Questions about JCAHO accreditation and your place of employment...

  1. On another thread I posted about yet another stupid JCAHO rule. One of the posters replied that he/she thought their facility was not going to do the JCAHO thing the next time they were scheduled. So that got me to thinking....

    Do any of you work for a facility that is not accredited with JCAHO? Do you think that makes a difference on how the public perceives your facility? Do you think your level of care is above average, average, or below average because of not being accredited?

    Is there anyone who has worked for a facility that was JCAHO accredited in the past but decided not to seek accreditation the next time? If so, do you know what the determining factors were in that decision? Such as cost of the survey, the tons of paperwork, or trying to reach the impossible goals that JCAHO has set.

    Any other questions, comments, remarks about facilities who were previously accredited by JCAHO but aren't now (by their own decision). Better yet, anyone have any links about hospitals refusing to do the JCAHO thing..


    Thanks for you input!!
  2. Visit deespoohbear profile page

    About deespoohbear

    Joined: Aug '01; Posts: 2,276; Likes: 42
    RN

    11 Comments

  3. by   webbiedebbie
    Hi...can't sleep either?

    I remember after I graduated, I was told to find a job in an accredited hospital, so I figure there are some that are out there that aren't. Wouldn't know which ones, though.
  4. by   MissdonditaBsn
    If I am not mistaken not being accredited by JACHO can directly effect Medicare reimbursement. I don't think that Medicare will pay if the institution isn't accredited. I may be wrong though.
  5. by   baseline
    Facts about Medicare+Choice and the Joint Commission


    In March 2002, the Department of Health and Human Services' Centers for Medicare & Medicaid Services (CMS) announced that Medicare+Choice organizations licensed as health maintenance organizations (HMOs) and preferred provider organizations (PPOs) accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) will be "deemed" for meeting Medicare certification requirements.

    This authority allows JCAHO-accredited HMOs and PPOs to be deemed in six categories:
    Antidiscrimination
    Access to services
    Quality assurance programs
    Confidentiality and accuracy of enrollee records
    Information on advance directives
    Rules regarding provider participation
    The federal government's Final Notice granting the deemed status option to JCAHO for its accredited HMOs and PPOs was published in the Federal Register on March 22, 2002. There are 153 health plans and PPOs currently approved by CMS to participate in the Medicare+Choice program.

    CMS found that JCAHO standards for Medicare managed care organizations meet or exceed those established by the Medicare program. The Balanced Budget Act of 1997 directed CMS to establish and oversee a program that allows private, national accreditation organizations to "deem" that a Medicare+Choice organization meets certain Medicare requirements.

    Health care organizations seeks JCAHO network accreditation for numerous reasons, including:
    JCAHO accreditation is highly customized, focusing on the needs and services of the specific network.
    JCAHO accreditation provides a framework for integration, helping leaders and staff focus on integrating operations and on facilitating the implementation of quality improvement initiatives across the organization.
    JCAHO's survey process directs attention throughout the network to network-wide goals for performance improvement, continuum of care, patient rights, and leadership.
    JCAHO accreditation is recognized as a symbol of quality by government agencies, providers, purchasers, payers and consumers.
    JCAHO accreditation demonstrates the network's commitment to quality and to providing timely access to services across the continuum of care.
    In more than 21 states, JCAHO accreditation meets state licensing and contracting requirements.
    JCAHO accreditation gives the network an edge over competitors when purchasers and payers are selecting participating networks, and when members have a choice in making enrollment decisions.
    JCAHO accreditation provides a mechanism to monitor performance.
    In addition to Medicare+Choice HMOs and PPOs, deemed status options are available for JCAHO-accredited ambulatory surgical centers, clinical laboratories, home health agencies, hospice organizations and hospitals.
  6. by   deespoohbear
    Originally posted by baseline
    Health care organizations seeks JCAHO network accreditation for numerous reasons, including:
    JCAHO accreditation is highly customized, focusing on the needs and services of the specific network.
    JCAHO accreditation provides a framework for integration, helping leaders and staff focus on integrating operations and on facilitating the implementation of quality improvement initiatives across the organization.
    JCAHO's survey process directs attention throughout the network to network-wide goals for performance improvement, continuum of care, patient rights, and leadership.
    JCAHO accreditation is recognized as a symbol of quality by government agencies, providers, purchasers, payers and consumers.
    JCAHO accreditation demonstrates the network's commitment to quality and to providing timely access to services across the continuum of care.
    In more than 21 states, JCAHO accreditation meets state licensing and contracting requirements.
    JCAHO accreditation gives the network an edge over competitors when purchasers and payers are selecting participating networks, and when members have a choice in making enrollment decisions.
    JCAHO accreditation provides a mechanism to monitor performance.
    In addition to Medicare+Choice HMOs and PPOs, deemed status options are available for JCAHO-accredited ambulatory surgical centers, clinical laboratories, home health agencies, hospice organizations and hospitals.

