October 29, 2018
A Look At The Joint Commission
By Michael D. Shaw
According to the US Department of Health and Human Services, the Joint Commission on Accreditation of Healthcare Organizations (generally referred to as the Joint Commission) is a private, not for profit organization established in 1951 to evaluate health care organizations that voluntarily seek accreditation. Currently, the Joint Commission evaluates and accredits more than 16,000 health care organizations in the United States, including 4,400 hospitals, more than 3,900 home care entities, and over 7,000 other health care organizations that provide behavioral health care, laboratory, ambulatory care, and long-term care services.
While competitive accreditation bodies do exist, the Joint Commission (JC) still has about 80% of the market. The “Joint” in the name reflects the fact that the American College of Physicians, the American Hospital Association, the American Medical Association, and the Canadian Medical Association teamed up with the American College of Surgeons as corporate members to create the Joint Commission on Accreditation of Hospitals. In 1987, the name was changed to its present designation.
The JC likes to trace its origins back to legendary American surgeon Ernest Amory Codman (1869-1940), who pioneered the notion of tracking medical outcomes (Codman called them “end results”), to improve the quality and safety of health care. He was one of the founders of the American College of Surgeons, which promoted his end results philosophy in its “Minimum Standard for Hospitals” in 1919.
Despite his many significant accomplishments in medical quality control and surgery, Codman infuriated his peers with undiplomatic attacks on their mercenary nature—as well as the failure of healthcare institutions to be diligent of end results. Owing to the collegial nature of medical practice, especially back then, Codman lost patients and died in relative obscurity—too poor to afford a headstone.
But, lucky for him, a mere 56 years after his death, the JC established its Codman Award “to showcase the effective use of performance measures, thereby enhancing knowledge and encouraging the use of performance measurement to improve the quality and safety of health care.”
JC accreditation is based on a survey performed by JC personnel called “surveyors.” During this process, surveyors select patients randomly and use their medical records as a roadmap to evaluate standards compliance. As surveyors trace a patient’s experience in a health care organization, they talk to the doctors, nurses, and other staff who interacted with the patient. Surveyors also observe doctors and nurses providing care, and often speak to the patients themselves.
The survey entails more than 250 hospital accreditation standards, addressing everything from patient rights and education, infection control, medication management, and preventing medical errors, to how the hospital verifies that its doctors, nurses, and other staff are qualified and competent, how it prepares for emergencies, and how it collects data on its performance and uses that data to improve itself.
This sounds great until you discover that the JC seldom pulls accreditations from hospitals. In September, 2017, the Wall Street Journal ran a scathing article on how hospitals with serious safety violations (and associated deaths) were allowed to maintain their gold seal of approval. The WSJ investigated JC surveys from 2014 to 2016. In 2014, about 350 hospitals with Joint Commission accreditation were in violation of Medicare requirements that year, and about a third of those facilities went on to have additional violations in 2014, 2015, and 2016.
In one particularly egregious case involving Cooley Dickinson Hospital in Northampton, MA, the safety problems were bad enough—including three related patient deaths within a few months—that Medicare was considering cutting off funding. Yet, this facility could still display its gold seal of approval. As such, there are certainly those who are not big fans of the JC.
And now, a new study out of Harvard concludes that:
“US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by the Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.”
Patient outcomes were examined at 4,400 U.S. hospitals, 3,337 of which were accredited by the Joint Commission and 1,063 that underwent state-based review between 2014 and 2017.
The researchers also noted that, “Hospital accreditation is a central element of the quality strategy for many countries and is thought to be an important component of maintaining quality and safety of care delivered. However, given the minimal benefit seen with accreditation in this study, it raises the question of whether our national efforts need to emphasize accreditation as much as they do.”
Well said, and unfortunately that complaint can also apply to many accreditation bodies and standards organizations outside of healthcare. For example, the well-known ISO 9001 quality standard is largely a matter of getting all the correct paperwork in place. But that is no guarantee that there will be any quality in the products or services themselves. Likewise, until hospital accreditation takes much greater notice of patient outcomes, it will be of questionable value.