It's a small trend for now but a significant one. More hospitals are questioning the value of being accredited by the Joint Commission on Accreditation of Healthcare Organizations, citing the high costs and cumbersome nature of the survey process.
One hospital system in Arizona recently told the JCAHO to take a hike. Another in Alabama is considering dropping the accreditation process for two of its three hospitals. They follow the move of a Missouri system that dumped the JCAHO about a year and a half ago.
John C. Lincoln Health System in Phoenix sent word to Joint Commission President Dennis O'Leary, M.D., earlier this year that the system no longer wanted to have its two hospitals accredited by the Joint Commission. Instead, 239-bed John C. Lincoln Hospital-North Mountain will be inspected by the Arizona Department of Health Services to be eligible for Medicare reimbursement.
John C. Lincoln Hospital-Deer Valley, a 97-bed osteopathic facility, will pursue accreditation only through the American Osteopathic Association's Healthcare Facilities Accreditation Program. Previously, both the JCAHO and the AOA surveyed it.
"We have concluded that the cost of participating in the JCAHO process is out of proportion to the value received," Dan Coleman, president and chief executive officer of Lincoln, wrote in a letter to O'Leary in January.
At Carraway Methodist Health System in Birmingham, Ala., assistant Administrator Michael Sheffield has the same concerns. Sheffield said he is giving "serious consideration" to pulling the system's two rural hospitals, 99-bed Carraway Burdick West Medical Center in Haleyville, Ala., and 63-bed Carraway Northwest Medical Center in Winfield, Ala., out of the JCAHO accreditation program before the facilities' next scheduled surveys.
"We may very well have to stop being JCAHO-accredited at those two outlying hospitals because of the cost," Sheffield said.
Coleman said his system disagreed with a JCAHO policy requiring health systems to have all of their healthcare services-including assisted-living facilities and school-based health centers-surveyed if they want their hospitals accredited. Lincoln complained that reviewing all those services was costly and duplicative because they were all surveyed annually by the state.
This requirement, referred to as the "tailored survey policy," is what drove 269-bed Freeman Health Center in Joplin, Mo., away from JCAHO accreditation in 1999. "That was the thing that triggered it for us back then," said Gary Duncan, Freeman's president and CEO.
"We are seeing a trend of more people raising the question as to the value of accreditation," said Donald Nielsen, M.D., senior vice president of quality leadership for the American Hospital Association.
The JCAHO said the heightened scrutiny of its value is a byproduct of the tough financial conditions hospitals have faced in recent years. "As cutbacks occur in their world their questioning, in regards to every expenditure, will be intensified," said Russell Massaro, M.D., the JCAHO's executive vice president of accreditation operations.
The number of hospitals the JCAHO accredits fell to 4,818 as of May 2001 from 5,313 in 1995, but the Joint Commission said most of that loss is attributable to hospitals closing or being swallowed in mergers. According to JCAHO statistics, in each year from 1995 to 2001, it has had more new hospitals initiate accreditation than voluntarily opt to leave the program.
Nielsen said he was not aware of hospitals voluntarily leaving the JCAHO with a frequency any greater than in the past.
Coleman's letter also attacked the JCAHO's increasingly prescriptive approach. "The Joint Commission needs to simplify its standards, define things that need to be addressed, and allow hospitals to address those standards in a way that makes sense for the communities they serve," Coleman wrote.
In May, the JCAHO announced what it said was a relatively sudden decision to begin a comprehensive overhaul of its hospital accreditation compliance standards. The Joint Commission said it was responding to hospitals' mounting concern that many of the JCAHO's nearly 500 standards were not relevant to patient care.
Lincoln estimated that it would have paid the JCAHO $86,000 for this year's survey, and it would have spent another $24,000 on a consultant to participate in the Joint Commission's outcomes reporting initiative, Oryx. Coleman's letter said these costs didn't include other JCAHO-related expenses, such as attending conferences, "to stay up with your ever-changing standards and their interpretations."
Inspection by the state health department, however, is free.
Hospitals opting out of the JCAHO accreditation program may continue to be eligible for Medicare payment either by pursuing accreditation through the AOA, as about 200 hospitals do, or by undergoing a state health department inspection to be Medicare-certified. HCFA contracts with states to perform the inspections.
The JCAHO's rule that it must survey all of a system's health services to accredit its hospitals has been contentious, Nielsen and Massaro said.
"(Hospitals) would prefer to be able to determine whether an aspect should or should not be included in the survey as opposed to being required to have it in the survey," Nielsen said.
The JCAHO has modified the policy in reaction to hospitals' concerns but won't scrap it because consumers assume that if a hospital is accredited by the Joint Commission then all of its services are also accredited, Massaro said.