JCAHO Accreditation Surveys May Become More Cumbersome

On March 26, 2009, the Joint Commission of Accreditation of Healthcare Organizations ("JCAHO" or "Joint Commission") announced changes to its accreditation and survey standards for hospitals. These changes revise the proposed set of changes that were announced earlier this year by the Joint Commission. In January, JCAHO proposed to issue more than 165 new and revised accreditation and survey standards. However, based on discussions between the Joint Commission and the Centers for Medicare & Medicaid Services ("CMS"), the number affected has now been reduced to 87. Nonetheless, these new and revised standards may make it more difficult for hospitals to obtain or maintain JCAHO accreditation.
The changes being made to the Joint Commission standards are the result of the CMS hospital deeming authority application process. Although accreditation of a hospital by JCAHO is not required for Medicare enrollment or participation, if a hospital demonstrates through JCAHO accreditation that all relevant Medicare Conditions of Participation are satisfied, then Medicare will deem that provider as having met the necessary requirements without further inspection. In order to possess such deeming authority for its accredited providers, an accreditation organization must receive approval from CMS. In the past, with regard to its accreditation process for hospitals, JCAHO was statutorily granted deeming authority. Based on this statutory grant of authority, unlike other accrediting bodies, JCAHO was not required to file an application for hospital deeming authority with CMS.
However, on July 15, 2008, the Medicare Improvements for Patient and Providers Act of 2008 became law. Among other things, this Act requires all accreditation bodies, including JCAHO, to now complete a formal application process in order to receive hospital deeming authority from CMS.
During this application process, JCAHO has been working with CMS to revise its accreditation and survey standards for hospitals. This joint effort and the application review by CMS is designed to ensure that the Joint Commission standards are consistent with, and as stringent as, the Medicare Conditions of Participation for hospitals. The resulting new and revised JCAHO standards include additional requirements regarding documentation, training programs for staff, medical staff leadership and availability, and written policies and procedures. Some of these new and revised standards are applicable to all hospitals seeking JCAHO accreditation and some are only applicable to those hospitals using JCAHO accreditation to receive Medicare deemed status.
CMS's final decision regarding JCAHO's application will be made later this year. Pending final approval by CMS, further changes (other than the current 87) may be made to the JCAHO survey and accreditation standards.
The Joint Commission began to survey hospitals using these new and revised standards on April 6, 2009. However, non-compliance with these new and revised standards will not impact the accreditation process until July 1, 2009. Therefore, hospitals expecting to undergo the initial or renewal process for JCAHO accreditation in the near future should become aware of these new requirements and make any changes necessary to ensure compliance. Some of these new standards, for example implementing additional written policies and procedures, will take significant time and effort to incorporate into hospital operations.
However, the benefits of accreditation outweigh the time and effort spent to receive such accreditation. In addition to granting Medicare deemed status, hospital accreditation by JCAHO can improve risk management and risk reduction, strengthen the hospital's perception in the community, potentially reduce liability insurance costs, improve business operations, and potentially fulfill the state regulatory requirements. For example, under the rules of the Alabama Department of Public Health, a hospital accredited by JCAHO is deemed to be licensable by the Department without further inspection or survey.
Because of these and other benefits, about 88% of the hospitals in this country are currently accredited by JCAHO. Most of these hospitals will (and should) continue to pursue JCAHO accreditation despite the additional hurdles they may face from the new and revised survey standards.
For further information on the JCAHO accreditation process and the new survey standards, visit the Joint Commission website at .

Kelli Fleming is an associate with Burr & Forman LLP and practices exclusively within the firm's Health Care Practice Group.

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