Joint Commission on Accreditation of Healthcare Organizations - Research Paper Example

 Healthcare organizations are controlled by the local, state or federal laws and regulations; the means of interacting with the organization is through the accrediting body that helps in presenting the best performing groups. One of the best known private U.S.A. based non-profit Accreditation Organization to improve the safety and care by setting certain healthcare standards is Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which issues the credit only to those organizations that meet the desired standards. HISTORY OF JCAHO Ernest Codman, M.D. proposed “end result system of hospital standardization” that determines the effectiveness of treatment and if it were ineffective then determines the reasons for its ineffectiveness. In 1918 the American College of Surgeons who followed this “end result” and started to develop Minimum Standards for Hospitals conducted the first on-site inspection of hospitals. The standard of care improved overtime with the American College of Physicians (ACP), American Hospital Association (AHA), American Medical Association (AMA) and Canadian Medical Association (CMA) joining the ACS to form the Joint Commission on Accreditation of Hospitals (JCAH), an independent not-for-profit organization providing voluntary accreditation. Later ACS transfers its Hospital Standardization Program to JCAH offering the accreditation to hospitals which later published “Standards for Hospital Accreditation” in 1953. JCAH began to charge for surveys and by the pass of Medicare Act in 1965, hospitals accredited by JCAH were deemed to be in compliance with Medicare Conditions of Participation for Hospitals thus being able to participate in Medicare and Medicaid programs. In the later years many changes were brought about and finally the organization name changes to Joint Commission on Accreditation of Healthcare Organizations (JCAHO) for the expanded scope of activities and “Agenda for Change” was launched to emphasize on the actual organization performance. Later as time passed the Sentinel Event Policy and the National Patient Safety Goals are established. Most recently the Joint Commission’s Report on Quality and Safety 2008 shows that the accredited hospitals have improved the quality of patient care. JOINT COMMISSION OF ACCREDITATION OF HEALTHCARE ORGANIZATION The mission of Joint Commission on Accreditation of Healthcare Organization (JCAHO) is “To continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.” The JCAHO certifies 16,000 healthcare organizations, this shows the act of recognition by the Joint Commission is nationwide highlighting the commitment of the commission in meeting their standards of excellence and performance. The Joint Commission conducts periodical surveys to verify whether the organization complies with the set standards. The standards set by the JCAHO are “Elements of Performance” (EP), Human Resources (HR), Leadership (LD) and Environment of Care (EC) which are in turn related to the federal regulations. The failure to meet these standards of JCAHO would result in losing the accreditation and a loss of money from the Medicare and Medicaid programs, however the organization is not given a fine is it does not meet the standards. These insurance programs are funded by the federal and state governments and desires that the organization is accredited by JCAHO. These accreditation standards are update on a yearly basis by the Joint Commission which is then posted on its Website, to make it available for anyone including institutions, practitioners, patients etc. Organizations must undergo the on-site, random, unannounced surveys by the Joint Commission to earn and maintain the Gold Seal of Approval every three years. Joint Commission Accredited Organizations are: · Hospitals · Long Term Care Facilities · Home Care Organizations · Clinical Laboratories · Healthcare Networks · Behavioral Healthcare Facilities and · Office-Based Surgery Practices. Benefits of the accreditation and certification are: · Gain confidence of community in regard to the quality and safety of care · Improve risk management · Professional staff recruitment and enhancing staff education · Used to meet the Medicare Certification Requirements and · Enhances the overall confidence. JOINT COMMISSION MISSION-RELATED COMMITMENTS To ensure and improve the quality and safety of care to the public Joint Commission maintains certain commitments like: · To enhance the value of accreditation and certification programs continuously. The Joint Commission makes sure that the programs are relevant, patient-centered and integral to the performance improvement activities of healthcare organizations. · To develop, utilize and maintain valid and reliable performance measures. · To ensure that the accreditation process is available to the public. · To making the safety of the patient necessary in all accredited organizations accomplished through the standards and policies of Joint Commission. THE WAY JOINT COMMISSION WORKS Every hospital provides its accreditation details to the public along with the date on which the organization was awarded with the seal thus stating that it meets the desired standards, but it does not provide any access to its underlying details to the public. It was observed that the hospitals in the USA were motivated to perform well during the period of the Joint Commission surveys as the accredited organizations are required to meet the Medicare and Medicaid certification requirements to gain reimbursement from these organizations. However the Joint Commission had to face criticism on their ways of operation within the USA. The Joint Commission usually informed the organization about their inspection in advance, this was the way they operated in the past. Later there were certain serious problems as the accredited hospitals did not deliver the desired care leading to the publishing of various articles in Washington Post and Boston Globe that stated that almost 99% of the hospitals accredited by Joint Commission did not meet the standards. Joint Commission responded to these criticisms and started to schedule unannounced evaluations of the organization, which sorted out the problems as the hospitals were not able to prepare for these surveys and had to maintain the adequate standards. The Joint Commission uses salaried employees to conduct these surveys in the healthcare organizations to evaluate their facilities and operational practices. ACCREDITED PROGRAMS BY JCAHO There are various accredited programs by the Joint Commission of Accreditation of Healthcare Organization. They are: · Ambulatory Care · Behavioral Health Care · Critical Access Hospitals · Disease-Specific Care · Health Care Staffing Services · Home Care · Hospitals · Laboratories · Long Term Care · Office-Based Surgery Practices THE JOINT COMMISSIONS ACCREDITATION PROCESS The accreditation process is through an on-site survey by the Joint Commission conducted more than once in three years. The main objective to conduct these surveys is to evaluate the hospital, educate and guide the staff to improve the overall performance. First a survey team including three trained and experienced healthcare professionals comprising of physicians, nurses and administrators visit the healthcare organization. This survey team spends few days at the hospital having a thorough observation of the hospital activities, interview the staff and the patients and review the documents of the hospital in detail. The process of tracking a patient throughout the stay at the hospital and judge the organization based on the scoring about their performance. There are various types of surveys conducted: 1) Random announced validation surveys: It is a “resurvey” and JCAHO allows you to decline the visit. They occur within seven days of the regular survey lasting the same length as the regular survey. 2) Random unannounced on-site validation surveys of Evidence of Standard Compliance (ESC): The purpose of this survey is to validate the statements made in the ESCs to evaluate whether corrective actions were taken. They are unannounced, last a day and are free. 3) On-site Clarification Validation Surveys: This survey is for JCAHO to validate any clarifying evidence submitted and ensure it has awarded the correct accreditation decision. 4) On-site Validation Survey To Follow Immediate Threat-To-Life Situations: It ensures safe patient care. The President of JCAHO is the only person to dispatch this survey team which may be announced or unannounced. The survey team works in different departments of the hospital but evaluate the whole survey process as a team to reach to a conclusion about the organization performance. The performance scored is based on 100 and the organization is expected to improve the standard over the period of three year time. There are various types of Accreditation Categories: 1) Accreditation without type I recommendations 2) Accreditation with type I recommendations 3) Provisional accreditation 4) Conditional accreditation 5) Preliminary non-accreditation 6) Not accredited and 7) Accreditation with commendation. Each of these categories differs in few of the aspects thus awarding the organization the desired accreditation. However, all the defects are to be improved until the next accreditation survey thus increasing the performance of the organization in regards to the safety and care of the patient. References: 1) Joint Commission of Accreditation of Healthcare Organization 2) Joint Commission Environment of Care, Sept/Oct 2000 American Society of Healthcare Engineering of the American Hospital Association, < http://www.ashe.org/ashe/codes/jcaho/survey/accreditation_categories.html> Read More