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Under the Microscope

February 23, 2024

March 2024

Hospital accreditation is necessary, but some think it goes too far.

Thomas R. Collins

Thomas R. Collins is a medical journalist based in West Palm Beach, Florida.

In 1919, the American College of Surgeons (ACS) Board of Regents approved a document called “The Minimum Standard” that was intended to boost safety and quality of care at hospitals. It was one of the earliest steps toward accreditation of health care facilities.

Today, The Joint Commission (TJC) — the body into which the ACS’s efforts ultimately morphed and by far the most prominent hospital accrediting entity in the U.S. — publishes a Hospital Accreditation Standards manual that includes its standards and elements of performance.

Though accreditation is acknowledged as necessary for safety, the process — which is mostly done through TJC in the U.S. — is now described as a never-ending, elaborate, and expensive endeavor, overseen by dedicated hospital staff and assisted by consulting firms, some of whom publish monthly newsletters that contain updates to help hospitals keep up with frequent changes to the standards. And, though officially voluntary, it is a process that almost all hospitals choose to go through, whether through TJC — as most do — or another accrediting body. At the very least, if they don’t meet the Centers for Medicare and Medicaid Services (CMS) standards, they won’t be eligible for CMS reimbursement.

“Those accreditation standards and participation in those programs really are tied to, for many hospitals, their ability to participate in the Medicare program, and using that voluntary process is one that hospitals typically avail themselves of,” said Nancy Foster, vice president of quality and safety policy at the American Hospital Association (AHA). “It’s hard to function and maintain financial stability if you are not approved to receive payment from Medicare and Medicaid.”

The safety process at hospitals, those familiar with the process say, is often specifically geared toward the accreditation process itself, making the very concept of hospital safety, in some sense, synonymous with TJC accreditation standards.

“Those, in my entire career in quality, have really been the North Star for quality standards,” Ms. Foster said.

Ms. Foster said AHA members praised TJC’s recent streamlining of standards and its method of ushering hospitals through a process of improvement when deficiencies are found. Over the years, though, questions have been raised about whether the need for all of the standards has been adequately explained by TJC and whether the evidence and rationale for them is always well understood by those tasked with meeting the standards when TJC surveyors inspect their facilities, unannounced, every three years.

“It’s not always obvious what benefits are associated with adhering to the various rules and benchmarks,” said Murad Alam, MD, vice chair of dermatology at Northwestern University’s Feinberg School of Medicine in Chicago, who did research into the evidence base for the standards after hearing skepticism from the medical field about their value. “Is the degree of benefit that would accrue from this really equivalent to the amount of inconvenience?”

The benefits and drawbacks of TJC accreditation seem to be topics that some centers are reluctant to discuss publicly. Two large academic medical centers declined to be interviewed for this piece.

Expanding Influence

TJC, headquartered in Oakbrook Terrace, Illinois, outside Chicago, is led by a 21-member board that includes physicians, hospital administrators, quality officials, nurses, and venture capital firms.

TJC’s influence and activities have broadened beyond accrediting U.S. hospitals. There is also Joint Commission International, which works with hospitals around the world on safety matters, and Joint Commission Resources, which offers consulting services to help hospitals with the accreditation process.

Three other entities — the Center for Improvement in Healthcare Quality, the Accreditation Commission for Health Care, and Det Norske Veritas — also accredit hospitals for compliance with CMS requirements. Additionally, hospitals can choose to undergo a free state agency survey.

But, there is only one Joint Commission “Gold Seal of Approval,” and most hospitals seek it out. According to TJC, 80% of U.S. hospitals are accredited through TJC, and out of all the hospitals in the U.S. that are accredited, 85% of them chose TJC. When a hospital has met TJC’s standards, it gets to display the seal.

The choices made by hospitals show that there must be value in TJC accreditation, Ms. Foster said.

“Hospitals continue to hire TJC to do the surveys,” she said. “If they didn’t feel there was value in what they were getting, they would stop.”

Continually Adhering to the Standards

TJC standards cover areas from patient rights to infection control to medication management to data collection to processes that use those data for the sake of improvement.

John Rosing, MHA, executive vice president and principal with Patton Healthcare Consulting, which works with hospitals on the accreditation process, said hospitals typically weave the standards into their overall safety procedures and protocols, which are part of a hospital’s day-to-day functioning.

“You usually have an individual or, in a larger hospital, a small department that pays constant attention to these requirements and watches for updates,” he said. They will often work closely with a firm like Patton to help them stay abreast of the changes, he said.

Hospitals must get re-accredited every three years to maintain the ability to bill Medicare and Medicaid as well as other third-party payers. As the time for a survey nears — they can happen as early as two and a half years after the last survey — hospitals will sometimes do a mock survey, either internally or with the help of a consultant, to make sure all their paperwork and procedures are in place, he said.

At larger hospitals, between six and 12 staff members will oversee safety issues, including compliance with the standards, Mr. Rosing said.

Sometimes a hospital system will have trouble with compliance when a clinic is under the hospital provider number and is thus also subject to the survey.

