Introduction to JCAHO

George Mason UniversityCollege of Nursing and Health ScienceRegulatory Requirements for Health SystemsSummer 2004

Used with Permission

JCAHO Mission:

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.

Historical Facts to Remember:

1910 Ernest Codman, M.D., proposes the "end result system of hospital standardization."

1913 American College of Surgeons (ACS) is founded. The "end result" system becomes an ACS stated objective.

1917 The ACS develops the Minimum Standard for Hospitals. Requirements fill one page.

1918 The ACS begins on-site inspections of hospitals (89/692). ACS sponsors start-up of Joint Commission on Accreditation of Hospitals.

1952 The ACS officially transfers its Hospital Standardization Program to JCAH, which begins offering accreditation to hospitals in January 1953.

1953 JCAH publishes Standards for Hospital Accreditation.

Historical Facts (continued):

1965 Congress passes the Social Security Amendments of 1965 with a provision that hospitals accredited by JCAH are "deemed" to be in compliance with most of the Medicare Conditions of Participation for Hospitals and, thus, able to participate in the Medicare and Medicaid programs.

1972 The Social Security Act is amended to require that the Secretary of the U.S. Department of Health and Human Services (DHHS) validate JCAH findings. The law also requires the Secretary to include an evaluation of JCAH's accreditation process in the annual DHHS report to Congress.

1975 Hospital accreditation moves from 1 year to 2 years with proof of deficiencies being corrected.

1982 The accreditation cycle increases from 2 years to 3 years for hospitals, psychiatric facilities, alcoholism and substance abuse programs, and community mental health centers.

Historical Facts (continued):

1983 JCAH establishes a tailored survey approach.

1987 The organization name changes to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to reflect an expanded scope of activities.

1988 The Indicator Measurement System® (IMSystem®)-an indicator-based performance monitoring system is launched.

1993 The Accreditation Manual for Hospitals is reorganized to focus on actual performance.

JCAHO begins conducting mid-cycle, random, unannounced surveys of 5% of accredited organizations across the nation.

The federal government announces that home health agencies accredited by JCAHO after an unannounced survey will be "deemed" to meet the Medicare Conditions of Participation.

Historical Facts (continued):

1994 The first organization-specific performance reports are released performance area scores and national comparative information.

Accreditation for health care networks begins.

1995 The federal government recognizes JCAHO laboratory accreditation services as meeting the requirements for Clinical Laboratory Improvement Amendments of 1988 (CLIA) certification.

1996 The Health Care Financing Administration announces that ambulatory surgical centers accredited by JCAHO will be "deemed" as meeting or exceeding Medicare certification requirements.

The Sentinel Event Policy is established for the evaluation of sentinel events in accredited organizations and their relationship to accreditation status. 

Historical Facts (continued):

1997 JCAHO launches ORYX: The Next Evolution In Accreditation(tm) to integrate the use of outcomes and other performance measures into the accreditation process.

1999 The Health Care Financing Administration approves JCAHO's application for hospice deemed status.

Arkansas becomes the 45th state to provide deemed status for hospital licensure. Under the act, JCAHO accredited hospitals are no longer required to undergo biennial inspections by the Arkansas Department of Health.

2000 Behavioral health care standards are revised to comply with HCFA “one-hour-rule” for restraints or seclusion.

JCAHO and the Occupational Safety and Health Administration (OSHA) in June extend an educational partnership agreement, established in 1996, that renews a joint commitment to help health care organizations efficiently meet both entities' requirements.

Historical Facts (continued):

2002 JCAHO announces the Shared Visions—New Pathways.

JCAHO establishes its first annual National Patient Safety Goals.

The Department of Health and Human Services' Centers for Medicare and Medicaid Services (CMS) announces that Medicare+Choice organizations licensed as health maintenance organizations and preferred provider organizations accredited by JCAHO will be deemed for meeting Medicare certification requirements.

CMS announces the granting of deeming authority for critical access hospitals to JCAHO. It also announces its continued approval of JCAHO as an accrediting body for review of clinical laboratories under federal CLIA regulations, and as a deeming authority for ambulatory surgery centers.

What JCAHO does:

The Joint Commission evaluates and accredits nearly 17,000 health care organizations and programs in the United States.

An independent, not-for-profit organization, JCAHO is the nation's predominant standards-setting and accrediting body in health care.

Since 1951, JCAHO has developed state-of-the-art, professionally based standards and evaluated the compliance of health care organizations against these benchmarks.

JCAHO accredits:•General, psychiatric, children's and rehabilitation hospitals.•Critical access hospitals.•Health care networks, including managed care plans, preferred provider organizations, integrated delivery networks, and managed behavioral health care organizations.•Home care organizations, including those that provide home health services, personal care and support services, home infusion and other pharmacy services, durable medical equipment services and hospice services.•Nursing homes and other long term care facilities, including subacute care programs, dementia special care programs and long term care pharmacies.•Assisted living facilities that provide or coordinate personal services, 24-hour supervision and assistance (scheduled and unscheduled), activities and health-related services.•Behavioral health care organizations, including those that provide mental health and addiction services, and services to persons with developmental disabilities of various ages, in various organized service settings.•Ambulatory care providers, for example, outpatient surgery facilities, rehabilitation centers, infusion centers, group practices as well as office-based surgery.•Clinical laboratories, including independent or freestanding laboratories, blood transfusion and donor centers, and public health laboratories.

JCAHO accreditation:

•Is recognized nationwide as a symbol of quality that reflects an organization's commitment to meeting certain performance standards.

•To earn and maintain accreditation, an organization must undergo an on-site survey by a JCAHO survey team at least every three years.

•Laboratories must be surveyed every two years.

JCAHO Governance:

29 Member -- Board of Commissioners

JCAHO Corporate Members:American College of Physicians

American Society of Internal Medicine

American College of Surgeons

American Dental Association

American Hospital Association

American Medical Association

Benefits of JCAHO accreditation:

• Leads to improved patient care.

• Demonstrates the organization’s commitment to safety and quality.

• Offers an educational onsite survey experience.

• Supports and enhances safety and quality efforts.

• Strengthens and supports recruitment and retention efforts.

• May substitute for federal certification surveys for Medicare and Medicaid.

• Helps secure managed care contracts.

• Facilitates the organization’s business strategies.

• Provides a competitive advantage.

• Enhances the organization’s image to the public, purchasers and payers.

• Fulfills licensure requirements for many states.

• Recognized by insurers and other third parties.

• Strengthens community confidence.

Sources

Joint Commission on Accreditation of Health Care Organizations (June 2003) website, Facts about the Joint Commission on Accreditation of Healthcare Organizations.

Joint Commission on Accreditation of Health Care Organizations (June 2003) website, A Journey through history of the Joint Commission.