March 5, 1999

As it reforms its survey procedures, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is reaching out to critics who maintain that the process it uses to accredit hospitals and other health care facilities is not as useful and effective as it could be.

Among the criticisms most often voiced by patients, health care consumers, and their advocates is that far too few consumers' opinions are included in the surveys, and the findings are shrouded in secrecy, thus depriving the public of valuable information they need to make health care decisions.

At a forum last month in Washington, D.C., JCAHO commissioners heard a wide array of complaints about the method it uses to evaluate facilities and got a mixed verdict on the steps it is taking to improve its accreditation procedures.

The forum was the last in a series of three the JCAHO has held to further its goal of obtaining more input from the people who rely on the facilities it accredits. The others were held in Los Angeles and Chicago.

The organization accredits hospitals, home health agencies, nursing homes, outpatient surgery centers, laboratories, and health plan facilities. It also accredits "behavioral health care" facilities, which include those providing mental health care, substance abuse treatment, and care for mentally retarded individuals.

Another major goal of the forums was to help the JCAHO decide which elements it should evaluate as it develops a more detailed and quantifiable concept of factors that reveal the quality of care provided by these facilities.

Among the quality of care dimensions JCAHO commissioners are exploring-and on which it asked for input from forum participants-are care outcomes, the occurrence of significant errors or "sentinel events," the care environment, the process of care, ease of access to services, patient rights procedures, and availability of disease prevention and wellness programs.

One theme that ran through the comments and suggestions by forum participants, most of whom were affiliated with health care advocacy organizations, was that the JCAHO needs to do a better job of obtaining the reactions of patients and other health service users to the care they received.

Another recurring theme was that the commissioners should provide more opportunities for nonmedical staff to discuss the facility in which they work without fear of being identified and punished for talking to the JCAHO. Without a confidential milieu, preferably off site, in which nurses and other staff can discuss problems at their facility, the accreditation evaluations will not be as comprehensive and informative as possible, said several of the health care advocates.

Jim McNulty, representing the National Alliance on Mental Illness (NAMI), stressed that the confidentiality concerns are particularly critical if the JCAHO wants to include comments from "real consumers" who have experience with mental health care facilities. Fear of being stigmatized because of their mental illness could deter them from cooperating in a survey unless the JCAHO can guarantee confidentiality, he said. JCAHO commissioner John Helfrick, D.D.S., replied that in the past year the commission did change its policy to ensure that patients who offer comments on their care will not have their identities revealed.

NAMI board member J. Rock Johnson strongly emphasized that the usefulness and objectivity of the JCAHO accreditation process are hindered by the fact that compliance by health care facilities is voluntary and that the results do not have the weight of a regulatory system. She urged the commission to ensure that consumers participate in the surveying process and not be limited to offering comments to other JCAHO surveyors.

In addition, because consumers' observations play a minor role in accreditation surveys, the commission pays too little heed in its questions to the "cognitive differences" that often exist between physicians and the people they treat, Johnson added. The example she cited was use of restraint and seclusion, which, she said, are often viewed by psychiatrists and mental health professionals as a therapeutic response, while patients see these steps as punishment.

Many of the health care advocates and consumers took the JCAHO to task for making it difficult for the public to obtain accreditation survey information. They attributed part of the blame to the inclination of the surveyed facilities to fight distribution of data that consumers need to make health care decisions, particularly when errors or deficiencies in care are included in reports that will be made public.

Helfrick of the JCAHO suggested, however, that compliance and willingness of the surveyed facilities to make data public improve when the facilities understand that the JCAHO is not assigning blame when it reveals problems, but trying to educate the public about their health care choices.

Solutions the attendees suggested for ameliorating the difficulty consumers have in locating JCAHO accreditation reports included increasing the number of reports available on the organization's Web site, making them available by mail, issuing press releases in the communities served by each facility it reviews, and placing news stories in the local press when a facility gains only a provisional or conditional accreditation or fails to win accreditation.

Others took the JCAHO to task for attaching its primary loyalty to physicians and facilities rather than to the public.

Another concern that the health advocates brought up repeatedly is the issue of unannounced visits. Several speakers stressed that their constituents do not consider survey results to be an accurate portrait of a facility when administrators have ample notice of the JCAHO's arrival for an accreditation visit. Calls for the JCAHO to conduct these visits without prior notice drew enthusiastic responses from attendees. Helfrick pointed out, however, that the commission does make unannounced follow-up visits to 5 percent of the facilities it surveys and has not ruled out increasing the number of unannounced visits. He suggested, however, that the commission views the prescheduled surveys as vital learning opportunities for the facilities and that the element of surprise would not necessarily enhance this aspect.

Information about the JCAHO survey process and criteria as well as reports of most accreditation reviews conducted since January 1, 1996, are available at the Web site www.jcaho.org