“Sometimes, because they don’t realize what standards apply to them or their clinic manager hasn’t been paying attention, they get tripped up on something that’s a basic requirement,” he said.

Often, he added, lack of compliance involves an issue that is hard to master because many people are involved in a process and “human nature” enters the picture.

“It’s an innocent thing, oftentimes, but it gets detected in the survey,” he said. For instance, he said, the rooms and doors for hospital storage rooms are fire-rated and close automatically with a latch to keep doors shut. However, staff members who need to go in and out of the room often might prop them open for convenience.

“It’s an example of where the staff might be thinking, ‘Hey, fires don’t occur often in hospitals.’ They may not even be thinking about the fact that it’s a fire door,” Mr. Rosing said.

He gave a different example regarding clinical care. TJC standards for anesthesia safety, based on association guidelines, require a list of assessment elements to be performed, and an anesthesiologist might not document all the steps.

“They may assess the patient and know in their head what the data point is or what the assessment result is, but failing to document it potentially would be noticed by a surveyor and cited.”

Food safety is another example, he said. Standards include how to thaw frozen chicken and other meats safely, how food should stay warm as it is delivered to patients, and hand hygiene training requirements to make sure meals don’t get contaminated, he said.

“It should be a year-round thing,” Mr. Rosing said. “You design what you’re doing to comply.”

The standards are divided into those that are CMS-mandated and required to meet for CMS reimbursement and those that are TJC’s own “above and beyond” standards, such as the National Patient Safety goals. Mr. Rosing noted, though, that TJC works closely with CMS.

“It’s a partnership between the two,” he said. “It’s not an adversarial thing between TJC and CMS.”

For instance, the CMS and TJC emergency management standards — which cover how hospitals will handle disasters, such as an influx of patients from a plane or bus crash, active shooter event, or hurricane — were developed and updated recently by TJC and CMS largely in tandem, he said.

The surveys and standards are strict for a reason, Mr. Rosing said.

“There can be a perception out there that TJC is unfair or too strict in their interpretation of their standards or CMS requirements, but I wouldn’t characterize it as unfair. I think it’s a rigorous process for good reason,” he said. “These standards exist ultimately to protect patients and provide safe care.”

Akin Demehin, MPH, the AHA’s senior director of quality and safety, described accreditation as an ongoing process.

“It’s really a continual readiness approach where it’s not just a ramp-up of activity in the few months before you expect surveyors to come to your door. It’s an ongoing process of assessing, measuring the processes inside hospitals,” he said.

TJC has adopted the “tracer” method of surveying, in which a few patients are selected and a variety of aspects of care for those patients is assessed, such as mitigation of fall risk. This is partly why a hospital has an approach of being ready all the time, Mr. Demehin said.

“That is in part how they will be surveyed,” he said. “It’s an approach that I know hospitals felt made a lot more sense for the work they do.”

Making a Difference or Making Busy Work?

Hard data on the outcomes that result from the accreditation process are difficult to come by, but some physician researchers have tried to assess TJC’s standards.

Dr. Alam said data on outcomes before and after a hospital was accredited are not readily available. So, in a British Medical Journal study, he took a deeper look at the evidence cited by TJC to support its standards, using reports known as Joint Commission “R3” reports, for requirement, rationale, and reference.2

“What motivated this research was the perception and feeling that TJC requirements are quite extensive, sometimes onerous, and even hard to implement,” he said. “Is this really making a difference in safety, or is it just making people tired from doing paperwork and busy work?”

Dr. Alam and his research team looked at the R3 reports for standards that went into effect between July 1, 2018, and July 1, 2019, and analyzed the cited references to see whether they contained evidence that the actions in the standard were efficacious. After excluding some standards because they overlapped in terms of the clinical care decisions they addressed or references cited, researchers were left with 20 standards to assess. When there was overlap, they used the standard that had the highest level of support.

They found that six of the 20 were fully supported by the evidence cited, six were partly supported, and eight were not supported.

An example of one standard the researchers deemed not to be supported was PC.01.02.07, EP 1, which stands for “element of performance.” It calls for organizations to have criteria for screening and assessing pain that are consistent with a patient’s age, condition, and ability to understand.

The references cited for the requirement include a review of the tools for psychological assessments for chronic pain, a review of evidence on the assessment and management of pain in older patients, a review of treatment approaches for chronic pain, a review of assessment and management of pain in children, and a section of a book on nursing and pain management. None have evidence showing efficacy of the requirement.

“The bottom line is, in many instances, they did not strongly support the assertion that was being made or the recommendation that was being made,” Dr. Alam said. “I’m sure they have good reasons, but it would be nice if there was some transparency about what those good reasons are. I would like to think they have some evidence or consensus work with experts that, for whatever reason, they haven’t shared.”

The R3 reports typically include a few lines with what TJC calls a “rationale” for the standards covered in the reports. The rationales, in many cases, are descriptions of the requirements themselves rather than descriptions of evidence. The one for the pain screening standard, for instance, says, “Organizations need to develop systems for pain screening,” and “The organization is responsible for ensuring that appropriate screening and assessment tools are readily available.”

