Should you tell the Joint Commission to take a hike? Maybe, but be careful
Fed up with threats and hassle, some risk managers seek alternatives
If you've been following the controversy over the sentinel event policy and worrying about its many threats to confidentiality, you've probably thought of this appealing option: What if your facility just told the Joint Commission on the Accreditation of Healthcare Organizations to get lost? Wouldn't that be fun?
Yes, it most certainly would. But would it be wise? Sources tell Health care Risk Management that dropping your JCAHO accreditation is a reasonable option, and many facilities are considering it. Although going without Joint Commission accreditation may seem like a radical response, more and more risk managers are seeing it as an appropriate reaction to what they call the JCAHO's increasing tyranny.
Chances are good you wouldn't be the first person in your organization to suggest the idea. Other hospital administrators probably have been mulling it over for years, but new liability issues might prompt risk managers to suggest the time is right for a change.
Hospital leaders have kicked around the idea of foregoing JCAHO accreditation for a long time, but few hospitals actually have decided to make the move, says Peggy Nakamura, RN, MBA, JD, DFASHRM, executive director of risk management and associate counsel at Adventist Health in Roseville, CA. Nakamura also is the immediate past president of the American Society for Healthcare Risk Manage ment in Chicago. She tells HRM she has heard a lot of risk managers discussing the move, and the recent controversy over sentinel events has intensified the debate.
"I think it's worth pursuing the idea," she says. "There are many aspects to that decision, and you can't take it lightly. You've had other hospital administrators thinking about this for other reasons, like the cost of preparing for a Joint Commission survey, but now the risk manager is looking at some liability issues and joining the debate."
Dropping JCAHO accreditation would be a major decision for the hospital, and Nakamura says it won't be made by a risk manager alone. But the risk manager should play an important role in advising the hospital's governing board about the liability issues involved with either staying with the JCAHO or dropping it.
"Like most business decisions, you should be presenting the risks and assisting with risk/benefit and cost/benefit analyses," Nakamura says. "And there are some significant risks to look at with either option."
When considering the move, immediately look at your provider arrangements and see if they require JCAHO accreditation. Many arrangements make that a requirement, but some will use looser language that allows you to ensure quality in some other way, such as state or fed er al inspections. Even if provider arrangements specify that you must have JCAHO accreditation, it may be possible to renegotiate them.
"The problem is that the Joint Commission has a lot of name recognition, and you're going to run into a lot of payers who expect you to have accreditation with them," Nakamura says. "You might be able to explain to them why you want to use some thing else and get them to rewrite their requirements, but don't be surprised if you hit some resistance from organizations that think it's just mandatory to have Joint Commission accreditation."
Nakamura also expresses some concern over whether bond language might require JCAHO accreditation, and she says some malpractice insurers also might have concerns. But at least one major health care liability insurer says there might be no problem with giving the JCAHO the boot. Annie Stoeckmann, RN, JD, director of risk management and education at the Farmers Insurance Group of Companies in Los Angeles, says she also has heard risk managers discussing the idea lately, and it doesn't surprise her.
"We can't say at this point whether losing JCAHO accreditation is a good idea or not for our insureds, but I can say that it's not necessarily something we would see as a negative when evaluating a provider," she says. "We would take a look at what you have in place instead of the Joint Commission, and it certainly would be an important concern. But there are other alternatives to JCAHO accreditation and we have used them as part of our underwriting evaluations in the past."
As examples, Stoeckmann cites accreditation programs offered by recognized authorities such as state licensing agencies, quality assurance organizations, and specialty organizations. Farmers Insurance would be interested in seeing whether those alternatives offer appropriate review of a provider's ability to deliver safe, quality care, she says. She hints that one reason the insurer would consider the alternatives is that the liability risks associated with JCAHO accreditation are growing so steadily, mostly due to the sentinel event policy.
"We're very concerned about the impact sentinel event reporting will have on an organization," she says. "Farmers believes that reporting a sentinel event to the Joint Commission is an insured's decision to make after they consult with legal counsel and take everything into consideration. It is completely voluntary. It's your own business decision to make, but we want you to really understand the risks of reporting."
Medicare status is a major sticking point
Of course, you can't just forego JCAHO accreditation and not replace it with something else. To be competitive in the health care community, you must have a brand-name seal of approv al. That will be necessary for participation in some government programs and, to a lesser degree, to assure patients you're a top-quality insti tution. As much as health care providers want to think patients are greatly impressed by JCAHO accreditation with commendation or other seals of approval, chances are good they don't even know what those honors mean.
