JCAHO to streamline its accreditation standards


JCAHO issues new standards for hospitals to meet


JCAHO to streamline its accreditation standards

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be cleaning house–and possibly sweeping out some standards it considers outmoded.

"We’ve received ongoing questions from our organizations about the value of our accrediting process," Mark Crafton, JCAHO’s director of state relations, told Hospital Pharmacist Report. "Many of our organizations have found some of our standards to be redundant and repetitive to the extent that they’ve hired consultants [to help interpret them]." Through a thorough evaluation of existing standards, JCAHO hopes to streamline compliance activities for its nearly 5,000 accredited hospitals, thus allowing the organizations to pursue their efforts to improve patient care, he said.

To get the initiative underway, a 19-member task force, which includes quality directors, risk managers, and other hospital leaders at JCAHO’s member organizations, was appointed. In the near future, each member of the task force, on an individual basis, will review JCAHO’s standards chapter by chapter. The task force members will determine if a standard is relevant and if it truly impacts patient care.

Besides the standards themselves, the task force will determine if the "evidence of performance" for the standards can be modified. For example, hospitals are often required to supply ample documentation to the surveyors. The task force will determine if all the currently required documentation is actually necessary, Crafton explained. It will also clarify common misconceptions and misinformation regarding requirements for demonstrating compliance with standards.

Some of the recently established standards–such as those dealing with pain management, patient safety, and restraint and seclusion–will be retained. These standards have already undergone the broad consensus-building efforts that JCAHO is now seeking for older requirements. The task force, however, will still study the "evidence of performance" requirements for those standards and may recommend some modifications, Crafton said.

Standards relating to Medicare Conditions of Participation (COPs) for hospitals will receive special consideration. While the task force will identify potential additions, deletions, or modifications to these particular standards, JCAHO recognizes that these new standards are the "law of the land," sanctioned by the Health Care Financing Administration (HCFA) and not subject to wording change. However, JCAHO hopes to use the recommendations of the task force as the basis for future discussions with HCFA about the standards, said Crafton.

Although there are no pharmacists on the task force, Crafton said he expects hospital pharmacists to play a pivotal role in the standard-review process. "I expect that these hospital leaders will consult hospital pharmacists about the standards that relate to the medication-use process," he said. And once the standards are reviewed, they will be subject to further scrutiny by JCAHO’s hospital professional and technical advisory committees (PTACs). Pharmacists serve on those committees, he said.

While the task force is expected to complete its review process by June 2002, a date has not been set for the streamlined version of the accreditation process to take effect. "We’re not sure if we’re going to make changes chapter by chapter or wait for all the chapters to be finished before we actually start making changes," Crafton explained.

The streamlined process can serve as a cost-saving measure for hospitals, Crafton observed. "This should reduce the evidence of compliance an organization needs to supply and thus reduce the time and energy spent on gathering that information." It will hopefully serve to reduce the need for consultants, as well, he added.

"Accreditation is about performance that directly impacts patient care and safety, not process and paperwork," said Charles A. Mowll, executive v.p., JCAHO. "We want JCAHO accreditation to continue to offer measurable benefits to hospitals and the patients they serve. A thorough, comprehensive assessment is crucial to ensure that JCAHO standards accurately reflect the dynamic environment of health care today."

Kathi Gannon

Eye on accreditation streamlining

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has appointed a task force to review its standards for relevance and redundancy. Specifically, the task force will consider the following criteria in its evaluation:

Continuing relevance in promoting patient safety or high-quality care

Redundancy with other external quality requirements

Applicability of standards to hospital care

Likelihood that compliance will be consistently evaluated

Extent to which compliance can actually be measured

Linkage to patient outcomes


Kathleen Gannon. JCAHO to streamline its accreditation standards.

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