Hospitals and other institutional providers may face regular accreditation surveys every 18 months rather than the current 36-month inspection cycle under a major reconsideration of how the Joint Commission on Accreditation of Healthcare Organizations does business.
If surveys are more frequent and more narrowly focused, the Joint Commission reasons, then organizations won't go through such a preparation frenzy every three years with possible dips in quality assurance in between. Instead, accreditation will be internalized as part of normal quality assurance.
In several well-publicized cases of adverse incidents at hospitals this year, the incidents occurred roughly at the midpoint of the hospitals' three-year accreditation cycle (May 15, p. 4).
The possible move to shorter accreditation cycles is part of a fundamental redesign of the accreditation survey the Joint Commission is studying.
The goal is "to engage the field with a blank slate," said Russell Massaro, M.D., the Joint Commission's executive vice president of accreditation operations.
In letters that will arrive this week, the Joint Commission is inviting hospitals and other healthcare organizations to reflect on how to make accreditation "more of a service than a commodity."
The Joint Commission performed 6,723 triennial surveys for all accredited organizations in 1999, of which 1,744 were at hospitals (See box). Survey revenue totaled $90.8 million in 1999. The JCAHO has 581 surveyors and also runs a consulting business to help hospitals prepare for their accreditation surveys.
In 1999, for the first time in 20 years, the JCAHO lost money on operations. Declines in survey volume cut into revenue projections. The agency eliminated 79 jobs last September (Nov. 22, 1999, p. 6).
It wants to hold survey fees at the current level under the new approach. The Joint Commission can't project yet how this new model would affect its revenue.
The agency insists that its motivation is to reduce hospitals' reliance on pre-survey consultants, cut the expense of the process and increase customer satisfaction at the same time.
The survey could become "more data-driven, less predictable and customized to the individual organization," according to a four-page Joint Commission white paper outlining the concept.
If the Joint Commission can live up to this goal of raising the value delivered, accreditation surveys three years from now could have a very different feel than they have today:
* The process could be more "continuous," with narrower surveys every 18 months. The accreditation would still be valid for three years.
* The Internet would be integrated into the survey process.
* A self-assessment process, now being tested in two states, would lessen the amount of standards-compliance checks in the surveys.
* Outcomes data from the Oryx performance measurement system would be used to show quality improvement, allowing the on-site survey to focus on critical patient-care and safety issues.
"I knew this was in the works," said Lynn Nicholas, president and chief executive officer of the Louisiana Hospital Association. "There's a lot of positive reform and good direction in what is being proposed."
However, she added, she doesn't think this concept will fundamentally reduce hospitals' costs or their reliance on consultants for survey preparation.
Likewise, Opal Reinbold, the West Coast director of accreditation services at the Premier hospital alliance, said she "wouldn't call this a revolutionary development. I'd say it looks as though these are the next steps in the process that they've been pursuing to get hospitals to be continuously ready."
Massaro said this initiative emerges from the Oversight Task Force for
Accreditation Process Improvement, which has been suggesting changes to accreditation since 1998. The rural and small hospitals task force also has made everyone aware of how burdensome the expense and preparation is for them.
The JCAHO recognizes that the ramp up to the triennial survey is wasteful and doesn't always pay off in long-term benefits to the organization, Massaro said.
"Our triennial is a final exam every three years," he said. "It's almost impossible not to have crash preparation. One idea is, could we have two smaller quizzes instead of one big final? You transform the Joint Commission accreditation into an operational paradigm, rather than a special project every three years."
Nicholas, who spends a lot of time visiting rural hospitals in Louisiana, isn't convinced that the Joint Commission's new model will make much of a difference to them.
"Smaller hospitals that don't have a lot of financial resources, I'm not sure they'll be able to stay with the process, regardless of these changes," she said, citing high direct and indirect costs.
Similarly, consultants will still be required. "It's easiest to call somebody in and have them help you do it," she said.
Sidney Wolfe, M.D., director of Public Citizen's healthcare project in Washington, said he doubted the agency's move would make much difference.
"They keep twisting around, trying to reinvent themselves, implicitly admitting that what they were doing before had no value," Wolfe said. "The only reconfiguring that would satisfy us is if they reconfigured themselves out of existence."