departmental divisions that cause problems like several-hour waits for a hospital bed after a patient is admitted.
With its emphasis on functions and organizations as supplier-customer linkages, Simmons considers ISO 9000 a viable systemwide quality program. He observes, "It's catching on with a vengeance in health care."
That may be so, concedes Rudolf, "But it doesn't guarantee that the end product is good."
Spears concurs with Rudolf to a certain extent. "ISO 9000 does not focus on the outcome of a service as much as the condition and quality of the outcomes. In some patient care areas," he suggests, "you would want to beef up outcome review beyond what is built into ISO 9000." On the other hand, he doesn't see that as justification to reject it as an enterprisewide quality assurance program.
At systems like the Mayo Foundation in Rochester, MN, ISO 9000 is one piece of the large QI picture. Carleton Rider, continuous improvement officer at Mayo, describes it as particularly useful for functions involving high volumes of similar operations. For example, he says, "Our lab is interested in it because we analyze specimens from all over the world in markets where ISO 9000 is the standard. It's more for production than for service."
Differences notwithstanding, ISO 9000 and JCAHO representatives have collaborated with NIST in developing the Baldrige health care criteria. As for JCAHO, Harry Hertz, PhD, director of the Baldrige National Quality Program at NIST explains, "We've had an ongoing dialogue since 1994 with the intent from both parties to have nothing at cross purposes with each other."
While funding of a national Baldrige award for health care remains uncertain, the marketing value of state and regional awards haven't escaped notice. Hellwig, who earned qualification as a Baldrige examiner, notes that "in this market-driven economy, any time you can demonstrate excellence, it makes you more competitive."
Martin Mariner, vice president for quality at Corning (NY) Inc., (a 1995 national Baldrige winner for industry) agrees with Hellwig. "When we see a Baldrige winner, we're excited," he says. "That organization is really on track for being customer-focused in contrast to an inward focus on making profits and complying with regulations. The Baldrige is equivalent to a Pulitzer prize."
Speaking from a health care purchaser's point of view, Mariner explains how a health care Baldrige winner would be perceived. "They would be focused on us, their customers, so we would be getting good care," he says. "They would be competitive from a cost standpoint, which is always important to us. We would be delighted to associate with a system with those kinds of core values."
As the Baldrige health care criteria become widely disseminated, "we would certainly encourage our health care suppliers to consider adopting them," Mariner says. "We would not be heavy handed about it, but it would certainly be a differentiator in purchasing health care services."
When more is better
So you think it's insane to even imagine introducing another quality system to your stress-crazed associates? It takes tremendous effort just to maintain accreditation, so we asked our sources how realistic it might be to initiate a Baldrige self-assessment, as well. The feedback might surprise you.
Sue Lawrence, MS, CPHQ, administrator of Clinical Resource Management at Lehigh Valley Hospital in Allentown, PA, has fresh records because the hospital recently completed a site visit and won a local "Baby Baldrige" award. A team of 12 people began monthly meetings about 24 months prior to the visit while a core group of five met more often than that.
The last six months before the visit, everyone met weekly. On the other hand, the Baby Baldrige team award application took three months. "We looked at what was already going on," Lawrence says. "We just wrote up the story and sent it."
Hellwig's facility also completed a JCAHO site visit and Baldrige self-assessment recently. She notes that JCAHO preparation is easier, having done the Baldrige application. "Accredita tion is more clinically oriented," she observes, "while Baldrige is an umbrella for the whole organization."
(Baldrige health care criteria offer the flexibility of organizationwide, as well as team, process, or departmental application. Learn more about it in "Local Baldrige networks offer more than awards," below.)
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