The Joint Commission on Accreditation of Healthcare Organizations may be coming to a state capital near you.
The Oakbrook Terrace, Ill.-based accrediting agency has launched a lobbying effort to get its key services included in state healthcare reform plans around the country.
The JCAHO wants state health departments or reform commissions to require the use of all or parts of the JCAHO's clinical indicator monitoring system, network accreditation program and public quality data disclosure system.
The JCAHO considers the three programs its main horses in the race to become the chief clearinghouse for quality data in the country, and mandated use of any or all three of the programs by a state would greatly help the cause.
Extending the mission? The JCAHO has characterized the effort as a simple extension of its mission to the state level from the federal level. The commission said that it's using a soft-sell approach, informing state policymakers of what services are available from the organization and hoping they adopt some of the JCAHO's ideas.
"If the Joint Commission wants to play a role in reform, it has to become more involved at the state level regardless of what's happening in Washington," said John Laing, the JCAHO's vice president of marketing and external relations. "We want to be seen as a resource where appropriate."
But the effort may raise some eyebrows in states where hospitals and hospital associations have panned the three programs. They may perceive the effort as an attempt by the JCAHO to go over their heads directly to state lawmakers to force hospitals to use services that they don't want.
In fact, some state policymakers and hospital executives aren't buying the JCAHO's characterization of the effort as that of a humble servant offering its assistance to states in need of its services.
Quality race. "What the JCAHO really is engaged in is a footrace with a number of other organizations over who's going to become the arbiter of quality data in the country," said Mark Legnini, deputy director of the California Office of Statewide Health Planning and Development in Sacramento.
California is one of seven states on the JCAHO's radar screen (See map, p. 18).
Late last year, the JCAHO's former vice president for research and standards, William Jessee, M.D., met with representatives of the state's health planning office to offer general information about the new programs at the JCAHO, including the JCAHO's clinical indicator monitoring program.
Under the JCAHO's program, hospitals collect data on as many as 30 clinical indicators, or outcomes measures, and submit the data to the JCAHO for analysis. The system is voluntary, but the JCAHO intends to make it mandatory for accredited hospitals as early as 1996. Hospitals have signed up for the system at a slower than anticipated rate (July 4, p. 4).
The state of California, meanwhile, is in the second year of the clinical outcomes data project under which hospitals are required to submit specific outcomes data to the state, which, in turn, releases annual hospital report cards to the public. Last year's report card covered heart attacks and back surgery. This year's adds childbirth outcomes.
"The message from the JCAHO was, `Let's keep the lines of communication open and consider the possibility of collaboration,'*" Mr. Legnini said.
Since Dr. Jessee's visit, however, the JCAHO hired lobbyist Fred Pownall, an attorney with the Sacramento office of Landels, Ripley & Diamond, to push the JCAHO's agenda with state lawmakers.
A spokeswoman for the California Association of Hospitals and Health Systems said the hospital trade group is aware of the JCAHO's efforts and "applauds" any effort to reduce duplicative data demands on hospitals.
However, the association would have concerns about the state requiring the use of the JCAHO's clinical indicator system, the spokeswoman said, because the value of the system in improving care hasn't been proved.
Florida campaign. In Florida, the JCAHO has hired lobbyist Stephen Ecenia, of the Tallahassee law firm of Rutledge, Ecenia, Underwood, Purnell & Hoffman, to push its agenda.
The JCAHO has two objectives in the state, according to various sources. A spokesman for the Florida Agency for Health Care Administration said JCAHO representatives approached the agency earlier this year and wanted it to mandate the use of the JCAHO's clinical indicator system to satisfy the data-reporting requirements of the state's new reform law. The agency is charged with implementing the law. The state has yet to act on the JCAHO's request, he said.
The Florida Hospital Association supports any effort by the JCAHO to help the state design its new outcomes data collection system, but it opposes any requirement to use the JCAHO's own system, said Mark Milner, FHA's vice president of professional services.
"The Joint Commission is lobbying states to create mandates for its services," Mr. Milner said. "Before any mandate we would want assurances that the (JCAHO) data offer value."
