Need JCAHO?  

The Joint Commission of Accreditation of Healthcare Organizations (JCAHO) is a good organization.  It goes beyond the standards of the Conditions of Participations that an organization needs for Medicare funding, but does it go too far and what are the alternatives.  I believe that everyone knows that passing the JCAHO triennial exam with a good score is important, but why?  

Let’s review what is necessary for Medicare funding.  HCFA has stated that in order to receive Medicare or Medicaid monies an organization must pass certain minimum standards.  These are known as the Conditions of Participation (CoP). This is a document of patient rights, etc., and is found in the Code of Federal Regulations at Section 42.  The standards are simple and easy to understand.   

Passing the CoP can be accomplished by having HCFA or its state designee, the Department of Health do a survey or have another private entity who has applied to HCFA for and been given “deemed status” do that survey. Two private organizations have also been given the green light to survey and if the survey is passed HCFA will agree that the organizations have passed just as if they would have surveyed them themselves (deemed).  These are the Joint Commission of Accreditation of Healthcare Organizations (JCAHO) and the American Osteopathic Association (AOA).  These private organizations use the Conditions of Participation as the backbone of their accreditation standards.   

Conditions of Participation  

These are the conditions that all institutions must meet to be accredited for receipt of federal (Medicare & Medicaid) funds.  This document gives the base quality standards.  There are different ones for various healthcare entities.  For hospitals they are compliance with laws, patients rights, governance, quality assurance, medical staff, nursing services, medical records, pharmaceutical, radiology, laboratory, food, utilization review, physical environment, infection control, discharge planning and organ donation.  The optional services covered are surgical, anesthesia, nuclear medicine, outpatient, emergency, rehabilitation, and respiratory.   There is not a lot of regulation in each section.  There is nothing in the CoP about re-credentialing physicians within two years or other items of minutiae and intrusion that are fostered by a private accreditation firm. The latest one is doing full soil and engineering testing prior to building or adding to a building.  This is for patient safety. Somehow, I don’t find that in the CoP.  


The Joint Commission grew out of the American College of Surgery.  In the early 1900s the College realized that many physicians were doing things that were outside of their scope of practice and that patients were being injured because of this.  The College began propagating rules for patient safety due to the improper care by untrained or inappropriately trained individuals. Later, in 1951, the Joint Commission was formed by the coming together of several individual entities such as the AMA that were placing their individual conditions on hospitals.  

The Joint Commission is a private non profit institution that has applied for and been granted deemed status by HHS.  The Service inspects the Commission on a routine basis and either continues to grant them deemed status or not.  The only condition is that the private organization use and make sure the CoPs are being complied with.  This is the baseline.  Anything the Joint Commission does above and beyond this is up to them. There is no requirement for a score.  The Joint Commission’s recent ruling that any score below a 79 will give a less than full accreditation is an edict by the Joint Commission and not related to their contract.  

In California , the Joint Commission does not inspect the medical staff or its policies.  They have delegated this to the Institute for Medical Quality (IMQ), a private arm of the California Medical Association.  The IMQ uses the same scoring as the Joint Commission and their scores are added to those of the Joint Commission.  The advantage of this arrangement is the consultive methods used by the IMQ and the inspection by physicians that are familiar with the local practices. The downside is the need to pay another entity.  Since there are already physicians on the JCAHO inspection team, although not necessarily from the same state as the institution, they could do the inspection.   

Until recently, when there has been more and louder criticism of their methods and costs, the Commission has not done any meaningful self-evaluation or performance improvement. As hospitals know, many Joint Commission standards are not relevant to patient care.  The Commission itself realizes this and is attempting to re-evaluate and remove non-relevant standards. 

Another of the Joint Commission edicts is if a hospital has affiliated medical groups or other agencies, they must be part of the inspection.  This magnifies the complexity of the inspection. As the Joint Commission is paid per inspection the cost that they command is also magnified tremendously.  They refuse to grant accreditation to a hospital without also looking at all the affiliated agencies at the same time.  Money is perceived to be a driving motive behind much of what the Joint Commission does. The Commission states it is because of public perception that if the hospital is JCAHO approved, all of its component parts are also JCAHO approved.  

Due to Joint Commission’s regulatory complexity, many hospitals hire outside consultants to help them prepare for the triennial survey.  This usually adds many thousands of dollars to the cost of the survey and by definition takes that money out of the patient care slice of the pie.  

