The Joint Commission on Accreditation of Healthcare Organizations has a big expansion project under way at its Oakbrook Terrace, Ill., headquarters. But the bricks and mortar visible from the road are only an outward sign of the expansion effort going on inside.
The quality-evaluation organization that once concentrated on setting standards for hospitals is attempting to enhance its service foundation to put it squarely in whatever path healthcare reform takes.
Expanding into quality-measurement areas outside the traditional hospital environment, such as the budding integrated provider networks.
Broadening JCAHO's appeal and reputation among the public and the purchaser community-two new customers of quality-measurement reports-while keeping its traditional client base of healthcare providers satisfied.
Positioning the organization as a player in the movement to develop report cards that measure the performance of providers and health networks.
Campaigning on Capitol Hill for changes in President Clinton's Health Security Act and competing healthcare-reform legislation. The suggested changes, if adopted, would play to JCAHO's strengths and maintain the role of private accrediting bodies in a nationally administered quality-assurance structure.
Targeting the lobbying stances of interest groups in the healthcare debate that come into conflict with JCAHO's legislative goals.
Making inroads with associations that represent the forces in state government likely to have a say in implementing healthcare-reform measures.
Internal, external stresses.All this comes at a time when the JCAHO is mobilizing to implement what President Dennis O'Leary, M.D., calls "a huge re-engineering project" within its accreditation operations.
The project, called the Agenda for Change, is an attempt to restructure the organization's survey process around service functions rather the department-minded, nuts-and-bolts emphasis of the past. Dr. O'Leary acknowledged that "the stress internally in this organization has been extremely high" as a result of all the implementation work going on.
A key component of that implementation is its indicator measurement system, which identifies clinical events that should indicate how well or poorly an institution is providing care. To house that operation, JCAHO is building a $3.8 million expansion onto its headquarters.
As MODERN HEALTHCARE detailed in its March 14 issue (p. 30), the IMSystem, as it's called, is facing outside stresses as well as internal work-load pressures.
Part of the commission's strategy straddles turf staked out by other quality-monitoring organizations, such as the National Committee for Quality Assurance.
The Washington-based NCQA became the principal accreditor of managed-care organizations in 1990, when JCAHO opted out of the area after a brief stay. But the commission's approval in January of accreditation standards for provider networks puts it back in the same game.
The NCQA also is launching a test of report-card measures at a time when Dr. O'Leary is advocating a separate initiative: a coalition to hammer out one set of performance measures that would be applied nationally.
It's all part of JCAHO's be-everywhere objective. "Our philosophy is to be providing evaluation services in the mainstream of the delivery system," Dr. O'Leary said. "In other words, whatever is going on in this country, we have had a philosophy that we should have an evaluation capability in that field."
The commission's multiple initiatives are driven by a sense of urgency resulting from a shortage of time and an impatient public.
"I would love to have until the end of the century to put all this stuff in place," he said. "I don't have that time, and I don't think the NCQA does. I don't think any of us in this business has that kind of time."
Industry observers said the commission also is trying to cover all its bases. "It appears that the Joint Commission is quickly positioning itself to catch whatever line drive Congress hits in the next inning," said David Siegel, M.D., medical director of the Health Alliance Plan of Michigan, who sat on the advisory committee convened to approve the provider-network standards.
Charging up the Hill.The commission in the past six months has been doing a lot of pitching as well as fielding in Congress. The activity was prompted by a turnabout in the president's Health Security Act that first included, then removed, standards enforcement as an evaluation tool for a federal quality-assurance program.
Standards are JCAHO's stock in trade, a dimension of evaluation that it has provided for decades.
The draft of the president's Health Security Act that surfaced in September included both standards and performance measures-the report-card concept that Mr. Clinton had advocated to make healthcare providers accountable to consumers and purchasers.
Dr. O'Leary said standards need to be included because "performance measures, while intuitively very attractive, are a measure of past performance, by definition-what you did right up to this minute. But that past performance doesn't really predict future performance." Standards play the predictive role, completing the picture for people trying to make healthcare choices, he said.
But when the president's September draft of ideas was transformed into the 1,344-page bill in November, it "indeed provided only for a state certification program," Dr. O'Leary said. "So that gave us-good, bad or indifferent-our issue."
The JCAHO has hammered away on that issue, repeating the call for including standards as well as two other themes:
That standards must be set at the national level to ensure results are comparable from state to state.
