July 25, 1997

Hospital accreditation inspection draws to a close

Hospital accreditation inspection draws to a close

Inspectors from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) remove their white gloves and wrap up their survey today, bringing an end to months of preparation on the part of Vanderbilt University Medical Center faculty and staff.

The surveyors spent the week at Vanderbilt University Hospital, Vanderbilt Medical Group outpatient practice areas and other VUMC facilities in the Midstate, inspecting numerous operations related to patient care and safety.

Vanderbilt's last JCAHO inspection was done in 1994, with the institution scoring an 80 out of a possible 100. In 1995, the average score among hospitals nationwide was 90, and Vanderbilt expects to improve on this score.

The JCAHO standards are organized under the following categories ‹ patient rights and organizational ethics, patient assessment, patient care, patient and family education, continuum of care, improving organization performance, leadership, management of the environment of care, human resources management, information management, and infection control.

The federal government requires JCAHO accreditation for Medicare and Medicaid reimbursement.

VUMC's preparations were, in a word, exhaustive.

Faculty and staff began gearing up for the inspection more than a year ago, with teams conducting assessment tests and gathering compliance data. In January, 'state of readiness' teams within each hospital unit and ancillary department were formed and recently mock hospital inspections and mock staff and faculty interviews were held.

The American College of Surgeons began on-site inspections of hospitals in 1918, at which time only 89 out of 692 hospitals surveyed met the minimum standards. In 1952 the ACS transferred its standardization program to the JCAHO. Today, 80 percent of the nation's hospitals participate, and, in addition to the federal government, many commercial payors as well as state licensing boards put their faith in JCAHO's evaluations and recommendations.

Three years ago, JCAHO turned up the heat a bit by issuing detailed consumer report cards for each institution surveyed ‹ report cards that have become marketing tools in today's hotly competitive health care marketplace.