Another relatively new JCAHO requirement is ORYX (Our Regulation Your eXpense).  This also takes significant money for technical consulting and inputting the information.  I have not seen much in the way of positive return from this program that could not be done on a non-individual input basis.  I also wonder how HIPAA will impact this program.  Is JCAHO a business entity and requires a business associate agreement or is it part of healthcare operations?  I believe that it is a business associate and as such will require about 20,000 business associate agreement contracts. Since it also looks at open and closed charts that contain personal health identification, the question unanswered as yet is will the hospital need to obtain authorizations and track disclosures.   

I believe that JCAHO stepped over the line with their sentinel report that has been found discoverable in New Jersey and their one-sided regulation that a licensed independent practitioner, even one not employed by the hospital, must tell the patient about any significant unanticipated outcomes.  Although I believe in open discussion, I do not believe in the intrusiveness of the hospital into the patient-physician relationship.  It is interesting that if one tells the patient of a complication that might ensue and the complication happens, it is not an unanticipated outcome.  Therefore, honest and open discussions are strongly encouraged, as they always have been.  

It is my contention that if a hospital is truly doing good patient care every day and paying attention and not just lip-service to the CoPs and performance improvement, they not only do not need a consultant but also do not need the required survey.  The survey is most helpful to those institutions that do not on a day in and day out basis look at their organizational structure and the patient care. I realize that in order to be paid one must be surveyed by an accrediting agency, but I wonder if this could not be done on a drop in basis with a one month heads up. This is especially true with the advent of validation State inspections.  These validation surveys are required for 5% of the hospitals accredited each year.  The hospitals that are picked are chosen by HHS.  

Department of Health  

Each state’s Department of Health has the authority to inspect and accredit institutions in lieu of the federal government.  When the Department inspects they use the Conditions of Participation as their manual. Therefore, most of the regulations of the private firms are not necessary.  The Department will accredit any institution that requests them to do it.  There are no grades given.  It is a pass/fail test.  The cost is reasonable.  There is no cost, it is free.  The problem is if you fail a private firm’s accreditation, you get a chance to make it right.  That does not hold with a State inspection.  If you fail, you are reported to HHS but retain appeal rights to correct any CoP deficiencies.  If all that is necessary is a fix on your policies and procedures, these may be mailed to the State.  If the needs are more, then the state may have to re-inspect.  The other related problem is the lack of significant consultive methods in the inspection.  The private firm’s surveyors will help you to improve your processes.  Another major downside is the need for yearly inspections and not every three years as with the private inspecting organizations. This may be a blessing in disguise since it makes the institution continually aware and updating their processes.  The State looks more at outcomes and interviews more staff and patients where the private accreditors seem to be more interested in processes, especially their own.  

Recently there has been a trend for more hospitals and hospital systems switching to the State for their accreditation.  This year a small system and several hospitals in Arizona have made the switch.

American Osteopathic Association  

The American Osteopathic Association (AOA) has been accrediting hospitals, osteopathic and non-osteopathic, five years longer than JCAHO.  However, they did not have the backing of the AMA and their subsidiaries so never became a large accreditation association.  They have all the same powers as the JCAHO but at less cost and have more flexibility.  They also accredit for more than the CoP but do not have all the other minutiae that plague the JCAHO.  They do not require all components of a hospital to be accredited to accredit the hospital. They are currently making a strong bid to become more of a competitor to JCAHO.  


The conclusion is an organization needs to ask itself why it would want to spend precious resources to pass a required evaluation.  Is it for ego satisfaction to know that your score is 94 and your competitor is 93?  Are you truly any better?  You are both only known as accredited and deemed Medicare and Medicaid certified.  There is no difference. The health community knows what accreditation is, the remainder of the world does not. They just assume their hospital is wonderful.  

Why wouldn’t the organization keep their processes up to date so that they could pass any evaluation regarding the Conditions of Participation and good performance improvement processes at any time?  Doing things right the first time and doing what is best for the patient is what’s important, not the score.  

I hope this article has opened up some discussion in your organizations where the alternatives are now known and considered.  It does not matter which organization you decide to use as long as it is the one that best serves your considered purpose.  

Please remember the famous Dan Quayle statement about the Chicago floods, “They need help, and we have helped, and we are here to help.  And we are helping, and we’re going to continue to help.”   Like the former vice-president, I am here to help.  I am here to help you with legal and consultive medical staff, individual health business including compliance and HIPAA privacy and peer review.   

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DISCLAIMER: Although this article is updated periodically, it reflects the author's point of view at the time of publication. Nothing in this article constitutes legal advice. Readers should consult with their own legal counsel before acting on any of the information presented.