The JCAHO Survey Makeover: Does it really make a Difference?
From the AATN (aatn.us)Team:
For years JCAHO has been the sole source of “certifying” health care providers and the data JCAHO and the Common Wealth Fund show clearly the JCAHO methods and requirements fail miserably to meet the needs of Health Care Providers
Below is an excerpt from Legal Nurse Consultant (http://legalnurseconsultanttom.com) on their their view of the culture JCAHO has helped create. Additionally, below is the latest score card showing just how much the JCAHO standards have impacted. Source the Commonwealth fund score card for 2008.
First a few questions to ponder.
First, as a health care professional or administrator, you should ask yourself a question, what is out there that goes beyond the “business as usual” of taking part of your budget every three years to hang the JCAHO certificate on your wall and is it adding value to your organization?
The second question is, does it pay or is it really mandated that health care providers be certified to JCAHO? And how many times will JCAHO change what they feel is meaningful to track?
JCAHO is loosing its long term control of being the ‘experts” in Health Care quality
The Tale of this story continues,
In 2004, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) instituted a major change in their survey methodology. They moved from conducting documentation and plant inspections to observing and following the care rendered to randomly selected patients from start to finish.
Kurt Patton, JCAHO’s executive director of the Hospital Accreditation Program, said on October 18, 2004 that the tracer methodology was going to improve the assessment of healthcare facilities; “After a complex analysis, we determined that tracing a patient’s stay in a facility is real assessment of a hospital organization.”
However, this event begs the question, “Does it really make a difference or are hospital providers still making the same mistakes?”Every hospital in America that wants to stay in business must be accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). This is a private not-for-profit group whose members are the organizations that are being scrutinized for the quality of their services. The pathway to being accredited is to submit to a survey every three years.With all deference to the JCAHO system, which is comprehensive in its detail, the certificate on the wall that imparts to the public that “this hospital has met the requirements for Joint Commission accreditation” is misleading. The consumer assumes that the health facility is continuously providing care consistent with the JCAHO standards. The usual scenario is that the subject hospital receives notification three months in advance of the survey. Once the notice arrives, the C.E.O. unofficially declares the hospital to be in “surrvey mode.” All personnel then quickly develop the “survey mentality.” Preparation then becomes the major focus. The management team brings in its consultants (usually ex-surveyors) and they start conducting mock surveys. Everyone is in a state of heightened awareness and the department managers begin putting in lots of extra hours. Staff people are reminded everyday about the survey and how to be on their best behavior and to display the highest quality of care. It’s a high stress grueling work environment and when the surveyors leave everyone heaves a big sigh of relief, the hospital management throws a party and then its business as usual until the next survey.Yet, the above scenario gives some insight to the disturbing reality that the average hospital in America does not conform to all of the JCAHO standards of care on a continuous basis. If they did, they wouldn’t have to spend so much time and effort preparing for the survey. Moreover, even more disturbing is the fact that in order to be in continuous compliance at current staff levels the managers would have to put in an inordinate amount of hours and virtually harass their subordinates into providing meticulous care and being able to answer all hypothetical testing questions related to clinical knowledge. The truth is that most people would quit any job that produced that much stress on a continuous basis or suffer from burnout. Thus it’s no wonder that hospital blunders are still the fifth leading cause of death in the United States today.In conclusion, the change in tactics from reviewing the documentation on procedures that already occurred to watching the performance of the health services does little to improve the ongoing level of compliance during the regular course of hospital operations. It does, however, improve the quality of clinical performance during this four month accreditation process. Hence, the safest hospitals may well be only those that have recently been notified of an upcoming JCAHO survey.
Its plain to see, an ISO based system with Lean Kaizen activities halts the “scramble” every three years and ingrains itself in the culture with a continuous improvement of the process, its inputs, its outputs, monitoring and measuring with INTERNAL AUDITING resources. Its a win win situation that JCAHO does not want to see happen, it might affect their “expert standings”. Its time to change and “Bring it Together as an Event”
Tags: APQP, Health QMS, ISO 9000, ISO 9001, QMS, The ISO Leadership Connection, TS 16949:2002