    My own theory....

    JCAHO is a money grabbing organization who has lost total touch with reality when it comes to direct patient care.

    Gee, I hate that organization....
  7. by   baseline
    Well, they certainly spend a great deal of time researching stuff that someone else has already completed ad nauseum, and then tweeks it just enough to make things double the work.

    Just for clarification, I didn't compose the statement in my original post....I took it off the JCAHO web site.
  8. by   sjoe
    It is just another "protection" racket, IMHO.

    Any facility whose operation would actually be improved by meeting JCAHO certification is in VERY poor condition to begin with, so they don't even try. (I have worked for 2 of them.)

    Any reasonably-run facility just gets bogged down with paperwork and misdirection of staff efforts in order to meet JCAHO certification.

    In either case, it is not useful to the patients.
    Last edit by sjoe on Feb 28, '03
  9. by   KaroSnowQueen
    JCAHO caused our hospital to make us get rid of med carts. We have to walk from the med room to the pt room with each med and the MAR, and walk back and repeat for each pt. If I"m on my usual unit with four pts, it's not bad. But when I'm floated and have to do this for eight pts that may or may not be near one another, let alone the desk, it's a pain in my butt.
    WHY can't we have med carts? Not because they are left unlocked or any thing like that. Nope. They "clutter the hallway" and might impede evacuation in case of fire, etc. Can you believe it? It's not just one facility, it's all five of them owned by the same company in the metro area. Good grief. Haven't been to any of the other hospitals in the area to see if they are doing the same thing.
    BUT the SNU is allowed to have carts on their unit, even though they are in the same building because they are considered a nursing home. What the heck sense does that make???????
    I think JCAHO needs to get a clue. Maybe two.
  10. by   P_RN
    No med carts?? How's that? I thought as long as they were double locked it was OK to have them. Is this possibly management getting back at someone for not locking it when the clipboard people dropped by?
  11. by   baseline
    We have med carts and are JCAHO approved. I don't understand that one. Sounds like a facility thing.
  12. by   deespoohbear
    JCAHO changes the rules everytime and with every facility. It depends on what surveyor you happen to get. You never know from time to time what the heck they want. What might be okay on visit might get you a Type 1 "recommendation" on the next. Talk about lunacy. In our facility the skilled nursing unit has to have their crash cart behind a locked door. But our med-surg unit doesn't. The skilled unit is one floor beneath us. How much sense does that make? Just what you want to do when someone is coding. Have to retrieve the crash cart from a very inconvenient location, behind a locked door. Talk about somebody needing a clue phone....
  13. by   Mofe'ny
    OH MY GRACIOUS!!! I HATE JCAHO! We just had our survey MId February. OK, the night before the surveyors were to come through our unit, our manager came through with a list of things to be done including: "Clean the wheels on all the IV poles." And we were also told not to leave any thermometers off their base or with an empty probe cover box or that was a Type 1 recommendation.

    Well, needless to say we told her that she would have to clean them herself since we already had 1 less RN than day shift, and 3 charts up of babies to deliver. I am thankful that the surveyors didn't come through on nights (even though we were told they DEFINITELY would), because I could care less about all of the paperwork that they passed out for us to 'memorize'. Especially since they were giving us new admission forms the week or so prior and wanting us to switch to those with no inservices! Well sure that's brilliant!
    What really gets me though is that the hospital has spent 12 months with a consulting agency coming through doing 'mock surveys." How much money was wasted on that? Personally, I think it is just a big old moneymaking scheme with the insurance company & governments blessing. (And no I am not normally paranoid )
    Oh and just a question to think about. With all of the new HIPPA regulations, why do the surveyors get to go medical records and dig through the charts? That just puzzles me.
    OK, sorry-- This is my new soapbox! But I'll get down now!

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