That private accrediting bodies should be included in any federal framework for measuring and monitoring healthcare quality. The president's proposal didn't specifically carve out a role for private accreditors such as the JCAHO.
"In urging this responsibility (for national, standardized measurement) upon the federal government, we emphasize the ability and willingness of the private sector to assist in this effort," Dr. O'Leary told a congressional subcommittee on Nov. 3, 1993. He then launched into a description of the commission's Agenda for Change.
During another hearing on Feb. 3, he recommended that a proposed national quality management council "be expanded or simply be required to include representation from those having expertise in direct quality evaluation."
The commission has submitted suggestions for changes in legislative language for the president's healthcare bill as well as those of Rep. Fortney "Pete" Stark (D-Calif.) and Rep. Jim McDermott (D-Wash.). The changes generally add standards, a national approach to quality oversight and private-sector roles to the proposals. But they frequently go further.
In the McDermott bill, for example, the commission recommends that the bill's quality-oversight requirements include standards "in at least the following performance areas: rights, responsibilities and ethics; management of information; human resources management; continuum of care; education and communications; improving network performance; and leadership and accountability."
These are the categories into which the commission's provider-network standards are organized.
The commission's efforts in Congress have been getting a boost from hired lobbyists since at least October. That's when it registered as a client of the Washington lobbying firm Gold and Liebengood, a giant on Capitol Hill with 45 clients. Gold and Liebengood is a subsidiary of Burson-Marsteller, the public relations firm the JCAHO hired last August.
The total budget for lobbying activities was unavailable-spokeswoman Cathy Barry-Ipema said it's "proprietary" information-but a required filing with the U.S. Senate in January disclosed that Gold and Liebengood received about $56,000 from the JCAHO during its first three months in the organization's employ.
Other targets.The commission also has targeted the National Governors' Association and the National Association of Insurance Commissioners as proponents of state authority that could weaken the drumbeat for national, standardized measures.
In a Jan. 15 report to his board on talks with the NGA, Dr. O'Leary said visits with Colorado Gov. Roy Romer and Vermont Gov. Howard Dean, M.D., resulted in "some success in explaining that the Clinton plan would do them no favors in delegating to the states responsibility for establishing the certification programs for health plans.
"In fact, this approach, as opposed to the federal standards advocated by the Joint Commission, is simply another unfunded mandate."
Dr. O'Leary said the commission needed "a broader audience among the governors to make our case and work to neutralize any potential NGA opposition to our position on the Hill." During an interview with MODERN HEALTHCARE, Dr. O'Leary produced a copy of an NGA policy statement that he said was newly revised to support federally organized quality standards.
Carl Volpe, who directs the NGA's healthcare reform initiative, said the group had advocated a federally organized quality framework for more than a year and that the revised statement didn't reflect a change in policy.
Report-card stakes. The JCAHO hasproposed a coalition that would iron out one set of nationally applied measures, dubbing itself "particularly well-suited to play the role of convener and coordinator" of such a project.
The proposal asserts that a growing demand for performance information has created "an increasingly chaotic measurement environment populated by growing numbers of commercial entrepreneurs, data base developers, narrowly focused health services researchers, quick-fix artists and special interest groups."
However, a significant amount of interest already has been generated in an NCQA-led project to develop a report card comparing the performance of 21 health plans covering more than 9.6 million enrollees.
Margaret O'Kane, NCQA's president, said she's not ruling out offers to cooperate with the JCAHO in other areas, but she told the commission in late February that the NCQA wouldn't participate in JCAHO's proposed coalition.
Dr. O'Leary said he has "no particular need to lead, and in fact would prefer not to lead, a consortium or coalition activity." But he added that it was "essential and inevitable" that a coalition be formed. "If we don't have a common hymnal, we are going to have a Tower of Babel."
Asked if he would concede the development of performance measures to others while concentrating on standards, Dr. O'Leary said he had "no intention" of that. "Our Agenda for Change commits us to a future accreditation process that is based both on standards and on performance measures. We're suggesting that others do that (work on measures), but we're sure going to do it ourselves."
Be everywhere. JCAHO's "do it ourselves" approach is reflected in its multiple initiatives to expand accrediting outside the traditional hospital and nursing home during the past few years.
Last September, the Medicare program conferred "deemed status" on the commission's home-care accreditation program, pitting it against the Community Health Accreditation Program run by the National League for Nursing, which also grants deemed status. Providers accredited under deemed status qualify for Medicare certification and reimbursement without having to go through a separate federal inspection.
