Joint Commission on Accreditation of Healthcare Organizations.DOC by suchufp



Agencies that Regulate Washington Hospitals ..........................2

Joint Commission on Accreditation of
Healthcare Organizations ..............................................................3

Washington Hospital Licensing Standards .................................4

Medicare Conditions of Participation ..........................................5

Summary of Primary Hospital
Regulatory and Accrediting Entities ............................................7

Other State and Federal Regulations ...........................................7

Local Regulations ............................................................................8

Summary ..........................................................................................8

References ........................................................................................9

Hospitals must comply with a number of regulations to carry out state and
federal laws. The two primary reasons for health care regulations are the
protection of the health and safety of patients and the government’s major role in
paying for health care, through Medicare and Medicaid programs.

In addition to providing a range of health care services, hospitals must obtain
multiple licenses and undergo numerous surveys. For example, a hospital that
offers acute care, home health care, hospice care and long-term care must have

separate surveys and a different license for each service. This is in addition to
the hospital’s license and Medicare certification.

Trustees should also have an understanding of the cost of complying with
regulations. Often, compliance requires the purchase of special supplies, hiring
of additional staff, architectural changes to a facility or the provision of services
that are costly to maintain.

For decades, hospitals participated in a voluntary self-regulatory process. In the
early 1950s, a program of hospital self-inspection, sponsored by the American
College of Surgeons, began expanding into the present Joint Commission on
Accreditation of Healthcare Organizations (JCAHO). Originally, the “Joint
Commission” surveyed and accredited only hospitals. Today JCAHO
accreditation includes critical access hospitals, pathology and clinical laboratory
services, home health agencies, behavioral health care services, long-term care
facilities, ambulatory care centers, health care networks and managed care. The
Joint Commission conducts a voluntary survey program of hospitals. A hospital
must request and pay for a survey.

Approximately two-thirds of hospitals in Washington state are accredited by
JCAHO. More information about JCAHO accreditation can be found on the
JCAHO website,

A multi-disciplinary inspection team spends at least two days in the hospital.
Standards that measure plant safety, medical staff, quality assurance, department
services and what the hospital is doing to improve the quality
of its services are used. The Joint Commission wants to see mechanisms and
processes in place to ensure that the Board has an oversight role in the
credentialing of the medical staff, quality assurance and continuous
improvements of the care provided by the hospital. The Joint Commission
awards a three-year accreditation to hospitals that meet its standards. In some
cases, it makes receiving accreditation part of meeting certain standards between
surveys. If these standards are not met, conditional accreditation or denial of
accreditation can result. Costs related to maintaining JCAHO accreditation
include a fee for the survey itself and expenses related to the cost of training,
publications, seminars and consultants.

Hospitals that are accredited are automatically eligible to participate in the
Medicare program. Accreditation or Medicare certification is required for
participating in most managed care programs.

The Governing Board must be an active participant in the accreditation process.
The JCAHO standards manual includes specific standards for the governing
body (see appendix). Board members must be familiar with these standards and
their requirements.

Some of these requirements are:
 Credentialing of the medical staff
 Board self-evaluation
 Orientation of new Board members
 Continuing education for the Board
 Adopting bylaws
 Conflict of interest statements
 Performance improvement

The Joint Commission wants to see mechanisms and processes in place to ensure
that the Board has an oversight role in the credentialing of medical staff, quality
assurance and continuous improvements of the care provided by the hospital.

During the survey, the Board should meet with the survey team. It is important
for Board members to participate in the exit conference with the team and hear
its recommendations. The CEO should supply the Board with the written report
from the JCAHO survey along with a plan for carrying out the
recommendations. The Joint Commission is conducting unannounced surveys
instead of scheduled surveys, except for initial surveys. The hospital does not
receive notice of its survey date.

Hospitals in Washington must be licensed by the state in order to operate.
Revised State licensing regulations (246-320 WAC, 70.41 RCW), modeled after
the JCAHO standards, came into effect in March, 1999. The regulations are now
outcome-based and streamlined.

