When the JCAHO undertook its indicator monitoring project more than seven years and several million dollars ago, it seemed a timely move to assist in the development of standards to measure quality at the nation's 6,000 hospitals.
But healthcare has changed greatly in the interim and, as problems with the Joint Commission's effort have become evident, the indicator project has been spurned by some influential hospitals and payers. By waiting too long to seek wider advice from users of the system, the organization's leadership has left itself open to accusations that the program's main purpose is to serve as a cash cow for the JCAHO.
From the beginning, hospitals that participated in alpha and beta tests for the project have complained about the administrative and cost hassles involved in developing the indicators, but the Joint Commission turned a deaf ear. Its answer has been that disgruntled hospitals were naive, didn't understand the commitment required and ultimately would find the system useful.
But most of those who stuck with the program through the testing phase discovered something more distressing than high costs and administrative hassles. They found that using the indicators didn't help improve care, which is their avowed purpose. Many hospitals that have advanced quality-improvement efforts under way say they find the commission program inferior to others they have used.
The Joint Commission also has failed badly in its attempt to explain the appeal of its system to the employers who foot most of the healthcare bill. In fact, many payers and managed-care organizations have ventured out on their own to develop "report cards" or to work with groups like the National Committee for Quality Assurance. The lack of coordination in the development of standards of compliance and performance measurement projects is an egregious failure on the part of all those working to improve outcomes measurement.
By failing to address payer concerns and charting a solitary course, the commission has missed an opportunity to reduce overlap and duplication of effort. As a result, obscenely large amounts of money are being devoted to the JCAHO indicator project. Hospitals already have borne the primary burden for research and development, and the JCAHO's plan is to saddle hospitals with the fees for operating the system without any guarantees of lower surveying prices. The fact that this unfair financial hardship was conceived with the tacit approval of the industry's trade association is unsettling.
Hospitals shouldn't be the primary means of financial support for the indicator project, especially because the JCAHO says its primary customer has changed from hospitals to employers, payers and the public. To the extent that hospitals are footing the bill, the Joint Commission needs to be a better steward of their funds. It's unseemly in this era of cost constraints to have the Joint Commission building a $23 million office complex in a posh Chicago suburb. Such accoutrements may confer prestige and protect against rent increases, but they have nothing to do with ensuring improved outcomes measurement and patient care by providers.
Finally, it's a misuse of authority for the Joint Commission to require mandatory hospital participation in the indicator program. Hospitals that want "deemed status" to be eligible for Medicare funds feel coerced into participating in a program they see as inferior. We've frequently railed against government regulation that stifles innovation. It's no more comforting to observe a tax-exempt organization governing by fiat.
If the indicator monitoring program is valuable, it should prove itself in competition with other quality programs.
Commission President Dennis O'Leary, M.D., believes his organization is addressing the concerns of hospitals, payers and the public. But Dr. O'Leary and the Joint Commission board need to better respond to issues raised by hospitals, payers and a public concerned about quality measurement.
The most valuable role the JCAHO could play would be to provide a stamp of approval for whatever quality process each hospital or system chooses. Such a process would encourage facilities to innovate. Healthcare doesn't need another huge, costly bureaucracy that stifles creativity and further stalls the long-overdue process of measuring and improving quality.