Major review of JCAHO requirements could bring welcome changes
Task force could throw out unnecessary standards
The Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations has launched a sweeping review of its hospital standards and requirements for demonstrating compliance with standards. Observers say this effort finally could make Joint Commission requirements less burdensome and more realistic.
Some health care providers say this is the kind of movement that everyone has wanted for so long, an admission from the Joint Commission that many of its standards are unnecessary or outdated, and that even the valid ones are full of confusing and misleading language. The more optimistic providers are hoping a new task force will bring meaningful change, but the pessimistic ones worry that the task force will be just another bureaucratic exercise with little result.
The Joint Commission certainly seems to have high hopes. Charles A. Mowell, executive vice president of the Joint Commission, says an 18-member task force will pinpoint which accreditation standards are most relevant to the safety and quality of patient care and target for elimination or modification those standards that do not contribute to good patient outcomes. In addition, the task force will identify "redundant and overly burdensome" documentation requirements with an eye toward streamlining and identifying areas that need more attention, Mowell says.
The project is part of what the Joint Commission calls a concerted effort to enhance the value and effectiveness of its accreditation process. The initiative will identify opportunities to streamline compliance activities for the nearly 5,000 accredited hospitals, allowing the organizations to pursue their efforts on improving patient care. The Joint Commission plans to conduct similar reviews for its seven other accreditation programs in the near future.
"Accreditation is about performance that directly impacts patient care and safety, not process and paperwork," Mowell says. "We want Joint Commission accreditation to continue to offer measurable benefits to hospitals and the patients they serve. A thorough, comprehensive assessment is crucial to ensure that Joint Commission standards accurately reflect the dynamic environment of health care today."
Only a few recently established standards — such as new requirements regarding pain management, patient safety, and restraint and seclusion — are exempt from scrutiny. Mowell says those standards already have been subject to the type of broad consensus-building efforts that the Joint Commission now is seeking for older requirements.
In addition, standards relating directly to Medicare Conditions of Participation (CoPs) for hospitals will receive special consideration. While the task force will identify potential additions, deletions, or modifications to this subset of standards, Mowell says the Joint Commission recognizes that these standards are the "law of the land" and are required for Medicare deeming. The task force’s ideas, however, may serve as the basis for Joint Commission discussions with the Health Care Financing Administration as changes are considered to CoPs.
Even those standards that will not be reviewed for substantive changes, such as the new pain management standard, still will be reviewed for procedural improvements, says Mark Crafton, MPA, CPHU, director of state relations for the Joint Commission.
"Those standards are not going to be reviewed in total because we feel like those more recent standards have already been through this intensive review from our customers as part of their development process," he says. "But how they demonstrate compliance — the paper and documentation that has to come together to demonstrate com- pliance — is on the table and can be discussed through this group."
The task force was established in an effort to make Joint Commission accreditation more valuable, Crafton says. "One component of the accreditation’s value is the relevancy of the standards. We’re also hearing from the field that the standards are not clear, that you need to hire consultants just to determine what the expectations are and what material needs to be shown to the surveyor. So we’ll be looking at the clarity of the standards anyway to make the language and documents easier for people in the field to understand."
Crafton says the task force is only the latest step in the Joint Commission’s efforts to improve its standards. An internal group has been reviewing the standards for months, but the task force is intended as a way to get input from the real world users of the standards.
Led by Ken Shull, FACHE, president of the South Carolina Hospital Association in West Columbia, the task force will include quality directors, medical records directors, nurses, physicians, engineers, risk managers, and other hospital leaders who have firsthand experience with Joint Commission accreditation standards and surveys. Furthermore, physician groups will be enlisted to specifically review medical staff standards.
Shull says he welcomes the opportunity to mold Joint Commission requirements in response to the everyday pragmatic concerns of health care providers. (See "Some providers unsure if task force will make a difference," in this issue.) "Many hospitals are faced with limited financial revenues, a national staffing crisis, and an ever-increasing burden of compliance demands imposed by state and federal regulators, accreditors, and managed care organizations," he says.
The criteria that the task force will consider in reviewing standards include:
- 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.
The Joint Commission also will ask the task force to identify common misconceptions and misinformation regarding requirements for demonstrating standards compliance. These fallacies often result in unnecessary costs for hospitals in both staff time and resources, Mowell says.
In addition to the comprehensive standards review, the Joint Commission in recent years has made a number of significant changes intended to enhance the evaluation of critical patient safety and patient care functions and to achieve an accreditation process that remains consultative and centered on performance improvement, Mowell says.
A redesigned on-site survey process now focuses more on individual-centered evaluations and allows more time for observation in patient care units. In addition, the Joint Commission is conducting pilot testing of a proposed model to assess staffing effectiveness and a more continuous survey process.
In addition to the substance of the standards themselves, such as the purpose of the standard and what it requires of providers, the task force also will look at how health care providers try to comply. The investigation will address not only what the Joint Commission expects and has specified for showing compliance, but what providers have come to think is necessary to show compliance. (For a summary of how the task force will operate and when results might be expected, see "Task force will study every chapter in manual," in this issue.)
"We hope that the group will help us, at the very least, streamline a lot of those standards and documentation," Crafton says. "We allow people to show compliance in a number of ways, and what happens a lot is that they pull together reams and reams of paper and put them in a binder on a table but then the surveyor makes decisions based on only one or two sheets of paper. A lot of wasted resource go into the months and months of preparation for the survey because we haven’t clearly articulated how to demonstrate compliance."
Shull, the task force chairman, says that goal may yield some of the most significant improvements. Much of the burden that people associate with Joint Commission surveys and compliance efforts actually may be unnecessary, he says. The Joint Commission has not made much effort in the past to dissuade providers from doing too much in showing compliance, and he says that has led to a lot of ill will toward the Joint Commission, even when a particular standard doesn’t require so much work.
"There’s good reason to believe that a lot of health care providers are doing a lot of things, taking a lot of extra steps, that are not necessary to comply with the standards," Shull says. "Either we heard some surveyor interpret it that way or some quality professional interpreted it that way, and now we have a whole set of things that we do even if surveyors don’t really expect it. We hope to identify those things and be able to say, You can just stop; it’s not necessary.’"
The task force should find plenty that needs to be changed, updated, or deleted entirely, Crafton says. The task force will conduct the first major review of Joint Commission standards since 1994, and seven years is a long time in the rapidly changing world of health care.
While it is too early to tell which particular standards might be changed, Crafton says, there is no doubt that the task force will yield many suggestions for improvement.
"There has been a lot of change in health care since 1994, and that includes some major changes that affect these standards," he says. "We want to know if the standards in that manual are not relevant any more. If there are standards that aren’t truly improving patient care and quality, we need to know about it, and those are the ones that are going to be targeted for change. We do think that this group of experts, the people on the front lines preparing their organizations for surveys, will find standards that are no longer applicable and find easier ways to prepare for the survey."
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