Over the course of two weeks leading up to the deadline for this article, TJC was unable to make someone available for an interview.

However, in a response letter to the study, David Baker, MD, MPH, executive vice president for health care quality evaluation and improvement at TJC, noted that the study included only four of TJC’s 36 R3 reports and might not be generalizable.3

“Despite the limited generalizability of their findings, the authors’ suggestions for how we can improve our processes and reporting transparency are consistent with planned changes by The Joint Commission: publish the methods for our literature reviews; classify the level of evidence for standards; justify instances where The Joint Commission believes evidence is not required,” he said.

Sometimes, he wrote, standards will need to rely only on expert opinion rather than controlled studies.

“In situations where a quality problem is well- documented, but adverse events are rare and interventions are difficult or impossible to study, we must rely on expert opinion and common sense,” Dr. Baker said. For instance, for a 2020 standard that each obstetric unit have a hemorrhage supply kit, he said, “No studies have shown that hemorrhage supply kits reduce the risk of morbidity or mortality, but experts strongly recommend this, and the Alliance for Innovation in Maternal Health recommends this as part of the bundle on which our standards are based.”

A 2018 study by researchers at Brigham and Women’s Hospital and Harvard University found no statistical difference in mortality or readmission between hospitals that were and were not accredited.4 They also found no difference between hospitals accredited by TJC and those accredited by other agencies.

“Should we give up on accreditation? Absolutely not,” said the study’s lead researcher, Ashish Jha, MD, MPH, now dean of the Brown School of Public Health, in a commentary at the time. “Hospital accreditation remains a cornerstone for ensuring at least a basic level of quality, at least for things that the health care system assesses. The problem, it seems, is that accrediting organizations are not focusing on what actually matters to patients. The criticism that these organizations spend enormous amounts of energy requiring hospitals to focus on things like signs in the hallway or how documentation is done appears to have some merit.”5

Scrutinizing Its Own Standards

Late in 2022, TJC announced it was eliminating 168, or 14%, of its standards and revising 14 other standards.6 That included deletions of 56 standards and revisions of four standards for hospitals. The changes came after a review of whether standards still addressed important issues, whether they were redundant, and whether the time and resources needed to comply were commensurate with the benefit, TJC said. In July 2023, TJC eliminated or consolidated 200 other standards, but just seven of those were in the hospital setting.7 TJC also froze its accreditation fees for 2023.6

“When we announced the first tranche of eliminated and revised standards in December 2022, hospital leadership and direct care providers alike were extremely supportive of the news that Joint Commission standards would be fewer but more meaningful,” said Jonathan B. Perlin, MD, PhD, president and chief executive officer of The Joint Commission Enterprise, which includes TJC as well as its international and consulting arms. “After such positive feedback, we are pleased to extend additional relief.”7 These comments came from a prepared statement at the time.

Ms. Foster said part of the reason no difference has been found for outcomes like mortality might be that many of the standards involve “foundational” aspects of a hospital, such as credentialing of medical staff, for which there would likely be no connection to such outcomes. Furthermore, she said, even those hospitals that are not accredited by TJC model their own protocols after those standards.

“We don’t know what we would have absent TJC because it is so ubiquitous, either because they are being surveyed by TJC or because they’re trying to emulate what TJC has laid out,” she said.

But, she said, hospitals have been happy with TJC’s willingness to revisit its standards — and some, perhaps on telehealth, might even need to be added.

“The concept was applauded, the idea that you should continuously look, see what’s outdated or no longer necessary, and take that out,” she said. “We’ve seen the weeding out of the standards that are not as effective as they were intended to be, and that’s good because no one wants to be doing things just to check a box to say they did something. Quality and safety of care is much too important. It’s got to be meaningful if you’re doing it.”

References

  1. American College of Surgeons. The “Minimum Standard” document. Accessed January 8, 2024. https://www.facs.org/about-acs/archives/past-highlights/minimumhighlight/.
  2. Ibrahim SA, Reynolds KA, Poon E, et al. The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. 2022;377:e063064.
  3. Baker D. Rapid response: Re: the evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. July 5, 2022. https://www.bmj.com/content/377/bmj-2020-063064/rr.
  4. Lam MB, Figueroa JF, Feyman Y, et al. Association between patient outcomes and accreditation in US hospitals: observational study. BMJ. 2018;363:k4011.
  5. Jha AK. Accreditation, quality, and making hospital care better. JAMA. 2018;320(23):2410-2411.
  6. Lyons M. The Joint Commission announces major standards reduction and freezes hospital accreditation fees to provide relief to healthcare organizations. The Joint Commission. December 21, 2022. Accessed January 8, 2024. https://www.jointcommission.org/resources/news-and-multimedia/news/2022/12/major-standards-reduction-and-hospital-accreditation-fee-freeze/.
  7. The Joint Commission. The Joint Commission eliminates additional 200 standards across all accreditation programs. July 26, 2023. Accessed January 8, 2024. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/july-26-2023/joint-commission-eliminates-additional-200-standards.

 

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