In July, the FHA board voted against becoming a "quality partner" in the JCAHO's clinical indicator system. To help solicit hospital participation in the system, the JCAHO offered state hospital associations tailored data reports in exchange for the associations agreeing to promote the system to their hospital members. Since the JCAHO began offering quality partnerships in September 1993, only two associations have signed up (March 14, p. 30).
"Our board recognized that it's just a marketing vehicle for the Joint Commission," Mr. Milner said.
Of more concern, Mr. Milner said, is the JCAHO's attempt to have the state of Florida accept JCAHO accreditation in lieu of state inspections for licensing purposes, as is the case in most states.
By creating a JCAHO layer between hospitals and the state, it will be tougher for the FHA to get rid of licensing requirements that it no longer deems relevant to hospitals, he said.
While the JCAHO's efforts in California and Florida focus on its clinical indicator system, the message in Washington state was the existence of the JCAHO's new network accreditation program.
The JCAHO's board of commissioners approved a set of accreditation standards for networks in January. To date, no network accreditation surveys had been conducted or scheduled, a JCAHO spokeswoman said, although one HMO has an application pending.
Equivalent service.In Washington, the state's healthcare reform law requires all state citizens to be enrolled in "certified health plans" by July 1, 1995. CHPs can be insurers or configurations of providers and insurers that meet the law's criteria.
One criterion requires the plans to be accredited. In addition to the JCAHO, the Washington-based National Committee for Quality Assurance, which has been accrediting managed-care plans since 1979, has been a contender for that job (See related story, p. 17).
Despite a last-minute visit by JCAHO representatives, the Washington Health Services Commission published proposed regulations on Aug. 24 that would require certified health plans to be accredited by the NCQA. However, the regulations said plans can be accredited by a "substantial equivalent" in the future.
"The Joint Commission came to us concerned that the NCQA was named in the rules," said Nancy Long, who staffs the quality improvement advisory committee of the commission. "At this point, we don't consider the Joint Commission to be a substantial equivalent."
The rules do give the NCQA a leg up, said Tom Byron, director of information services at the Washington State Hospital Association, but the rules leave the door open for JCAHO accreditation.
"Our position is that we'd like to see the state recognize several accrediting agencies," Mr. Byron said.
Washington's reform law also requires the state to construct a statewide health services information system to be up and running within four years. Certified health plans and providers would submit information, including outcomes data, to the system, which, in turn, would generate public report cards on plans and providers.
Ms. Long said JCAHO representatives also have provided information to the commission about its clinical indicator monitoring system, but the commission will design its own system, she said.
Meanwhile, Minnesota's healthcare reform law requires a similar statewide data system. To satisfy the requirement, the state health department and a consortium of provider, insurer, employer and consumer groups have formed the Minnesota Health Data Institute to design, implement and operate the system.
An organization that may provide hospital data to the institute at some point in the future is the Minnesota Health Information Network.
The network is a joint venture between the Minnesota Hospital Association and the Metropolitan Healthcare Council in St. Paul. The network collects standard hospital billing and discharge data but intends to add clinical outcomes data to its roster of data elements gathered from hospitals.
Dale Shaller, the health data institute's executive director, said that he's had no contact with the JCAHO. But the network has.
"The JCAHO is interested in working with us," said Tom Evans, the MHA's senior vice president for member services.
Specifically, the JCAHO wants to help the network design a system to supply hospital outcomes data to the statewide system, Mr. Evans said. He said the MHA welcomed the advice.
Just the facts. "We want states to know that our system is out there," the JCAHO's Mr. Laing said. "Our hope is that they accept our system in whole or in part rather than reinventing the wheel."
Whether it's the clinical indicator system, network accreditation standards or proposed star rating system for the public release of hospital accreditation data, the JCAHO doesn't ask to be the exclusive provider of the services under a reformed state delivery system, Mr. Laing said.
"We just want them to consider what we have done," he said.
Mr. Laing's job recently was split in two, and the JCAHO is hiring a new vice president to head a new JCAHO operating division for government relations (Aug. 29, p. 44). The new vice president will oversee the state lobbying effort.