The Joint Commission Survey and
What It Tells You
In most hospitals, when you enter the lobby you will see a large plaque on the wall stating that the facility was "accredited" or "accredited with commendation" by the Joint Commission on Accreditation of Healthcare Organizations. JCAHO is a not-for-profit organization whose members are hospitals, nursing homes, home-care agencies, and in-home surgical supply and medical equipment vendors. The surveyors thoroughly inspect all areas of the health-care facility for environmental safety, cleanliness, documentation, emergency procedures, patient care protocols, and credentialing of professional staff, just to name a few. They also work from a clearly delineated set of standards and rate the hospital as to the percentage of compliance with all the criteria. This system is one of self-regulation and based on the now known fact that accredited hospitals accidentally kill approximately 100,000 and injure about 300,000 people per year, it is an abject failure.
Notwithstanding the sophistication and meticulousness of these surveys, there is one major reason for the gargantuan letdown: in all cases JCAHO notifies the surveyed facilities about three months in advance of the inspection, which occurs once every three years. Therefore, any representation that a JCAHO accreditation assures quality of care is suspect. The accreditation only shows that the facility has been compliant with JCAHO standards for about thirty days before and during the survey once every three years.
Moving forward, the hospital scene during the three-month period prior to the inspection is a flurry of activity, with mock surveys, managers' meetings, staff meetings, and scrambling to provide previously neglected in-service and to update personnel files and patient documentation. The level of management scrutiny and dedication to upholding the highest standards is at its peak during this period, and it is a time of high levels of stress and anxiety, long hours, and fear of job loss. The period that follows is one of celebration for the relief from the stress. Unfortunately, this is followed by the relaxation phase when everything slides back to the "normal" way of doing things, with the supervision becoming much less stringent. In many instances, the usual way of managing is blatantly substandard, with an illusion of propriety displayed for the surveyors during their stay. As soon as the survey is finished, the mirage evaporates.
For example, a hospital in New York City spent about $30 million building a high-tech emergency suite designated as a level I trauma center. The problem was that it was too small to serve the needs of the surrounding community. Consequently, the hospital management adopted a policy of placing two patients in each of the cubicles that were designed for only one. This was being done in violation of JCAHO standards and health department regulations. The CEO issued strict instructions prohibiting the diversion of patients to other facilities because diverting patients is equivalent to diverting revenue.
After a year of this state-of-the-art facility's being continuously operated in the aforesaid substandard mode, JCAHO notified the hospital that the surveyors were coming in ninety days for the accreditation inspection. The management immediately instituted a hospital-wide program of mock surveys, in-service conferences, patient chart review, and examination of the professional credentialing files to bring everything up to standard. Not surprisingly, during the week that the surveyors were on the premises, the emergency department had only one patient per cubicle. This was accomplished by diverting ambulances to other hospitals during peak times and speeding up the process of admitting or discharging patients from the emergency room. In short, the hospital became generally more efficient during the survey with more staff people working overtime. The overcrowding and chaotic ambience resumed as soon as the inspectors were gone because the ambulances were no longer being diverted and the extra overtime was eliminated.
During the survey preparatory period, the hospital's nursing education department hired me as a consultant to review the credentialing files of the emergency department nurses and bring them up to date for the survey. There had not been a nurse educator assigned to the emergency department for almost one year, so it was no surprise that when I started to review the files, I found that more than 50 percent of them were missing one or more requirements. The missing items were continuing education courses and skills evaluations including, in some cases, the basic and advanced life-support certification. In short, about half the nurses in the emergency department were unqualified to work there. Furthermore, the only motivation for updating those files was the JCAHO survey.
I worked feverishly with another educator and the staff nurses to provide classes and testing. The day before the survey, one of ten files still had something missing. The director told me to stay home during the survey because my job was done. Afterward, she told me that the education department got a perfect rating. Somehow, the surveyors never saw the files with missing requirements. Whether that was the result of hiding the incomplete files or just plain luck, I do not know. However, the fact remains that the surveyors never knew about the way in which the education department normally conducted its affairs and that the "perfect score" was undeserved.
Notwithstanding the reality that the system of self-regulation in the hospital and nursing home industry is nothing more than an elaborate charade, the public has the right to hold the health facilities accountable for failure to adhere to the standards promulgated by JCAHO. Such standards include the following:
- appropriate skill level of those performing invasive procedures
- environmental safety
- adherence to patients' rights
- infection control
- prevention of medication errors
- prevention of decubitus ulcers
- prevention of falls
- maintenance of biomedical equipment
- emergency supplies on hand
- emergency protocols in place
- staff knowledge of emergency procedures response time to patient calls for assistance
This information should be useful as a checklist when having a conversation with a hospital manager about the quality of services that you or a loved one receives. The more knowledge you have about how things are supposed to be, the more responsive those managers will become to your complaints. JCAHO publishes several volumes of standards by which the organization conducts surveys. More information is available at jcaho.org.
Nonetheless, let there be no misunderstanding—it takes a huge amount of effort for a hospital or nursing home to receive a greater than 90 percent compliance rating (as most of them do). Management personnel have to put in long hours and conduct frequent inspections and scrutiny of their staff. Ideally, this is how management should be conducting itself at all times. In fairness, I don't know if it is possible to maintain such a gargantuan effort on a perpetual basis. Managers would burn out, and staff people would be running for the exits. On the other hand, a constant vigil with even a fraction of the vigor found during survey time would save lives.