JCAHO Defines (Hospitals' Quality of Care) Deviancy Down

The Los Angeles Times reported how the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has lowered their quality standards for hospitals. Apparently after getting "better-trained inspectors and switch this year to surprise reviews," JCAHO found they were finding more problems when they inspected hospitals. So, Joseph L Cappiello, Vice President of Accreditation Field Operations for JCAHO, said, "we shouldn't deny accreditation to 10 or 15 or 20% of all hospitals in the United States." Instead, they have increased the allowable number of deficiencies.

US Senator Charles E Grassley (R-Iowa), Chair of the Senate Finance Committee, commented, "goverment investigators have already documented that the Joint Commission misses too many serious problems and rarely drops any hospital's accreditation. This move to weaken standards seems to be going in the opposite direction of what makes sense for quality of care."

We physicians hear more and more about how many errors we allegedly commit, and about how our reimbursements will soon be subject to pay-for-performance (see previous post). Yet while physicians feel ever increasing pressure to increase quality of care, when more stringent hospital inspections find more problems, the hospital inspectors decide that they will make their grading standard more lenient. How curious.

The LA Times article did note that JCAHO is paid by the hospitals it inspects, and "owns a consulting business that helps hospitals prepare for its reviews." In a previous post, we also noted reports of other possible conflicts of interest affecting JCAHO. These possible conflicts are important because the federal government has given JCAHO responsibility for most evaluations of hospital quality. Do these possible conflicts of interest have anything to do with what could not be called JCAHO's defining down (hospitals' quality of care) deviancy? Once again, inquiring minds want to know.

Addendum (14 April, 2006): In a letter to the LA Times, Dr Dennis S O'Leary, Presidence of JCAHO, stated that "this article misses the markin in suggesting recent changes ... reflect a relaxation in performance expectations for hospitals." He noted, "the changes in the review threshold are simply designed to assure that the right hospitals are the subject of intensified review. The changes are part of a series of steps being taken to refine the accreditation decision process. Pending their finalization, no adverse decisions for hospitals evaluated in 2006 have yet been rendered. This will begin to happen in May. Because nothing has happened yet, there have been no expressed concerns among accredited organizations about the new process, and the joint commission has received no pressure from any source to make its accreditation process more rigorous."

Post Title → JCAHO Defines (Hospitals' Quality of Care) Deviancy Down

Allegations of Conflicts of Interest at JCAHO

The Washington Post has been running a series on Medicare. One particularly significant article was on how Medicare has farmed out most evaluation of health care quality to the Joint Commission on the Accreditation of Health Care Organizations (JCAHO), pursuant to language in the original 1965 legislation that set up Medicare. Also, many states have closed down their inspections of health care facilities, and rely on JCAHO accreditation. For example, "Maryland regulators used to conduct their own hospital inspections until a wave of deregulation swept the state in the 1980s and state legislators agreed to accept joint commission accreditation for licensing purposes. According to Carol Benner, director of the state Office of Health Care Quality, Maryland 'had no authority' over the joint commission: 'We couldn't tell them what to look for in their surveys, and they didn't consult us.'"
Yet the article stated, "the joint commission's practices raise questions about potential conflicts of interest and the rigor of its hospital surveys." The article charged:

• There have been "glaring examples" of JCAHO missing important quality problems, notably at Redding Medical Center (California), Maryland General Hospital, Norwalk Hospital (Connecticut), and Palm Beach Gardens Medical Center (Florida).
• "The board of directors of the joint commission is dominated by representatives of the American Hospital Association and the American Medical Association." [The listing of the current Board of Commissioners is here. The listing does not appear to have many people with overt associations with the AHA and AMA. The web-site describes the Board as having "diverse experience in health care, business and public policy. The board consists of 29 individuals, including physicians, administrators, nurses, employers, a labor representative, health plan leaders, quality experts, ethicists, a former health insurance executive, a consumer advocate and educators."]
• "About 99 percent of the hospitals reviewed by the joint commission win accreditation...." "Some critics point to the approval rate as evidence that the joint commission is captive to hospitals."
• JCAHO sells hospitals "We Are Accredited" products, e.g. "banners, coffee mugs and enamel pins."
• JCAHO has a "subsidiary, Joint Commission Resources, [which] was established in the 1990s to consult with hospitals on how to gain accrediation and improve their performance." "Directly or indirectly, most of JCR's nearly $33 million in revenue comes from helping hospitals win the joint commission's seal of approval." JCR CEO Karen H. Timmons "said that there is a firewall between the subsidiary and the joint commission...." However, there are substantial money flows between the groups. "In the past three years, JCR has paid its parent about $10.5 million in management fees and $867,000 in royalties. And according to its 2003 tax return, JCR owes the joint commission nearly $8.4 million."

In my humble opinion, if the main function of JCAHO is for hospitals and other health care facilities as a group to improve their own health care quality, that would be admirable, and the practices above would not constitute problems, for the most part. However, if the federal and state governments have out-sourced quality control to JCAHO, the questions about conflict of interest raised by the Post become very serious.

Post Title → Allegations of Conflicts of Interest at JCAHO