The Who, What, When, Where and Why of JCAHO – The Joint Commission on Accreditation of Healthcare Organizations
Ken Tyler
The Five W’s of JCAHO
The JCAHO is the nation’s predominant standard setting and accrediting body in health care. They evaluate and accredit about 19,000 health care organizations and programs within the United States. They are also extensively involved internationally. Established in 1951, the organization has developed state of the art, professionally based standards and evaluated the compliance of healthcare organizations against constantly changing benchmarks.
JCAHO’s mission is to continuously improve the safety and quality of care provided to the public through the provision of healthcare accreditation and related services that support performance improvement in health care organizations.
Accreditation by the JCAHO is recognized nationally and internationally as a symbol of quality and that accreditation certifies that a specific organization meets or exceeds JCAHO standards. To earn and maintain accreditation, an organization must stand the rigors by a JCAHO survey team on a random selective basis.
JCAHO has many accreditation services including:
· General, psychiatric, children’s and rehabilitation hospitals,
· Healthcare Networks and Preferred Provider networks
· Home Care organizations and durable medical equipment services
· Nursing Homes and other Long Term facilities
· Assisted Living services
· Behavioral Health Care Organizations
· Ambulatory Care Providers
· Clinical Labs
JCAHO standards address an organizational level of performance in key areas, such as patient rights, and the standards focus not only on what the organization has, but what the organization accomplishes. The JCAHO develops their standards in consultation with health care experts, providers and consumers. These standards set forth performance requirements andexpectations for most activities that affect patient care.
According to the JCAHO, organizations seek accreditation because the JCAHO
· Assist organizations in improving their quality of care
· May be used to meet certain Medicare certification requirements
· Enhances public confidence
· Provides a staff educational tool
· Enhances Medical Staff recruitment
· Expedites third party payments
· Fulfills many state license requirements
· Enhances access to managed care contracts
· May favorably influence bond ratings and access to financial markets
In 1996 JCAHO introduced a primary performance management system for the accreditation process called ORYX – a reporting mechanism for accreditation which is also used to monitor the results of that accreditation yearly. The system became active in 1997 for hospitals, long term care, networks, home care, behavioral care and labs.
In addition to offering accreditation the JCAHO sponsors a variety of educational programs and provides an extensive list ofpublications for health care managers. The national conference for JCAHO this year will focus on Patient Safety and Quality of Care. There are numerous other seminars and conferences that address every standard component.
Based in Chicago, the JCAHO is governed by a 28 member Board of Commissioners which includes nurses, physicians,consumers, medical directors, administrators, providers, employers, labor representatives, planners, quality experts, health insurance administrators and educators. Its board of commissioners brings countless years of experience and expertise in the health care, business sector. JCAHO corporate members include the American College of Physicians, American Society of Internal Medicine, the American College of Surgeons, the American Dental Association, the American Hospital Association and the American Medical Association.
JCAHO Surveys and Healthcare Laundries - "What to Expect"
By Ken Tyler
While much time is spent preparing for JCAHO surveys, the impact and importance is directed at patient care and documentation that supports that activity. If there was ever a true definition of direct and indirect patient care, a review of JCAHO survey protocols and processes would easily layout the definitions. Activities such as housekeeping, laundry activities, grounds management, and other support functions are considered solely indirect patient care. Although many would argue this impropriety, those are the facts.
Certainly survey managers with the JCAHO pay much attention to the aesthetic environment such as the interior design of the facility and the cleanliness and sanitary condition of a healthcare facility. This is simply because it becomes part of the environment the survey manager directly views. Laundry facilities, in house or contract can go overlooked - but you may get a walk through especially if the survey team receives advance word that laundry programs do not meet expectations for delivery and quality. If a walkthrough of your laundry is conducted, you should have in-house documentation available that address both quality and delivery.
If the survey manager is made aware of problems with the laundry, it will then receive more focus, especially in the area of safety, and documentation of training initiated with all employees. The Environment of Care Standards that are used to review laundry programs don't really address specifics related to laundry programs. The JCAHO has virtually relied on the survey technician to address concerns that are not specifically mentioned in the standards.
So what can you expect? Just about anything. Using the Boy Scout motto of "be prepared" is critical. Mock surveys usually will address more specifics in the arena of activities that may be considered indirect patient care.
Ithere are very few instances where the laundry activity has had any direct or any indirect significance related to the score given by the JCAHO. This is not to say the JCAHO does not recognize the importance of laundry programs, it does. However, the generic criteria does not permit the survey technician from specifically evaluating the program as a stand-alone function.
Regardless, laundry managers should continue to provide the quality of services that most provide. The lack of survey instruments or standards should not deter the laundry from meeting specific goals. If your facility has goals in place, then as a preparation for the JCAHO survey process, the laundry facility management should make sure these goals are met and that documentation is available to support this facet of the program. On the other hand if your laundry has specific regulations in which to follow, like conduct of wash testing, maintaining performance expectations, maintaining certain FTE levels etc., then the JCAHO surveyor may consider these requirements internal and expect that the facility has documentation to support the program. This is especially true with government facilities as directives and regulations become the rule of the day and the JCAHO may attempt to validate that you are meeting these requirements especially if it become apparent from the clinical managers that your facility may not be living up to expectations.
Once again it becomes apparent that laundry facilities will either survive or not survive based on the managers ability to assure the following:
• / Safety plans are in affect to insure that patients will always receive quality laundry service.
• / Documentation is routinely updated that reflects training conducted
• / Employees understand and can explain the requirements of the facility.
• / Plans in process address the future, equipment replacement etc.
• / A contingency plan insures your customers will always receive the linen/textiles they require.
• / Your laundry facility is clean from top to bottom!! This includes both production and non-production areas.
• / Everything possible is being done to insure that the facility is safe.
• / It can be demonstrated that the facility meets any external requirements that are required by any other internal or external authority.
• / The surveyor can be provided with a tour of the facility and can explain every facet of the operation.
• / As the laundry plant manager you have the qualifying credentials. While no requirements exist, credentials are important.
• / If laundry equipment was purchased, it was inspected to insure it was safe, that it would meet your requirements and that your employees were trained.
• / The ability to demonstrate/document that you are meeting some quality requirements/expectations and that you discuss these issues with your customers