Accreditation Overview

 

This November, Citrus Valley Medical Center is scheduled for its triennial CAL (California Accrediting and Licensing) Survey.  Three agencies conduct this survey:  the California Department of Health Services (DHS), responsible for licensing; the California Medical Association’s Institute of Medical Quality (IMQ), responsible for Medical Staff standards and quality; and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), responsible for accreditation.  But what is JCAHO and what is accreditation?

The mission of JCAHO is “to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations.”  The Joint Commission sets standards for, evaluates, and accredits nearly 20,000 health care organizations and programs in the United States, including over 11,000 hospitals and home health agencies.

Physicians played a key role in the formation of the Joint Commission.  It was created to take over the work of the original hospital standardization program started in 1918 by the ACS.  The Commission was founded as the Joint Commission on Accreditation of Hospitals in 1951 by a collaboration of the American College of Surgeons (ACS), the American Medical Association (AMA), the American College of Physicians (ACP), and the American Hospital Association (AHA).  Reflecting its professional origins, all surveyors remain physicians and other health care professionals.

The public role of the Joint Commission was enhanced by Medicare legislation passed in 1965.  Hospitals accredited by JCAHO gained “deemed status” and are said to be “in compliance” with Medicare conditions of participation.  This allows them to be eligible for reimbursement from the government.  The Joint Commission is the only private sector entity entrusted by the government with quality oversight of an industry with such immense impact on individuals’ lives.  As such, JCAHO standards and the accreditation process are under constant scrutiny.  This scrutiny has resulted in a “shift” in the standards from measuring the capability of a hospital to perform to measuring actual hospital performance.

The JCAHO standards push towards uniformity and improved quality of patient care, treatment and services.  An overview of those standards and the accreditation process will be reviewed in the coming months.