I am writing in response to the Commentary by V. Clayton Sherman ("JCAHO's relevance is in question," July 11, p. 40), in which Mr. Sherman states the Joint Commission on Accreditation of Healthcare Organizations is "an organization past its prime, showing the symptoms of advanced age, still trying to control by fiat, but unable to perform. Maybe it's time to let it go."
Mr. Sherman has provided an excellent example of the old saying, "It takes a skilled craftsman to build a barn, but any jackass can kick it down." Unfortunately, recently too many people who ought to know better are taking potshots at the JCAHO without thinking about exactly what the alternative is likely to be if the JCAHO disappears.
The JCAHO does have major problems, no doubt about it. My own experience with the organization is multifaceted. For many years I was a medical staff member in several hospitals. Then I was CEO of a mental health residential treatment center, which applied for and received its initial accreditation during my tenure. For the past several years I have been a part-time hospital surveyor for the JCAHO.
Few people, I believe, have seen as closely and from so many angles as I have the many mistakes, misdirections and inefficiencies that bedevil the JCAHO. Indeed, surveyors probably suffer more than any other group from these problems. Yet I have repeatedly seen the many benefits and successes the JCAHO brings. We occasionally see the absolute disasters the JCAHO prevents or at least catches in the early stages when some hospitals, perhaps under financial pressure or in response to misguided administration, cut corners at the expense of patients.
We also see, in some of the states that currently carry out their own hospital inspections in addition to JCAHO accreditation, the striking differences in the effectiveness of the two approaches. JCAHO accreditation basically represents consultation among colleagues. State inspection represents law enforcement.
As we all know, there is no way the average consumer can adequately judge the technical aspects of care or the quality of the outcome. Eliminating accreditation surveys and instead simply giving customers more information will never solve the problem. Professional expertise will always be necessary.
Mr. Sherman compares the JCAHO with the full-service airlines, which he foresees succumbing to innovative newcomers, something he apparently believes should happen to the JCAHO. The comparison is inappropriate. Airlines are in a competitive marketplace, and their reason for existence is to make a profit. In many aspects, the consumer can easily and promptly arrive at a judgment of the quality of service. Yet who would want to fly one of the new airlines if we knew they were reducing fares by cutting back on maintenance, safety or other areas hidden from public view. What allows us to fly inexpensive airlines with a secure feeling is the knowledge that they cannot fall below minimum standards in these areas because they are monitored by an outside agency. These new airlines can attract customers in large part because everyone knows the outside agency is doing its job.
One of the weakest aspects of Mr. Sherman's criticisms, and of those who espouse similar sentiments, is the outside perspective it takes. The JCAHO is not an outside agency imposed on us by some unsympathetic group of enforcers. It is a creation of the healthcare industry, and its board includes representatives of the American Hospital Association, the American Medical Association and others. If hospitals are unhappy with the JCAHO, why don't they express their unhappiness through the board and take some positive steps to improve things without risking destroying their own organization. Do critics think that if they knock off the JCAHO any successor organization is likely to offer them more of a say in governance?
Years of effort to develop and refine a process that is fair, effective and, more importantly, applicable to the wide variety of hospitals we have in this country, have gone into producing the current JCAHO approach. Every JCAHO surveyor and many headquarters personnel have spent significant parts of their careers in front-line healthcare administration.
Contrast that with what could conceivably take the JCAHO's place. We might have a government agency with hospital inspectors hired into civil service positions right out of college and with most of their knowledge drawn from thousand-plus-page rule books. Their primary concern would be to find all the deviations from the rules they can and then apply the appropriate penalties. Mr. Sherman complains about bureaucracy. How would the government do better?
The easiest thing in the world is to gripe about something and wish for its disappearance without having to think through the consequences. We already have an organization that exists, gets the job done and is preparing for the future. Admittedly, the JCAHO has problems, but we, the healthcare professionals, control the organization. We can fix it, but only if we know what we really want.
JACK ZUSMAN, M.D.
University of South Florida, Tampa
The above letter represents Dr. Zusman's personal opinion, not that of the JCAHO.