The Joint Commission on Accreditation of Healthcare Organizations, or JCAHO, is a nonprofit organization based in the United States that accredits over 20,000 healthcare organizations and programs in the country. The JCAHO commonly is referred to as the Joint Commission in the healthcare industry and among governmental industry regulators on the federal and state levels. The Joint Commission is the successor of an organization established in 1951. Since then, it has grown to be the largest accreditation commission in the United States. The Joint Commission consists of a 21-member Board of Commissioners that include health care providers, educators and advocates. The commission employs over 1000 surveyors dedicated to improving the quality of patient care.
Goals and Objectives of the JCAHO
The JCAHO has an explicitly stated mission:
“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.”
A major objective of the Joint Commission is to continually improve and enhance the quality and safety of healthcare delivery in the United States. Towards this end, the Joint Commission makes a concerted, consistent effort to engage patients in issues associated with improving the quality and safety of healthcare delivery across the country. For example, JCAHO has focused intensely on the matter of infections that arise in healthcare settings, including surgical site infections and multidrug-resistant or MRSA infections.
The Joint Commission has grown to include accreditation and safety protocols to improve patient safety in a wide range of healthcare settings. Hospitals, of course, are the original focus but over the years the Joint Commission has expanded their focus to include surgical centers, pharmacies, nursing home and long-term care facilities, ambulatory health care centers, assisted living communities, behavioral health and human resource facilities, laboratories and many more. They have work continuously to improve safety protocols and have developed many specific practice area certifications. Education is also an important function of the commission. Standards are constantly evolving with input by the Board of Commissioners and feedback from healthcare providers, the latest scientific literature, government agencies and consumers all with the goal of improving health care quality. These standards are designed to help organizations assess, measure, and improve performance. Standards provide a method for surveying an organization and set expectations for organizations to achieve performance goals.
The Joint Commission also provides a certification process for programs and services within the organization. These certifications are program or treatment area specific. The benefits of certification include reduction in clinical process variations to improves patient care and a structural and management framework for the program.
The Joint Commission reacts to current issues in medical care to improve outcomes and safety. Examples of this include studies of patient suicides to improve behavioral health standards. The Joint Commission reacted to the COVID-19 pandemic by assisting hospitals in establishing emergency protocols to protect healthcare workers in the absence of adequate personal protective equipment. The Joint Commission also added a new board member to address concerns about the disparity in patient outcome based on race in the pandemic. The Joint Commission works to improve healthcare quality in the United States and internationally as well.
Cost of JCAHO Accreditation
Healthcare organizations and programs that seek certification via the Joint Commission are required to pay the costs associated with this process. This includes the underlying fee for certification as well as associated costs. Associated costs include the travel expenses of those individuals from JCAHO that will be undertaking the certification review process at a particular hospital, medical center, research facility or other entity seeking this designation from the Joint Commission.
While accreditation may seem like a costly and lengthy process, there are many advantages. Joint Commission accreditation shows a commitment to quality patient care and patient safety. This will inspire community confidence in the organization and signal their focus on quality care. This may give the organization an edge in a competitive healthcare marketplace.
Joint Commission standards are designed to help improve quality of care. Using these standards will help an organization manage and reduce the risk of error or low-quality care. The Joint Commission standards are developed by experts in their field and periodically put up for field review. Through this process, practitioners may submit comments and suggestions to continuously improve standards and make sure they stay up to date with current practice. Accreditation may make liability insurance easier to obtain and possibly lower the cost. Depending on the location of the organization, accreditation may fulfill local or state regulatory requirements. Accreditation can satisfy requirements for Medicare and Medicaid without additional surveys required. Accreditation is increasingly a requirement for contract bidding for insurance companies.
Accreditation and ongoing review can aide an organization in developing improvement protocols. The survey is conducted by experts in their field who can provide tools for improving quality and maintaining structural improvement. Maintaining high quality care will attract and help recruit high quality personnel while developing current personnel.
Organizations that wish to pursue accreditation, may contact the Joint Commission to determine if they are eligible. After obtaining access to the accreditation standards, the organization can compare the standards to their own performance standards to determine if the organization is ready for the accreditation process. The organization can then submit an application to begin the process. The next step is a comprehensive on-site survey of the organization. Once an organization is approved for accreditation, the Joint Commission will assist in publicity to promote the newly achieved accreditation. In order to maintain accreditation, organizations will need to have an on-site survey every three years, except for laboratories which are surveyed every two years.
Alternatives to JCAHO Accreditation
Although JCAHO is the industry leader when it comes to healthcare organization and program certification, it is not the proverbial “only game in town.” Some states in the United States have their own certification agencies and do not rely on the Joint Commission to provide this service. States that undertake this effort on their own are in a minority at this juncture in time.
There are other nonprofit certifications in the country. These organizations tend to focus on segments of the healthcare industry and are not as expansive or comprehensive in their reach as is the Joint Commission. Alternatives certification agencies in operation in the United States are:
- Accreditation Commission for Health Care – The Accreditation Commission for Health Care, or ACHC, provides accreditation standards for the home health and alternate site healthcare industry. The ACHC provides accreditation to such healthcare providers as: hospice, home infusion, acute care facilities, surgical centers, ambulatory care centers, pharmacies, private duty providers, renal dialysis centers and sleep clinics. The ACHC prides itself on excellent customer service and an educational approach to accreditation. Their standards are industry specific and easy to understand. Their surveyors are experts in their field and help requesting organizations to meet standards and achieve their goals. Requesting institutions are assigned advisors to guide them through the process.