In Washington state there are separate licensing standards for specialty hospitals,
such as psychiatric and chemical dependency facilities.

Key sections of the state licensing standards are noted below (see the appendix
for the governance section of the state licensing standards):

   Governance
   Leadership
   Management of human resources
   Medical staff

   Management of information
   Improving organizational performance
   Patient rights and organizational ethics
   Infection control program
   Regulations for the range of services a hospital provides, such as
    pharmaceutical, diagnostic, inpatient and outpatient and specialized care
   Management of environment for care (assures a safe environment for
    patients, staff and visitors)
   Design, construction review and plan approval
   Facility requirements (for clinical, non-clinical and specialized services areas)

All Washington state hospitals participate in the state licensing survey process
which occurs every 18 months for non-JCAHO hospitals. JCAHO accredited
hospitals are surveyed by the state once every 3 years because the JCAHO
accreditation survey substitutes a licensing survey. Once the survey is complete,
the Board should receive a copy of the findings along with recommendations for
correction of any problems.

The Medicare Program is the primary source of health care payment for the
nation’s and state’s elderly population. Medicare is a federal program
authorized by Title 19 of the Social Security Act (also see finance chapter).
Hospitals that participate in the Medicare program must be certified.

In order to be Medicare-certified, a hospital must comply with the Medicare
Conditions of Participation. These conditions set forth the standards for health
care provided to Medicare beneficiaries in the hospital setting.

If a hospital meets the standards for Medicare certification, this qualifies the
hospital for participation in the Medicaid program. The hospital is not required
to undergo an additional survey to qualify to participate in the Medicaid

The Medicare Conditions of Participation contain requirements regarding the
governance and administration of hospitals, patient’s rights, quality assurance
and utilization review, required and optional services and requirements for
staffing. The Conditions of Participation require the medical staff be composed
of physicians and allow the Governing Board to appoint other practitioners to
the medical staff. All patients in a Medicare-certified hospital must be under the
care of a physician and a physician must be on call 24 hours a day. The hospital
must have nursing services on a 24-hour basis, and all nursing care must be
provided or supervised by a registered nurse (RN). Critical Access Hospitals do
not have to be open 24-hours a day and seven days per week, they may staff with

mid-levels, and do not always need an RN if they receive a state licensure

There are several services that Medicare-certified hospitals must either provide
within the facility or make available through a contractual or consulting
arrangement. These include:

   Pharmaceutical services
   Diagnostic radiology services
   Clinical lab services
   Dietary services

The Conditions of Participation establish standards for optional services for
Medicare-certified hospitals. These include surgery, anesthesia services,
outpatient services and rehabilitation, nuclear medicine and respiratory care.
Medicare-certified hospitals are not required to provide emergency medical
services, but must have written policies appraising, treating and referring
patients needing emergency care. Standards for the physical environment are
not as stringent as the facility requirements in the state’s Hospital Licensing

The Washington State Department of Health conducts Medicare certification
surveys under a contract with the Centers for Medicare & Medicaid services, Each year a few randomly selected hospitals that are JCAHO
accredited undergo a validation survey while non-JCAHO hospitals usually
participate in a Medicare Certification Survey. The Medicare certification and
the hospital licensing surveys are generally conducted at the same time. The
hospital is notified of the date that its Medicare survey will occur.

The only time a hospital survey is unannounced is when the Department of
Health has received a complaint.


