In fall 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced significant changes to its accreditation process. "Shared Visions" represents JCAHO's collaborative vision with health care organizations, health care oversight bodies, and the public, to bridge the chasm between the current state of health care and the potential for safer, higher quality care. "New Pathways" represents a new set of accreditation process approaches that will support fulfillment of the Shared Visions.
Q What are some of the New Pathways?
A This new model, being implemented in January 2004, includes the following six pathways:
1. The Joint Commission consolidated standards to reduce the paperwork and documentation burden of the accreditation process and to increase its focus on patient safety and health care quality.
2. Periodic performance reviews will make the accreditation process more continuous, reduce the "ramp-up" efforts many organizations undertake before the on-site survey, and promote continuous organization compliance. This process requires each accredited organization to conduct a mid-cycle self-assessment against applicable JCAHO standards, develop an action plan to address identified areas of noncompliance, and identify measures of success for validating resolution of problem areas when the organization undergoes its complete on-site survey, 18 months later.
3. The process directs a focused, on-site survey to aggregate organization-specific information through an automated, rules-based tool, and to identify systems and processes relevant to patient safety and health care quality.
4. In the on-site survey's "tracer" methodology, surveyors assess operational systems and processes in relation to actual patients' care experiences.
5. The Joint Commission revised individual organization performance reports to add performance information not provided by the current reports.
6. Physicians and other direct caregivers will actively participate in the new accreditation process.
Q Will accreditation decisions remain the same?
A No. As of January 2004, scores will be obsolete and accreditation decisions will change. Because of the emphasis on continuous compliance, JCAHO will eliminate the category of "Accredited with Requirements for Improvement" and will institute new rules for "Conditional and Preliminary Denial of Accreditation" decisions. The new accreditation decision categories will be: Accredited; Provisional Accreditation; Conditional Accreditation; Preliminary Denial of Accreditation; Denial of Accreditation; and Preliminary Accreditation (under the early survey option).
Q Will performance reports change?
A Yes. In July 2004, JCAHO will begin publishing new quality reports, which will compare the organization to similar JCAHO-accredited facilities across the state and country. The reports will also highlight organization performance related to compliance with JCAHO's national patient safety goals.