- American Osteopathic Association – The American Osteopathic Association is dedicated to supporting osteopathic medicine and its practitioners in providing medical treatment geared to the whole-person and focused on prevention and self-healing. The organization supports students of osteopathy and provides board certification for graduates of osteopathic medical schools. The organization also promotes scientific research in osteopathic medicine and advocates on issues of concern to doctors of osteopathy and their patients. The American Osteopathic Association provides accreditation to osteopathic medical schools to further the practice of osteopathic medicine.
- Commission on Accreditation of Rehabilitation Facilities – The Commission on Accreditation of Rehabilitation Facilities, or CARF, provides accreditation specific to facilities involved in rehabilitation. In order to achieve accreditation, an organization must study and evaluate their organization based on CARF standards. Facilities seeking accreditation, must implement and conform to CARF standards a full six months before submitting to an on-site survey. Following the survey, the facility is provided a report that outlines the facility’s strengths and areas for improvement. After accreditation is approved, the facility is required to submit annual reports for the duration of the accreditation term. At the conclusion of the term, the facility is required to submit to a resurvey for renewal.
- Community Health Accreditation Program – The Community Health Accreditation Program, or CHAP, provides accreditation to community and home healthcare facilities that provide infusion therapy, pharmacy services, home medical equipment, hospice care and home health care. The first step in CHAP accreditation process is gaining access to the standards, a self-evaluation of the organization and submitting an application. CHAP provides readiness tools to help facilities match their practices to CHAP standards. Once a facility is deemed ready, an on-site survey is scheduled. After the survey, the Board of Review will evaluate the survey and develop suggested corrections as necessary. Once accreditation is approved, CHAP has a process in place to ensure the facility maintains the level of care indicated in the standards.
- Healthcare Facilities Accreditation Program – The Healthcare Facilities Accreditation Program, or HFAP, recently merged with the Accreditation Commission for Healthcare (ACHC). HFAP, established in 1945, is the nation’s oldest healthcare accreditation program. The merger with ACHC provides an extensive range of certification and accreditation options for laboratories, hospitals and community-based providers.
- National Commission on Correctional Health Care – The National Commission on Correctional Health Care, or NCCHC, provides accreditation for healthcare facilities in prisons, jails and juvenile facilities. Health care in correctional facilities has a unique set of challenges that NCCHC is dedicated to addressing and improving. Accreditation shows an acceptable level of care for a facility’s inmates as guaranteed by the Constitution. Following NCCHC standards of excellence results in better overall health of the facility, a reduction in the number of grievances, and better community health after the inmate’s release.
- Utilization Review Accreditation Commission – The Utilization Review Accreditation Commission, or URAC, sets rigorous standards of care for its accredited institutions. These standards are developed by a panel of industry experts and subjected to public comment and review. The URAC offers accreditation in the areas of pharmacy, patient care management, administrative management, health plans and mental health. Facilities undergo a thorough examination. Accreditation can be achieved in as little as four to six months. The process involves submitting an application and all relevant documents. The application is then reviewed to ensure all standards are met. A validation review is then used to determine if the facility is adhering to standards in practice. Finally, the anonymous report is sent to the review committee for final approval. After accreditation, there is an annual review of quality measures.
Joint Commission Speakers Bureau
The JCAHO maintains an extensive speakers bureau. The speakers bureau is made up of experts in their field. Making these speakers available to facilities is an important part of JCAHO’s commitment to continuing education and support of their accredited facilities .The commission believes that making reliable information about quality and safe healthcare delivery widely available is crucial to improving the overall operations of hospitals, clinics, and other healthcare providers in the United States. As a result, JCAHO speakers bureau has experts available to address vital topics that include:
- Accreditation of:
- Ambulatory Health Care Centers (sleep clinics, surgery centers, imaging centers, urgent care centers)
- Home Healthcare Agencies
- Nursing Care Facilities
- Behavioral Health Care Centers
- Performance Measurement
- Quality Improvement
- Infection Control
- Heart Failure and Stroke Measures
- Health Services Research
- Staffing Certification
- Emergency Management, Life Safety, Environment of Care
- Management of Medication
- Patient Safety Goals
- Patient Communication Standards
- Electronic Clinical Quality Measurement
- Survey Process
- Tobacco Use Screening
- Root Cause Analysis
- Perinatal Core Measures
The JCAHO is committed to helping organizations find the right speaker for their interests. Education and information are important functions of the commission. In order to find the best speaker for the event, requests should be made as early as possible, preferably at least eight weeks in advance of the event. After a speaker has been confirmed, the requesting organization will be put in contact with the speaker to work out the details. An honorarium will be charged for each speaker and the amount differs based on the specific speaker. The requesting organization is required to reimburse JCAHO for the speaker lodging, travel and meals.
The majority of organizations and programs within the healthcare industry are certified via the Joint Commission. Accreditation by the Joint Commission continues to be the Gold-Standard for health care certification. Joint Commission accredited institutions show a strong dedication to quality health care to health insurance providers, liability insurance providers and the community which are ultimately the consumers of the organization’s services. The major role that JCAHO plays in the healthcare certification process is expected to remain into the future.
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