Hospital 'fires' JCAHO, stays in business
Hospital 'fires' JCAHO, stays in business
ISO 9000 boosts facility above minimum standards
In 1993, Leonard Spears, vice president and chief operating officer of American Legion Hospital in Crowley, LA, was feeling increasing pressure from Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements. Keeping up with the seemingly perpetual changes required a steady output of staff time and training fees. "It was a source of distress to ourselves and others," he says.
The last straw came when JCAHO reported that some of the medical staff's scores were in the nation's bottom fifth percentile. "We sent a letter to the Joint Commission saying we fired them," Spears says. In looking for an alternative to JCAHO accreditation, Spears thought he could mobilize his peers to generate something through the Chicago-based American Hospital Association. "Others were in agreement with us, but they faded away when it was time for action."
That left American Legion to figure its own way of doing business without the accreditation it had held for the better part of its nearly 70-year history. With 140 acute and 38 psychiatric beds, the hospital serves 35,000 people in and around Crowley. Keeping Medicare and Medicaid reimbursements presented no difficulty. "But we wanted to do more than meet minimum requirements," he notes.
Beyond JCAHO standards
Spears stumbled across the ISO 9000 through a colleague from a local manufacturing company. The program offered the type of quality assurance support Spears sought as an alternative to accreditation. He likes its nonprescriptive nature. "ISO 9000 lets the organization run itself. They insist that you have a quality standard to direct how you do your service. It helps us, the management and employees, create a system of continuously upgrading patient care." (For more on ISO 9000, see this month's cover story and "Elements of 'Big 3' Quality Programs," p. 93.)
The continuous quality assurance impact of ISO 9000 is lacking in the accreditation process where, Spears contends, "Everybody works hard for one year before the site visit, then they heave a sigh of relief because it's over. In another three years, they do it all over again."
"With ISO 9000, an internal audit is required. It could be by your own staff. But we have an outside consultant do an unannounced quarterly internal audit of a department chosen at random. Every three years we have a general audit. Our people are aware that at any time they could be audited."
Spears also praises the constancy of ISO 9000 standards. It's the user who designs and revises them. "It has done a wonderful job of getting our employees involved in setting quality standards," he notes, "but it does take a few years."
Like any quality improvement program, ISO 9000 can be put to the wrong use. Spears warns that if you bring it in as a foil for cost cutting, employee support will dry up in a hurry. "We have to separate the two 'E words' - efficiency and effectiveness." The accountants are concerned with efficiency, as they should be, he says. But with cost cutting, your employees have a right to know how you're planning to do it, or they'll suspect all quality improvement programs as ways to cut staff, he says.
At American Legion hospital, the "E word" pertaining to patient care effectiveness comes under the domain of Angie Wadlington, director of practice management/quality. Spears says facilities using ISO 9000 will want to build up their patient care outcomes review processes since that is not integral to the program. American Legion augments its ISO 9000 with separate outcome review processes.
ISO 9000 and accreditation can coexist
The two quality programs are not mutually exclusive. Spears theorizes that American Legion's ISO 9000 certification was much easier because it did meet JCAHO standards for so many years. Actually, he says, "a lot of the ISO 9000 standards are lifted from the accreditation guidelines." The biggest hurdle American Legion faced with ISO 9000 was in document control. "I don't know of any hospital that could pass that part without significant effort."
Admitting to second thoughts immediately after parting ways with JCAHO, Spears looks back on it as a positive move for his facility. He says that ISO 9000 has caught on as the quality standard in his area. Even the city's administrative offices are using it. Today, Spears often receives calls from hospitals contemplating a move similar to the one he made five years ago.
"We didn't set out to be mavericks when we fired the Commission," he remarks, "but I guess we're looked at as mavericks."
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