The Joint Commission Survey

A Hospital Survey

I hear talk from people about the way The Joint Commission works and what exactly is their role in keeping patient’s safe.

As an example of what may happen at a typical hospital following a tragic event, let’s follow a complaint about a young woman who dies from an infection in a Joint Commission-accredited hospital. The family reports the incident to The Joint Commission (the name was changed from Joint Commission on Accreditation of Healthcare Organizations, aka JCAHO).The Joint Commission takes the report, sends an acknowledgement letter to the family that the report was received, and offers to get back to the family after action is taken about the complaint. Weeks go by and they hear nothing. Assuming nothing is being done, the family tells people The Joint Commission is not doing anything; But that is not true.

The Joint Commission accredits more than 19,000 health care organizations, including hospitals, ambulatory care services, home care and mental health services. These customers pay The Joint Commission for their survey. Joint Commission surveys are more rigorous than the surveys of other accrediting organizations. The standards are much higher and the survey is more detailed and difficult to pass.

In the case of the infection-control related death illustrated above, a “for cause” survey may be done when a complaint is brought to the attention of The Joint Commission about a Joint Commission accredited organization. A team of surveyors go to the organization with no notice to the organization and evaluates the organization to determine if the organization is doing what they are supposed to. For example, they may not be complying with The Joint Commission’s infection control standards.

There are 294 Joint Commission standards. If there is a problem that is not life threatening, the surveyor will look for a pattern. If it is simple to fix, the surveyor will tell the organization to fix the problem immediately. If the problem is more complex, the surveyor will write up an RFI, Requirement for Improvement. If the accreditation decision will be affected, a report about the problems at the organization is presented to The Joint Commission’s Accreditation Committee. The committee meets with Joint Commission staff to review the problems.

In the case of the woman who died from an infection, if there were no patterns of breakdowns in infection control practices, no action would be taken upon the hospital where the young woman died. The death is tragic, but not because the organization was not doing what it was supposed to. In other instances, it could be a series of problems that led to this one death; similar to the Swiss Cheese effect (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1298298/ ).

If there was a pattern of breakdowns in infection control practices at the organization where the woman died, the hospital would have to complete a written report and take immediate action to fix the problems.When health care organizations do not fix problems in a timely manner, Joint Commission staff may recommend that a follow-up survey be conducted, which could lead to preliminary denial of accreditation, or even denial of accreditation.

When accreditation is denied, the organization can request a hearing. The hearing is conducted by an independent panel, including a board member who is unknown to the organization, which reports their recommendations to the Accreditation Committee.

Although this process takes time, it “works” because it enables – and supports – the organization in its efforts to correct its problems so that care can continue to be provided to patients in a safe manner. I don’t think anyone really wants a hospital to close its doors. However, we should all want and expect excellence. That is best achieved if the health care facility follows the procedures and meets The Joint Commission standards.

Some people want the survey information made public. The state surveys are transparent so why shouldn't The Joint Commission survey be too?

The Joint Commission standards are much higher.  If the survey findings were open to the public, organizations may leave the Joint Commission and use the state survey system.  Since the states constant cutbacks, there may be many opportunities to cut back on surveys.  How could the state commit to offering a service if there isn’t enough staff.   I would fear the surveys may not get done at all.  When healthcare organizations pay for the service, there needs to be enough people to do the job.

And if you are concerned about your state being neutral in the process, check to see how much money is distributed in campaign funds……………..