Experience with the Joint Commission on Accreditation of Healthcare Organization’s (JCAHO’s) changing approaches to surveying seems to engender skepticism. This is not to say that JCAHO has not developed several promising ways of evaluating quality of care over the last decade, such as the “Agenda for Change” and the ORYX^® initiative, but these were preceded by several false starts. The surveys began, in theory, to become more relevant in the 1980s when JCAHO rediscovered Donabedian and Deming and the virtues of concurrent monitoring as opposed to the older chart-oriented, search-and-destroy approaches of the 1970s. JCAHO saw the value of predicating quality improvement on verifiable measurements of structure, process and outcome integrated with the industrial model of continuous quality improvement (CQI). The commission consulted with Organizational Dynamics, Inc., and propounded a well-thought-out approach to making the accreditation process a means by which hospitals could learn how to manage their problems using well-established CQI tools.

Despite aggressively promoting CQI through the “agenda for change,” this new performance-improvement model did not entirely find its way into the survey process. Surveys continued to suffer from the almost religiously orthoprax notion that complying with the more than 2,000 JCAHO standards is in some way related to good performance. The survey process also was seriously flawed by a lack of predictive value, which meant that the outcome of patient care within a hospital and the relative outcome of care between institutions could not be determined from the results of the survey.

JCAHO raised expectations that surveys would have a more consultative purpose to identify and help hospitals correct problems in performance that, left unchecked, would predictably lead to deterioration in outcomes. Yet surveys continued to feel like an adversarial procedure. JCAHO seemed to have become the institutional equivalent of the Titanic: too large, too hard to maneuver and overconfident in its abilities.

In 1994 I wrote a position paper for my hospital to use in its response to its survey. It contained important issues for JCAHO to consider if it planned to remain relevant. Some of these are abbreviated below:

1. Generations of surveys have provided JCAHO with one of the most comprehensive databases of hospitals' problems and how to resolve them. Use this knowledge to help us survive in a competitive world by maintaining quality while managing our limited resources.

2. Be a consistent and reliable source of comparative performance data. To do this, perfect inter-rater reliability; make sure that compliance scores will not deviate by more than a defined range, no matter who performs the survey. If this cannot be accomplished, change the survey process to eliminate surveyors, and rely on the transmission of aggregate data that describe the patient cohort, services patients receive and the resulting outcomes.

3. Formulate the regulations, enumerated in the Accreditation Manual for Hospitals, for processes demonstrated to improve outcome, quality and resource utilization. Provide hospitals with clear examples of how to comply with necessary regulations and measure the expected outcome derived from that compliance. If the regulated processes have no proven relationship to outcome, eliminate them.

4. Make the survey process, whatever it becomes, continuous and ongoing. Eliminate the triennial blitzkriegs. Therefore do not presume that the status of a hospital during the week of an audit reflects the rate at which its performance is changing, the direction of the change or how it is progressing compared to other institutions.

While there is no way to know how or if these ideas ever reached JCAHO, increasing criticism of its accreditation process and lack of correlation with findings of state inspectors appears to have generated a positive introspective process. In addressing the January 2003 plenary session of the JCAHO Professional Technical Advisory Committees that are composed of industry and health care professionals, JCAHO President Dennis S. O’Leary, M.D., shared a vision of the “Shared Visions,”¹ that is less dramatic than Ezekiel’s but also suggestive of an epiphany that moved JCAHO to finally take health care professionals’ suggestions seriously. To do this, JCAHO would seek to protect performance data by asking Congress to protect the reporting of sentinel events and make the business case for quality and safety as a strategic management tool worthy of resource. Dr. O’Leary acknowledged the need for JCAHO to cooperate with other organizations such the Leapfrog Group without becoming subordinate to them. He acknowledged that performance information needed to be acquired from nonaccredited health care organizations (HCOs), as well as accredited ones, if meaningful comparisons were to be made. He also noted that the media had pilloried JCAHO, asserting that there was no relationship between compliance with standards and measured outcomes. He acknowledged that JCAHO needed to “rebuild” its credibility and survey process and that if it could not do better with this, they would just be rearranging the chairs on the deck of the Titanic. It is in this context of acknowledging previous missteps that JCAHO is rolling out “Shared Visions,” which gives one hope that this is not just another furtive effort. The name “Shared Visions” is intended to indicate that JCAHO is trying to give itself, HCOs and patients a common vision of what constitutes safe, high-quality care. “Shared Visions” is the successor to the “Agenda for Change.” ORYX, the JCAHO outcomes database (named after an animal that looks like it was designed by a committee), will continue, at least for the time being, as a mechanism for very specific, focused studies.

