The Joint Commission on Accreditation of Healthcare Organizations will stop recognizing hospitals that score extremely well on its accreditation surveys, and surveyed hospitals will pay more no matter how well they do.
So says the JCAHO's board of commissioners, which on Nov. 5 decided to eliminate the accredited "with commendation" citation and raise hospital survey fees.
The JCAHO announced the board's actions last week. They take effect on Jan. 1.
The commendation recognition was the gold ring awarded to those organizations that passed surveys without any Type I recommendations, or serious quality-assurance infractions.
In its last three-year survey period, the Joint Commission has awarded accreditation with commendation to 720 hospitals, or 14.5% of all surveyed hospitals. Many hospitals that receive the recognition use it in their marketing efforts as a proxy for high-quality care.
The JCAHO created the special accreditation category in 1991 in reaction to complaints by hospital executives, who felt that the organization needed a positive alternative to the newly created category of "conditional accreditation" under which hospitals with quality-assurance problems were put on six-month probations.
The vote by the JCAHO's 28-member board to kill the recognition was unanimous, said Dennis O'Leary, M.D., the JCAHO's president and chief executive officer. The American Hospital Association has seven representatives on the board.
The board's accreditation committee had been discussing the matter for more than a year, and it had been reviewed by purchasers, surveyors and hospitals themselves (June 21, p. 8).
"By the time it got to the board, people were pretty comfortable with the recommended action," O'Leary said.
HHS' inspector general's office recommended in a critical report last summer that the "accredited with commendation" category either be revamped or dropped (July 26, p. 2). The agency said the distinction needs to have more rigor.
"Hospitals use it for marketing purposes to suggest a degree of excellence that can be misleading," according to the report.
The weaknesses of the citation were several, O' Leary said. First most organizations do very well on their surveys, obtaining total grid scores of over 90 out of 100.
"The distinction between those who get commendation and those who fall just short is artificial in many respects," he said.
The loss of the commendation category didn't particularly bother Cal Isaacson, vice president of clinical services at 265-bed Swedish Covenant Hospital in Chicago, which was accredited with commendation on Oct. 12, 1996.
Swedish Covenant's number came up again last week, when a team of JCAHO surveyors reviewed the hospital's operations for three days.
"While we scored very well, we didn't maintain our commendation," Isaacson said.
He said it would have been nice to have been accredited with commendation again, but the termination of the category won't affect how the hospital prepares for surveys.
"We don't necessarily gear our programs around the Joint Commission," he said. "They come in and survey what we're already doing, which is providing good care."
Opal Reinbold, a survey-preparation consultant with the Premier hospital alliance in San Diego, said the problem with commendation was that it was subject to variances among survey teams.
"One survey team might give it, and another might not," she said.
The Service Employees International Union, a leading JCAHO critic, issued a statement commending the JCAHO "for taking this small step," but said it would have little impact on hospital quality.
Meanwhile, the JCAHO's board raised accreditation survey fees by 3.25% across the board. The average hospital now pays $20,000 for its full triennial survey.
In addition, the board decided that follow-up focused surveys, which are done to review high-priority patient-care problems, will cost $2,500. That fee had been abolished in 1995.
The moves are expected to generate about $4 million in additional revenues for the JCAHO next year.
This is the first survey fee increase since 1994.
In 1997, the JCAHO collected $78.4 million in survey fees from accredited healthcare organizations.
O'Leary said the JCAHO's operating costs are increasing, especially for travel and paper, and it is no longer able to make budget by controlling expenses. Last month, for example, the JCAHO eliminated 79 positions at its Oakbrook Terrace, Ill., headquarters (Oct. 11, p. 8). Additional revenues are needed, he said.