The Role of Joint Commission on Accreditation of Healthcare Organizations Standards

Lawyers often ask me to explain how I use the JCAHO standards in evaluating medical malpractice cases and whether this evaluation will assist them in their pursuit of justice for their clients. I usually start my explanation with a brief history of the Joint Commission and its role in hospital operations and reimbursement.

The JCAHO was formed in 1951 by several professional organizations: the American Hospital Association, the American College of Physicians, the American College of Surgeons, and the American Medical Association. Its mission is “To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value”. To accomplish this mission, the JCAHO has developed standards for accrediting hospitals and other types of healthcare organizations that focus on the delivery of the highest possible quality patient care as well as ensuring a safe environment for patients and staff. While a hospital’s participation in the JCAHO accreditation is technically voluntary, the federal government requires hospitals to meet their standards in order to receive reimbursement from the Medicare and Medicaid programs. Obviously, this requirement essentially mandates that all hospitals meet the JCAHO standards or one of the few other organizations that are included in this payment mandate. While the process is voluntary, it is important to understand that the standards are mandatory and that receiving a full accreditation from the JCAHO is still the gold standard for a hospital’s quality of care.

The JCAHO is continuously updating their standards and issues a new standards manual each year. While the actual changes made each year may be minimal, they often occur as a result of information sent to the JCAHO by hospitals regarding medical errors under the so-called Sentinel Event standard. For our purposes, it is important to use the correct annual edition of the standards in evaluating a medical malpractice case.

The accreditation process focuses on following randomly selected actual patients to care from admission to discharge. The strength of this process is that it does look at actual care processes rather than the former process which only looked at whether the hospital complied with the standards on paper. Its weakness is obviously that most patient care is performed correctly and most patients receive high-quality care while being accredited does not mean that every standard was complied with and some important processes may not be evaluated in the every-three-year survey process. Hence, a fully accredited hospital may have some issues and problems that the accreditation process does not uncover.

With this background in mind, I recommend using the standards to evaluate the hospital’s corporate responsibilities in delivering care to their patients. The standards include such things as the board’s responsibility to lead the hospital, the administrator’s job requirements, how physician credentialing should be accomplished and the overall delineation of the way patient care should be delivered. The standards require the hospital to have a number of policies and procedures in place and further require that they are actually followed uniformly for all patients regardless of their ability to pay or the type of insurance they have. While it is important to note that these policies must exist, the JCAHO does not typically prescribe how the hospital should accomplish the required activities. Each hospital has a great deal of latitude in how they do things and this often provides us with key insights into how seriously the hospital takes this process. For example, the hospital should look at all key policies annually and update them as needed based on their own experience as well as industry information regarding changing processes. Hospitals often do not do this on a regular basis and it is not unusual for me to see policies that have not really been changed for many years.

In today’s complex healthcare delivery environment it is crucial for a hospital to understand that its corporate responsibilities must be taken seriously and I often counsel hospitals on how to improve their risk management processes. Conversely, in my work with patient’s counsel I look for evidence that any deviation in implementing these corporate responsibilities caused the hospital to bear some responsibility for a medical malpractice event. In my opinion, this evaluation should take place in every case in order to determine if the hospital has essentially participated in the process that caused the case to occur.