Standard             Washington State         Medicare               JCAHO
                     Hospital Licensing      Conditions of         Accreditation
                        Standards            Participation

                       (all hospitals in     (required if a       (voluntary self-
                      WA state must be     hospital desires to      regulation)
                           licensed)        treat Medicare

Agency/              Washington State      Centers for           Joint Commission
organization         Department of         Medicare &            on Accreditation
                     Health                Medicaid Services     of Health Care

Survey               Every 18 months;      Every 3 years;        Surveys are
                     if the survey         Medicare              performed every
                     occurs in the same    Certification can     three years
                     year as a JCAHO       be obtained via a
                     survey, the           validation survey
                     hospital may          (for JCAHO
                     request an            accredited
                     exclusion             hospitals)

The Washington State Department of Health is involved in many hospital
activities including hazardous waste management, construction and remodeling
of facilities, infection control practices, medical device reporting, gathering and
compilation of health statistics, reporting of births, inspection of radiographic
machines, inspection of clinical laboratories and communicable disease

The Department of Social and Health Services (DSHS),,
monitors the care provided to patients in nursing homes and long-term care

facilities. Staff conduct unannounced, on-site inspections on a regular basis and
investigate complaints.

Workers' compensation in Washington state is regulated by the Department of
Labor and Industries. Its sets the fee schedules for physicians, x-ray, and
diagnostic tests for hospital outpatient fees and sets what is called the Percentage
of Allowed Charges (POAC) for self-insured hospitals to pay.

Nongovernmental hospitals come under the jurisdiction of the U.S.
Occupational Health and Safety Administration for the prevention of job-related
accidents and illnesses. All hospitals must comply with federal requirements
related to non-discrimination on the basis of age, sex, race, national origin,
religion and handicap.

A special area of concern for hospitals is the requirements of the Americans with
Disabilities Act. Hospitals must be fully accessible for visitors, employees and
patients. All hospital services must be accessible. This means that information
may need to be available in Braille or large type, and by telecommunication
devices and sign language.

Physicians, nurses, radiological technologists, nursing home administrators,
pharmacists, social workers, respiratory therapists, physical therapists, dietitians
and physicians assistants must be licensed or certified by state boards before they
can practice in their fields.

Hospitals are also subject to local regulations including local building codes, fire
safety regulations, food sanitation codes and zoning regulations. In urban areas,
compliance with these regulations can be costly and complicated. In some rural
areas, the effect of these regulations is minimal.

Trustees need to have an understanding of regulatory agencies and the
importance of compliance with their regulations. A special challenge of the
Board is to respond to this oversight in a positive and cost-effective manner.

Bailey, Charles, General Counsel, THA-The Association of Texas Hospitals and Health Care
Organizations, Austin, TX, January, 1998.

Brown, Fletcher, Shareholder, Davis & Wilkerson P.C., Austin TX, January, 2006.

Claymon, Jennifer, Associate, Davis & Wilkerson, P.C., Austin, TX, January, 2006.

DSHS (AASA) website,

Griffith, Richard and Dewey Johnson, Texas Hospital Law, Austin, TX: Butterworth Legal
Publishers, 1990.

Health and Safety Code, Vol. 1 and 2, Titles 1 to 5, Vernon’s Texas Codes Annotated,
St. Paul, MN: West Publishing Co., 1992 and 1998 supplement.

Hospital Licensing Rules, 25 TAC 133; Psychiatric Hospital Licensing Rules, 25 TAC 134.

Joint Commission on Accreditation of Healthcare Organizations, 2006 Comprehensive Accreditation
Manual for Hospitals: The Official Handbook, Oakbrook Terrace, IL, 2006.

McGuire, Catherine, Mary Walker, and Deborah Molsberry, Rural Hospital Models and
Recommendations for Their Implementation, Austin, TX: Health Care Options for Rural
Communities, August, 1993.

Reed, Kevin, Shareholder, Davis & Wilkerson P.C., Austin, TX, January 2006.

Suiter, Brenda, Director, Rural and Public Health, Washington State Hospital Association, Seattle,
WA, September 2006..

Sjoberg, Elizabeth, Staff Attorney, THA-The Association of Texas Hospitals and Health Care
Organizations, Austin, TX, January, 1998.

Wagner, Carol, Director, Patient Safety, Washington State Hospital Association, Seattle, WA,
September 2006.

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