Joint Commission On Accreditation Of Healthcare Organizations

The Joint Commission on Accreditation of Healthcare Organizations or the JCAHO is the board responsible for making the standards for the clinical engineering programs. In addition, JCAHO is a non-profit and an independent organization (Subhan, 2007). In addition, JCAHO is the national accrediting group health care delivery organizations such as hospitals. For instance, hospitals would ask JCAHO to evaluate their facility. There are of course charged a fee. As accreditation is not automatically renewed, there is a required full accreditation survey at least every three years (Bandy, 2004).

Founded in 1951, the Joint Commission on Accreditation of Healthcare Organizations actually officially changed its name in 2007 to The Joint Commission, while its mission is unchanged. The author thus remains to use JCAHO when referring to this JC. This Joint Commission accredits and certifies health care organizations such as laboratories, hospitals, long term care facilities, and small ambulatory practices with the objective of ensuring patient protection and outcomes. The JC visits organizations every three years, assessing performance ranging from patient care to record keeping and from infection control to leadership, and the methodical official approval procedure is charitable, while it confers a typical of customer assurance.

Also, JCAHO is an organization that makes the standards for healthcare organizations and “issues accreditation to organizations that meet those standards.”  The organization makes intervallic surveys on-site in order to verify that accredited organizations comply with the Joint Commission standards. Also, it is to improve the care and services. Standards given by JCAHO attend to an organization’s performance in input functional areas (Practice Greenhealth).

A number of the standards address environmental issues as a lot of the environmentally related Elements of Performance fall under the “Environment of Care” or the EC standard. However, others are incorporated in the Leadership and Human Resources standards. This Guide relates each JCAHO Element of Performance to specific federal regulations, to help facilities be in compliance with both. The Guide also suggests steps that facilities can take to encourage environmental performance improvements.  A comprehensive environmental program, including waste minimization and pollution prevention initiatives, can not only ensure compliance, but can also help reduce the costs of compliance (Practice Greenhealth).

JCAHO is now monitoring how well the country’s healthcare organizations treatment, assessment, and management of pain. JCAHO surveyors had been assessing compliance since 2001 as was said by the end-of-life coalition Last Acts since the new pain management standards are included in the manual standards of 2000 to 20001. In line of this, doctors and nurses would now be expected to treat the patients’ pain and continue to assess treatment during and even after their hospitalization, while patients will be asked about pain and its intensity, sometimes by rating it on a “zero to 10” scale under the JCAHO standards (Fryling, 2001).

According to Carole Patterson MN, RN, director of the Standards Interpretation Unit of JCAHO these standards recognize that pain is a condition that needs explicit attention because data presents that pain at the end of life and surgical pain has not been well-managed in the past. Thus, the standards should have a major force on pain management for patients. Patterson told Last Acts that these standards should “convey that pain should be monitored with the same vigilance as blood pressure, pulse, temperature and respiratory rate, according to an article titled.” (Fryling, 2001).

How does JCAHO affect the healthcare system?

JCAHO in 2004 began using “Shared Visions-New Pathways,” a new accreditation process. Therefore, starting last 2006 surveys on accreditation should be conducted in an unannounced basis. This “Shared Visions–New Pathways?” is that health care organizations are dedicated to providing high quality and safe healthcare. In line of this, JCAHO, share the vision, and thus, providing a process to support a health care organization’s quality and safety efforts by their accreditation. This also presents a new set of approaches to the accreditation process that will support the shared visions (Bandy, 2004).

In addition, this JCAHO:

“identifies priority focus areas (PFAs) for each hospital based on a combination of the PFP, on which surveyors initially will focus during the initial part of the on-site survey, and on systems and processes that are relevant to patient safety and health care quality. For example, systems and process include such things as assessment and care, medication management, credentialing, equipment use, infection control, etc. Information management is one of the PFAs” (Bandy, 2004).

JCAHO looks upon the tracer methodology as a mode to provide education to the group leaders and staff. The new processes are available on the JCAHO site via videos, and under this new decision process, every standard is judged either “compliant” or “not compliant” based on the scoring of the EPs (Bandy, 2004).

The Agency Carrying its Duties: Cases

One example of the JCAHO doing its job is the “Medical Equipment Standards” they created. There are two main JCAHO medical equipment standards-EC.6.10 and EC.6.20-are in the “Management of the Environment of Care (EC)” chapter. Each JCAHO standard is divided into requirements called elements of performance (EP). EC.6.10 has eight EPs, which are discussed individually below.

First is the Medical Equipment Management Plan. This EP says that the hospital must have a written plan. This plan should provide an overview of how the equipment is managed at the hospital. Also, it should describe the processes for managing the safe, effective, and reliable operation of medical equipment. Hence, it is not simply a recitation of the medical equipment standards. It should also be a link between the JCAHO medical equipment-related standards and the function of managing medical equipment at the hospital.

Second is the Selection and Acquisition of Medical Equipment. Such EP requires the hospital to describe its manner of selecting new equipments. Process of acquiring includes evaluating the medical equipment for “clinical effectiveness, patient safety, and human factors before final selection” as this should include needs selection criteria, comparative evaluations, assessment, and a life-cycle cost analysis.

Third is the Inclusion of Risk Criteria. This EP gives the hospital a choice to either include all of the equipment in the program, or to select certain types of equipment to be included in the program based on equipment function; physical risks with use; and incident history, which are called inclusion or risk criteria.

Fourth is the Maintenance Strategies, an EP that requires the appropriate selection of maintenance strategies for all of the equipment in one’s medical equipment management plan inventory. These are listed in the JCAHO standards include predictive maintenance “(using the concepts of reliability-centered maintenance), interval-based inspections, corrective maintenance (that is, repair or replace if defective), and metered maintenance (hours of run time or number of images processed, for example)” (Subhan, 2007).

Fifth is the Maintenance Intervals, an EP which necessitates the hospital to define appropriate maintenance intervals for their equipment based on manufacturers’ recommendations and the organizational experience. JCAHO in 2001 removed the annual performance and safety testing requirement for medical equipment, and this transformation was the sign of the admission that the safety and reliability of medical equipment has improved significantly at present. (Subhan, 2007) While sixth is the Hazard Notices and Recalls, and this EP requires the hospital to be able to set up a process for monitoring and acting on hazard notices and also recalls that pertain to their medical equipment. The process would include reviewing and acting on recalls and alerts from the manufacturers and others (Subhan, 2007).

Seventh is the 1990’s Incident Reporting and Monitoring- Safe Medical Devices Act/ This EP needs an account of the hospital program for monitoring and reporting incidents as required by the SMDA, while the eighth one is the Emergency Procedures. This eighth EP requires the hospital to develop emergency procedures. These procedures are needed so that there will be role and responsibility identification of maintainers and users. These two should assess the medical services provided by the hospital to decide which types of tools are critical for patient car. Hospital should develop procedures for managing the clinical consequences of critical equipment failure (Subhan, 2007).