It appears that in this latest approach, JCAHO is beginning to get it right. Emphasis is shifting away from the compartmentalized approach in the “Agenda for Change” to a continuous, more systemwide approach that emphasizes the details of how health care professionals actually care for patients. JCAHO believes that too much time and resources were spent on preparation for triennial surveys rather than using its standards to drive systemwide improvement. The focus will shift from policy, procedure and structure to patient care and improvement. JCAHO also is paying attention to lowering the cost of the survey and improving surveyor skills. JCAHO expects HCOs to use the standards as tools to drive management strategies rather than just as a mechanism to obtain accreditation.

JCAHO has completely revised the organization of the Comprehensive Accreditation Manual for Hospitals² (CAMH) and other manuals by making the language that is common to all identical in them all. This new restructuring of the manual is the product of the two-year “Standards Review Project” that reorganized and substantially reduced the number of standards to eliminate redundancy and inconsistency. The new standards are clearer and have a concise statement of intent followed by elements of performance (EP) that describe how the standards are to be implemented. The new EPs replace the old “intent statements.” EPs will be surveyed, rather than the standards themselves, making expectations more explicit.

Emphasis on self-assessment puts emphasis on very concise self-evaluation and electronic extranet reporting of problems and corrective action planning at the midpoint of the three-year cycle. Problems found and reported at this 18-month point will not affect accreditation and will not require on-site review. More time will be devoted to resolution of action plans at the triennial survey as well as randomly selected standards.

A new point of focus, the Priority Focus Process (PFP), also was introduced. PFP will use presurvey data (demographics describing the types of services, teaching status, self-assessment data and complication rates) for each of the “critical foci.” The critical foci include patient assessment, communication, credentialing, equipment use, infection control, medication use, organization structure, rights and ethics, quality improvement, safety and a few others. The presurvey data will be analyzed using the Priority Focus Tool. “The tool uses sets of rules to sort the [presurvey] data and turn it into valuable information that focuses the on-site survey on critical areas of focus.” For example a hospital serving a geriatric population with a high rate of medical admissions would have critical foci of medication use and the communication of do-not-resuscitate orders. JCAHO expects the PFP to improve consistency in evaluating similar types of HCOs.

A shift from process and policy evaluation toward an evaluation of the continuum of care will occur using “tracer methodology.” This method traces the care of a number of active patients along their care pathway from admission to discharge. Using the chart to locate where the patient went, the surveyor will follow that path and ask the staff about how care was rendered for that patient and other patients of the type being reviewed. The surveyor will ask questions that determine how this care relates to standards. This may seem rather hit-or-miss because the statistical power behind the approach is low, but it is not a method for finding out the frequency of problems in a particular area. This method is more of a way for evaluating how staff members apply standards to health care.

Accreditation reports will phase out the Type I recommendation and replace it with unranked recommendations. Standards compliance scores will be confidential. HCOs will not have their category of accreditation or requirements for improvement published.

In short “Shared Visions” involves simplification and clarification of the standards. Reorganization of the CAMH and other JCAHO accreditation manuals will improve clarity, reduce redundancy of standards and introduce a systems approach to CQI. The extranet reporting at the middle of the triennial cycle with triennial surveys will focus hospitals on current improvement action plans. The care pathway-oriented survey process will make accreditation a continuous process designed to improve actual care of patients. Type I citations will be eliminated, and the level of accreditation will not be published.

References:

1. Shared Visions — New Pathways, Joint Commission Perspectives. 2002; 22(10):1-15. <www.jcaho.org/accredited+organizations/svnp/index.htm>.

2. Joint Commission on Accreditation of Healthcare Organizations. 2004 Comprehensive Accreditation Manual for Hospitals: The Official Handbook. Oakbrook Terrace, Il: JCAHO; 2004.

Jerry A. Cohen, M.D., Associate Professor of Anesthesiology, University of Florida, Gainesville, Florida.