"I never felt that the public had any familiarity with Joint Commission accreditation," Nakamura says. "And after all, if anyone knows anything about the Joint Commission, they'd probably understand why you're considering something else."
One option is to forego JCAHO accreditation and just undergo annual inspections by the Health Care Financing Administration. If your only concern is to be able to participate in Medicare, that could work. But most third-party payers require participation in some sort of quality program. One possibility for health care organizations is ISO 9000.
ISO 9000 knowledge is scarce
Don't feel bad if you know little or nothing about ISO 9000 certification. Few health care professionals do, and the health care community is just now starting to get involved, says Kathleen Stillwell, RN, MPA, HSA, a risk management and quality consultant in Los Angeles. Stillwell helps health care organizations learn about ISO 9000 and pursue the certification, but she says few organizations have gone so far as to rely on ISO 9000 as their assurance of quality.
"Absolutely, you would be on the cutting edge if you decided to drop your Joint Commission accreditation and go with ISO 9000 instead," Stillwell says. "ISO is just now beginning to make inroads into health care."
ISO 9000 has been implemented in other in dustries for more than 10 years. Stillwell says the quality program is just as applicable to health care as it is to auto manufacturing, for instance, because it concentrates on universal quality elements like processes, documentation, and materials management.
Stillwell says it is entirely reasonable for risk managers to consider dropping JCAHO accreditation, whether it's because of frustration with issues such as the sentinel event policy, the cost of preparing for inspections, or exasperation with JCAHO's whole attitude.
"It is a misconception that there is nothing other than the Joint Commission for assuring quality in your organization," she says. "There are hundreds of hospitals that are not Joint Commission-certified, relying instead on the annual inspections from HCFA. That is an option, and so is ISO 9000."
Is either option right for your hospital? That huge decision is unlikely to be made by a risk manager. But Stillwell says the risk manager does have a responsibility to present options to the organization's senior executives, and you may enhance your standing in the organization by doing so. Particularly if you see liability risks increasing because of JCAHO policies, it may be incumbent upon you to suggest that the CEO look at alternatives such as ISO 9000.
"A great deal of the move to ISO 9000 in health care will be driven by payers, so it won't be an internal move in many cases," Stillwell says. "Managed care payers will start requiring ISO 9000 participation from their providers, and that will spur some organizations to look at that option. I think we're looking at a five-year curve here. There will be a lot more health care organizations involved in ISO in five years."
One of the big problems with dropping Joint Commission accreditation in favor of ISO 9000 is that ISO 9000 does not have "deemed status" with Medicare. The JCAHO's deemed status means health care organizations with JCAHO accreditation don't have to undergo separate review by HCFA to participate in Medicare. Those certified under ISO 9000 instead of JCAHO will have to undergo HCFA surveys every 10 years or so, at an average cost of $3,516 per survey.
ISO 9000 advocates say they hope the program will receive deemed status within a few years, but there is no indication of how soon that might happen. And Stillwell points out that ISO 9000 certification might not move you completely away from the JCAHO bureaucracy. She predicts that, as ISO 9000 certification becomes more common in health care, the Joint Commis sion will become involved as an auditor, meaning it could be the inspector that determines whether you're complying with ISO 9000 requirements.
Hospital opts out, finds less hassle
One hospital that decided to forego JCAHO accreditation is American Legion Hospital in Crowley, LA. After 33 years of traditional JCAHO accreditation, the 178-bed hospital became one of the first to switch to ISO 9000 certification. Chief executive officer Leonard Spears says the decision was made four years ago because the Joint Commission accreditation had become "overly prescriptive and bureaucratic." And that was before the most recent developments with the JCAHO. He says "there is widespread dissatisfaction with JCAHO" and that his hospital wanted to find a way to assure quality without having to deal with the Joint Commission.
ISO 9000 certification was determined to be the best alternative, so the hospital contracted with Kemper Registrar Services in Flemington, NJ. The company helped the hospital prepare for the audit, involving hospital staff in all aspects of the preparation.
"One of the most arduous tasks was to adapt our document and data-control system to become compatible with theirs," Spears says. Though the hospital had maintained detailed records on its operation and patients, its record keeping had to be streamlined and merged into one system of data flow and documentation.
Because ISO 9000 does not have deemed status for Medicare, the certification could not replace the functions of the previous JCAHO certification; the hospital had to undergo a state quality survey and a HCFA survey. Spears says he's satisfied that hospital leaders made the right decision in foregoing the JCAHO accreditation.
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