To combat the perception that accreditation surveys are more regulatory than consultative, the American Hospital Association has asked the Joint Commission on Accreditation of Healthcare Organizations to experiment with teams of volunteer non-JCAHO surveyors drawn from hospitals.
"It would be part of the whole notion of saying that accreditation ought to be a peer process," said AHA President Richard Davidson. "Instead of fully paid, full-time employees of the Joint Commission, we get people to volunteer their time-and be coordinated by a Joint Commission employee, any way they might choose to do that."
JCAHO President Dennis O'Leary, M.D., said some form of the proposal "is definitely worth pilot-testing," but he also said the training requirements would be stiff. Volunteers would have to put aside problems at their home organizations and be very focused on their survey duties to avoid inconsistency of surveys-a chief complaint among hospitals, he said.
Davidson unveiled the volunteer idea during a joint interview with O'Leary conducted by Modern Healthcare. The May 28 conference call covered a range of conflicts between the two organizations and the steps taken to resolve them (June 3, p. 6). Among those issues was a continuing perception in the hospital industry that the JCAHO had its regulatory hat on when surveyors visited hospitals for triennial accreditation surveys.
By giving hospitals the option of a volunteer team of physicians, nurses and administrators, "that would change the whole mentality of the accreditation process; if you are being looked at by peers and working with peers, your perception of what they are doing there is one of trying to help you," Davidson said. "We think that could give a much different feel to the process."
The "atmosphere and environment" of accreditation was part of O'Leary's and Davidson's discussion on how the JCAHO can open up a traditionally rigid, three-day period of scrutiny that favors covering a lot of ground in the voluminous JCAHO standards manual instead of concentrating on a healthcare organization's particular problems and suggestions for improvement.
Though the AHA contrasted the voluntary approach to that of a full-time JCAHO survey force, only 21 of the current 163 surveyors are working full time, said Kurt Patton, executive director of hospital accreditation services for the JCAHO. The rest are paid $400 to $500 per day as "intermittent" surveyors, who are committed to one week per month, or part-time surveyors working two weeks per month, Patton said. Most are hospital chief executive officers, nurse executives and medical directors, he said.
Hospitals "would like different options on the accreditation process," Davidson said, acknowledging that the JCAHO is working on it. "We have been sending supportive signals to provide more choice opportunities, so that there are different ways one can become accredited as opposed to a standard, `Here it is: one, two and three.' "
O'Leary said a "fairly radically altered accreditation process," set to begin in 2004, will address many of the concerns about regulatory atmosphere and insufficient value of accreditation.
But the makeup of survey teams is not much of a factor, he said. The JCAHO is "boxed in by the design of the survey process. (If) you create a different survey process, you create a different perception about the competence of the surveyors," O'Leary said.
The new option of an 18-month survey process, which has been field-tested in eight hospitals, calls for a self-assessment at the midway point of a three-year accreditation cycle, followed by a correction plan reviewed by JCAHO staff or surveyors. During the next regular survey visit, surveyors will look at elements of the plan for evidence of progress, pick some other standards at random and accept all other findings reported by the hospital.
"That frees up a lot of on-site time, and we now combine this with a software tool (that) identifies potential issues that are specific to that organization," O'Leary said.
Lastly, the survey team will select a group of discharged patients whose conditions are relevant to the areas of focus, "reviewing how the hospital did on a standards-compliance basis against the real experience of that patient," he said.
The preparations for those tasks cost the JCAHO about $27,000 per surveyor, which includes classroom hours, training in standards technology, use of a laptop computer on-site and four outings during which new surveyors first observe and progressively get involved in the interviewing and scoring.
"What you want in a survey is very skilled people who know the standards," said Karen Fernandes, chairman of a JCAHO professional and technical advisory committee and director of quality management for Tenet Healthcare Corp. "I don't know if you'd have the volunteers out there to meet the demand."
O'Leary said he would prefer to consider having a volunteer force to observe other surveyors and provide another viewpoint rather than to participate in evaluating and scoring hospitals on accreditation.
"The longstanding complaint about Joint Commission surveyors, which is less so now because we're working on it, has been consistency: Are the surveyors interchangeable?" he said. "I guarantee that if you go in there with a volunteer fleet, the first complaint you're going to get is consistency."
Fernandes said hospitals "may not have the confidence in them that they have in the Joint Commission surveyors." If volunteers are not sufficiently trained and focused on the job while away from their day-to-day hospital position, they "may be a lot more subjective," she said.