After nearly a decade of criticism about the hefty cost and questionable relevance of its evaluations, the Joint Commission on Accreditation of Healthcare Organizations is vowing to radically reformulate the accreditation process to spur meaningful measurement of patient care in place of rote compliance with lists of standards.
The declaration comes against a backdrop of simmering discontent from providers, declining survey volume and dozens of hospitals opting out of accreditation each year. In addition, providers are under increasing public pressure to show evidence of good clinical performance and patient-safety practices, not just good scores on surveys every three years.
But scenarios for substantial change and better attention to value have come from the Oakbrook Terrace, Ill.-based agency for more than 15 years in response to one criticism or another, starting in 1986 with the vaunted Agenda for Change initiative.
A spontaneous flare-up of provider criticism in 1994 resulted in another reform plan called Orion, which subsequently faded from view. Objections to JCAHO efforts to mandate the use of a homegrown performance measurement system led to the 1997 launch of the Oryx clinical-measure project, which handed off the development to outside vendors.
However those efforts and more recent examples, such as reporting of sentinel events and issuing new directives to adhere to proven patient-safety practices, still relied on voluminous standards and involved high costs-the core of provider opposition to the burden of accreditation. By contrast, the latest plan for the first time seeks to fundamentally change the premise as well as the process.
"On paper, it looks great," said Richard Wade, American Hospital Association spokesman. Among other improvements, "it means a new kind of surveyor with a new kind of attitude." But the execution is what counts, he added. "There's been much promised here, and our members want to see the promises fulfilled."
The top-to-bottom redesign of accreditation, unveiled last week, includes major efforts to reduce the number of standards by which provider organizations are judged. It also de-emphasizes the all-out importance of documenting compliance with hundreds of standards during a three-day visit by a survey team.
Instead, much of the burden of demonstrating compliance will be addressed by walking providers through a self-assessment at the 18-month mark of the three-year accreditation cycle, in which a healthcare organization will evaluate its own compliance with applicable standards and develop a correction plan to be validated by surveyors during their triennial visit.
That will free up surveyors to focus on a handful of critical patient-care priorities identified prior to the visit, using computerized methods that the JCAHO asserts will make surveys consistent among similar institutions instead of influenced by the biases of individual surveyors.
And because most of the accounting for standards compliance will have been done through the self-assessment and resulting operational changes, healthcare organizations won't feel pressure to spend sometimes hundreds of thousands of dollars to "ramp up" for any twist or turn a survey might take as surveyors select from the thick manual of standards, said Russell Massaro, M.D., the JCAHO's executive vice president of accreditation operations.
JCAHO officials said the prevailing cost of compliance will decrease, though survey fees will remain steady at an average of $22,000 per hospital survey. Undergoing the self-assessment, which will be completed through a secure Web-site connection and follow-up phone calls, should require no new resources, they added.
Tackling chief complaints
The redesigned process, which takes effect for all accreditation programs in January 2004, is the result of an internal review that began in 1999 in consultation with healthcare providers seeking changes and improved value, Massaro said.
But rampant dissatisfaction about accreditation goes back at least to late 1994, when the AHA took the JCAHO to task for a long list of grievances that included uneven surveyor competency, subjectively applied standards and costs that were too high for what hospitals got out of it (Jan. 2, 1995, p. 20).
Eight years later, providers are still frustrated by the same concerns, Wade said. "Our members don't feel the process has pushed them along the road to quality-it's just filling out a checklist," he said.
Just last April, AHA President Richard Davidson dashed off a highly critical letter to JCAHO President Dennis O'Leary, M.D., that questioned the commission's commitment to resolving "serious problems surrounding the accreditation process, the development of standards and other issues critical to (its) core mission."
Davidson subsequently learned the JCAHO was completing a plan to address those problems, pulling together several pilot initiatives that were being tested by nine hospitals.
"I think it has the ingredients to be successful," said Kevin Keighron, chief operating officer of 127-bed Yavapai Regional Medical Center, Prescott, Ariz., one of the test sites.
"With some polishing and refinement of the process, I think they're on the right track," said Mark VanderLinden, director of quality management at another pilot site, 486-bed Washoe Health System, Reno, Nev. After the mock survey ended Sept. 20, "all managers felt it was a much-improved process and preferred over the traditional review."
VanderLinden characterized the survey as "a real-time, real-life assessment of performance," but he was skeptical of promises that the new routine would eliminate the subjective aspects of accreditation. "It still has the potential for survey variation based on surveyor bias and experience," he said.