The commission also announced the formulation of standards for subacute-care providers by January 1995. And last month, it spun off a new consulting unit to conduct business internationally.
But the JCAHO's decision to enter the field of healthcare networks takes on an organization that has reviewed about a third of the nation's 500 HMOs.
The NCQA, which was formed by two managed-care trade groups in 1979, has devised a survey process that concentrates on evaluating how well an organization provides comprehensive benefits to a defined population over time, with an emphasis on preventive and therapeutic services. Those also are principal features envisioned for accountable health plans in the Clinton plan.
"We're kind of rueful that they're coming into a field where we've made such strides," said the NCQA's Ms. O'Kane. "I guess we're going to be competing. The challenge is to work out the grounds for competition that won't hurt the industry or confuse the consumer." That includes avoiding two sets of conflicting requirements for health plans, she said.
The JCAHO developed and released its accreditation standards for networks in eight months flat.
Dr. O'Leary said the project was put on "a high-burner, move-quickly, compress-it-all-together" track, using roundtable discussions of industry representatives, an advisory panel and "some general principles" from the commission's managed-care manual dating back to 1990. "The revisions process moved very briskly, and the standards that came out the other end of the pipeline barely resembled what went in on the front end."
Health Alliance Plan's Dr. Siegel, who also performs accreditation reviews for the NCQA, said he was surprised at the speed. "Recognizing that the Joint Commission had in the not-too-distant past developed standards for accrediting managed-care organizations, the pace at which the standards for provider networks was passed nevertheless was startling," Dr. Siegel said. "The reality is, these are new standards designed to accommodate a variety of emerging provider relationships."
Dr. Siegel said the commission appeared to be out to "accredit whatever life forms of healthcare delivery exist after healthcare reform."
The managed-care decision. The commission was positioned for health plan accrediting once before, but the board voted to back away from it because of what it considered lack of interest.
"That was not a decision that I was particularly happy with, but I'm a good soldier," said Dr. O'Leary. "I thought we left a little bit early."
Lance Hoxie, who was director of ambulatory-care accreditation from 1988 to 1993 and had responsibility for developing the managed-care program, said, "I personally believe it was a very big mistake to get out." Managed care, he said, "represents a substantial component of healthcare delivery." He said the recent decision to accredit networks "sent a subliminal message that they did make a mistake and better get back in."
Mr. Hoxie, now a healthcare consultant with Downers Grove, Ill.-based Webb Associates, said several pressures combined to force the pullback in 1990:
There was a "great deal of angst" among managed-care groups over whether the JCAHO was the appropriate body to accredit them. As a result, there was "relatively little support" within the industry, Mr. Hoxie said.
The survey process was a difficult match with the field because of the popularity at that time of independent practice associations, which defied the ability to meet the commission's requirement for a centralized operation.
The commission was gearing up for its Agenda for Change and indicator measurement testing, which required substantial investments of staff time and money. Board members, Mr. Hoxie said, "didn't want to dilute their attention" from those efforts.
The hospital factor. The decision to leave managed care helped marshal resources to concentrate on hospital accreditation, but it distanced the commission from purchasers, Mr. Hoxie said. "They left a real bad taste in the mouth of the people in the industry who were working with them," he said.
Meanwhile, the NCQA put big employers on its board, a contrast to the provider-group makeup of JCAHO. "The driving customer for the NCQA appears to be the purchaser and employer community, which results in a creative tension between the NCQA and the organizations it accredits," said Dr. Siegel. "It appears the Joint Commission has a much more traditional relationship with the industry it accredits."
The commission has been trying to reverse that image by convening a series of forums with Fortune 50 companies, speaking to business groups and adding six public representatives to the board.
But hospitals still pay the survey bills, and that makes any move toward public accountability likely to cause a backlash.
Last October, the American Hospital Association's coordinator of state associations, Thomas Granatir, observed in a memo on the IMSystem that the American public was becoming the JCAHO's primary customer. The memo said accredited organizations are the key customers by virtue of the fees paid, and it recommended that the IMSystem "should focus on quality improvement, not public accountability."
Dr. O'Leary said the relationship with hospitals hasn't changed: The commission has a "continuing obligation" to provide "a rigorous, fair evaluation" for paying customers.
"On the other hand, there are people who are the beneficiaries of that evaluation and the information that results from it. And we prefer to portray the public and creatures of the public-like purchasers, government, consumer groups-as beneficiaries of our services and other services provided by the organizations that we accredit," he said.