Is JCAHO Effective? The MNA Safe Care Campaign Want’s Your Input

The MNA’s Statewide Campaign for Safe Care is working with other advocacy groups to increase accountability within the health care industry as the system continues on a path of corporatization and deregulation.  A priority for the campaign in the coming year will be to examine the effectiveness of external agencies in their oversight of the health care industry.  Specifically, the campaign will investigate the effectiveness and legitimacy of the Joint Commission on Accreditation of Health Care Organizations (JCAHO) in its role as the official monitor and arbiter of the safety and quality of the health care industry. 

Coincidental to this initiative, the Office of the Inspector General (OIG) of Health and Human Services (HHS) recently released a report called The External Review of Hospital Quality:  A Call for Greater Accountability. The report summarizes the strengths and weaknesses of hospital accreditation and certification processes, and the lack of accountability of the surveying agencies to the Health Care Finance Administration (HCFA).  HCFA is the federal agency charged with administration of Medicare and Medicaid and with ensuring that basic standards of quality care are delivered by those receiving federal reimbursement.  The report also outlines recommendations for improvement.

The report takes issue with the overly collegial approach utilized by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in its surveys and is critical of JCAHO’s inability to find problems not put directly before them. Specifically, JCAHO surveyors lack the time and expertise to delve below the surface to discover problems, and state agencies have neither the staff nor the priority to conduct unannounced, random surveys of facilities.

Why is this important to nurses and their patients in Massachusetts?  Because JCAHO accreditation is the key trigger for any serious monitoring of health care quality by the Mass. Department of Public Health, which licenses health care facilities in the state.  Jean Pontikis, who works for the Division of Health Care Quality at DPH, stated in an earlier article in this publication that the DPH will not visit or inspect acute care hospitals that have received JCAHO accreditation, because by virtue of that accreditation, DPH “deems” those hospitals to be safe. As a result, the only way DPH will visit a hospital and review its practices is in response to a complaint or in response to a major event, like a reported patient death.  If the accreditation process for hospitals is seriously flawed, then the reliance on that process to deem hospitals as worthy is also flawed and the public is not being protected. 

A number of nurses have submitted complaints to the MNA about the activities of JCAHO and its practices.   The MNA wants to learn more about what nurses think about JCAHO.  We are working with other advocacy groups to collect information to present to JCAHO and other policy makers to help them improve the system. 

You can help by sharing your experiences with JCAHO when they came to your hospital or facility to conduct an inspection.  For example:
 

• Were staffing levels increased only on days JCAHO inspectors were in the hospital?

• Were patient files updated only for the JCAHO inspection?

• Were you made aware of particular areas JCAHO would be concentrating on?

• How far in advance of the inspection did JCAHO inform your facility of the pending inspection?
• Were cosmetic changes made to the hospital to make it more presentable (walls painted, carpeting replaced, potted plants brought in, etc)?

• Were employees briefed on how to answer questions or how to speak to JCAHO surveyors?

• Were employees with grievances purposefully kept away from JCAHO inspectors?