Narrowing the survey focus
A key element of the revamped approach is a presurvey review of data specific to the organization, using a computer analysis to sift through disparate sources of data and identify critical areas on which surveyors can focus. Much of that data already gets into the hands of surveyors for clues on how to proceed, but the computerized method "automates what has been going on in the surveyor's head all these years," said Jerod Loeb, vice president of research and performance measurement at the JCAHO.
The data will include results from the earlier self-assessment and past surveys; details from the latest accreditation application; statistics on mortality and complications from Medicare's Medpar database; and performance on up to six clinical measures of an organization's choosing that Oryx began requiring of accredited providers starting in 2000.
As of July 1, the JCAHO began to require accredited hospitals to collect data on two sets of standardized performance measures from a list of four initial sets covering heart attack, congestive heart failure, pneumonia and management of pregnancy. Those Oryx core measures will be added to the presurvey mix after the January 2003 deadline for sending the data to the JCAHO, Loeb said.
A standardized review of presurvey data will isolate four to five critical focus areas from among 14 areas identified as having a significant effect on patient safety and quality of care, Massaro said. With the self-assessment in hand, "surveyors will have the luxury of being able to prioritize what they're looking at because all the standards have been looked at once," he said.
One upshot will be less huddling with surveyors in documentation reviews. Two sit-down sessions will be eliminated (See chart above).
Surveyors will instead spend about two-thirds of their time visiting hospital floors, surgical departments and ancillary areas to check how care was recently provided to patients still in the facility, Massaro said.
By choosing active medical records at random and tracing a patient's treatment throughout a hospital stay, surveyors will be able to evaluate actual performance against standards of good practice, he said.
For example, he said, if a patient was restrained in the emergency room, surveyors will ask questions about how it was done and relate the response to JCAHO restraint standards. If the patient is wheeled into an X-ray room and speaks only Spanish, the attention to that need will help assess how the hospital handles patient-rights issues.
Every standard is in play, Massaro said, but instead of surveying standards for their own sake, the new process surveys how care is delivered in terms of the standards for that care.
"It really brought to light the focus on day-to-day operations," VanderLinden said. In the September mock survey, three surveyors followed a dozen or more patients through their stay, and the result was "truly a more accurate picture" of how the organization operates, he said.
The new approach extends to the final accreditation rating, which will eliminate numerical scores and drop an accreditation status that advertises lingering noncompliance with some major standards. Massaro said the scores are an element in accreditation decisions but weren't intended to spur campaigns to achieve high scores as a function separate from maintaining and improving operations.
To foster cooperation rather than the fear of being penalized, the JCAHO will end the accreditation status "with requirements for improvement." Survey teams will disclose serious noncompliance at the end of the visit and give organizations 30 days to submit corrective action before a decision is published. Those passing the initial evaluation or meeting the remedial deadline will be given an "accredited" rating while organizations with continuing problems will get a status of "accreditation pending."
Old ways die hard
In practice, the revamped approach's success depends on reorienting an army of JCAHO surveyors to the new angle of relating patient-care performance to standards compliance instead of hunting for problems to mark down on a report, JCAHO officials acknowledge.
That won't be easy, Keighron said. For example, one surveyor moving through patient-care areas using the new "tracer" methodology got sidetracked when he looked inside a refrigerator that was reserved for medications and found a wrapped muffin. The surveyor started writing up the facility for that infraction.
"This is what kills the Joint Commission," Keighron said-jumping on standards with no relationship to quality or safety. Even the pilot-test observers on the scene agreed JCAHO instructors "still have to train surveyors to get away from looking for the muffin and concentrate on the tracer," he said.
Massaro said surveyors will undergo comprehensive retraining, including a curriculum to be developed by Northwestern University's Kellogg School of Management on organizational systems analysis skills. The goal is to get surveyors to make the connection between standards and the care processes they measure, he said.
The AHA's Wade said no less than the future of voluntary accreditation is at stake. "There's going to be a lot riding on this for our members," he said. In light of the pressure to submit hard evidence of quality, for example, "this will take us along that road if it's successful."
But the JCAHO also has an incentive to stem the slide of survey volume and total accredited hospitals during the past several years. The number of accredited hospitals has slipped to 4,801 at the end of 2001 from 5,080 at the beginning of 1999, according to JCAHO figures. A majority of the attrition came from hospital closures, mergers and acquisitions, but 38 hospitals withdrew from the program in 2001, along with 43 in 2000 and 38 in 1999.
The new approach either will "largely erase" doubts about the JCAHO's ability to demonstrate its value "or it will set us back," Wade said. "Considering the importance of voluntary accreditation to the field, this can't afford to fail. And there's going to be a lot of folks looking at it."