In what way is JCAHO accreditation helpful by fdh56iuoui


									In what way is JCAHO accreditation helpful?
JCAHO supports compliance with Medicare Conditions of Participation

Keeping JCAHO on the table 24/7/365 and integrating it into Compliance

Defines primary goals to comply with

Policy awareness and development

Educates staff by knowing by meeting JCAHO accreditation we are providing
documented/integrated healthcare

Standards used

It's one more area that we review as part of our program.

Period Performance Review (PPR) helps us identify areas that need attention.

Linkage to regulatory requirements

As another tool for measuring compliance

Brings issues that need to be address to light. Bubbles them to the top.

Assists when addressing certain patient care/patient safety issues

Our Administration chose not to include compliance with JCAHO standards in our
Corporate Compliance Program.

Additional guidelines

We are ACHC accredited not JCAHO

Ties in compliance policies with JCAHO requirements

Public awareness

Adds to a culture of compliance

Used when seeking additional certifications

Pressure to implement changes

We are not JCAHO
Quality of Care/PI standards, HIM standards, Medical Staff standards

Gov agencies, e.g., CMS, OIG, appear to acknowledge - patient safety, env issues etc. are
essential to an effective compliance program. Hence, JCAHO accreditation is vital (CMS
relies on JCAHO surveys).

CMS deems an accredited hospital in compliance with conditions of participation

Guidance to personnel responsibilities; requirement checklists

We can use it as a club

JCAHO standards and CMS standards of participation are similar

Risk/Accreditation and Compliance work together to maximize education and employee

It is another set of regulations that an agency has to comply with.

Compliance with JCAHO standards are reviewed during audit of specific areas.

Particularly in relation to our Ethical Standards of Conduct

JCAHO compliance issues may be part of our compliance auditing activities

By providing additional incentive to have the program.

Useful guidelines for industry standards by which to measure my organizations activities

JCAHO standards business Medicare documentation requirements

Comprehensive, system wide review of standards.

Provides additional enforcement tool

Quality of care

Considering the JCAHO standards in relation to a cross walk with CMS's Conditions of
Participation, it gives perspective on regulators thinking.

Provides a standard and is also supportive of activities needed

Specific standards that can lead to better quality of care.

Review of standards as they affect areas of audit/risk assessment
Ensure compliance program matches JCAHO standards

Compliance with defined standards

Integrated as part of overall Compliance with Regulations, etc.

Reinforces compliance topics to workforce members.

There is some overlap with CMS requirements; view the more stringent

Not necessarily helpful, but we may audit compliance with JCAHO requirements when
doing a compliance audit

Credentialing set up

Contracted Providers

Organization is used to following rules

Similar goals and standards


Not really helpful, but incorporate JCAHO standards into billing audits done

Another reference for standards as well as developing comprehensive audits

Linked to COP

Comparing JCAHO standards to CMS regs. Goal to encompass both.

Encompasses compliance standards

Vigilance in keeping our JCAHO accreditation requires auditing/monitoring

Patient safety goals

Similar provisions and policy overlap

JCAHO encourages a culture of P.I. which is congruent with compliance corrective

We consider all requirements of JCAHO, OSHA, and others to be a part of what has to be
in compliance at our organization

We are not accredited, but keep their patient safety goals in mind, for example.
Compliance with JCAHO standards useful in decisions to what to monitor

Can sometimes use JCAHO standard as basis for requiring a change in processes

Provides a set of standards to address and measure to

It covers compliance overall and focuses on the quality issues

Provides additional standards with which to measure performance

The Compliance Program is responsible for leading compliance in the chapter on Patients
Rights and Ethics.

Provides reinforcement for standards/practices

Helps keep focus on quality, and need for management leadership in this area

They have standard requirements across all areas - all areas are reviewed

Clear standards set to establish a baseline for organizational expectations and to begin
looking at various activities in the organization from an ethical perspective

Keeps compliance in forefront

It reinforces CMS rules and regulations

Additional reference for support or questions.

It reinforces the Program efforts. JCAHO has been late in integrating Compliance
Programs in its survey. They cannot change my Program at this late stage. However, as
a source of quality benchmarks, JCAHO's input will be quite useful.

JCAHO carries weight

It follows the CMS regulate, so we are truly in compliance with the major players.

JCAHO is another set of standards to which the hospital must demonstrate compliance

Licensing and scope of practice issues

Use the standards in audits for compliance

Reinforces compliance program

Ties a regular outside survey to the Conditions of Participation.
May increase emphasis on program

JCAHO = Compliance with Medicare Conditions of participation

Provides standards of care to monitor

We actually have a different accrediting body (HFAP); HFAP reinforces the basics of our
compliance program.

Helps to maintain compliance with certain aspects of healthcare business. Doesn't
necessarily help to IMPLEMENT the program though

Report findings, recommendations

They were the only 'compliance' organization at the start.

Similar regulations as Medicare

Regulatory guidance

Reinforces compliance and ethics principles

Quality of Care Standards

Focus is clinical except for the governance standards re: conflicts of interest

Compliance with standards

More guidance toward surgery center

Sets some minimum standards

JCAHO standards provide a regulatory floor.

Sets quality standards; standards often reflect safety and other regulations; compliance
with JCAHO helps staff comply with other regulations/standards

It is sometimes given more importance

Conflict of interest requirements

Considered in auditing and compliance with Medicare COPs

Establishes standards of practice for most operational activities.
In Leadership portion- evaluation of vendors

best practice standard

Compliance to the JCAHO standards is an important part of our compliance program
which emphases quality of care as the focus of the program.

Helps in justifying the monitoring of different activities

The standards are used to ensure policies are appropriate development which ensure the
compliance program effectiveness

Provides a reference for standards

If we choose to become JCAHO accredited it will help

Reevaluation of program and standards

Documentation standards drive billing and coding

Conditions of participation -integration of quality requirements

The standards allow a framework to teach from. It helps employees know what is
expected of them.


Standards that apply to areas covered by program

Can benchmark to JCAHO standards in many areas of quality care and programs

Helps clinicians understand some of the compliance requirements

Many JCAHO standards are consistent with laws, regulations, etc.

Work with the Regulatory Compliance Manger to be sure we are not working at cross
purposes. Need the cooperation of many of the same staff, and need to work together to
not demand too much of them simultaneously. We all work under the Quality umbrella.

JCAHO Stds provide another reason to support general compliance

Basic understanding of patient safety, patient rights, auditing and monitoring

Provides standards and boundaries for acceptable practices

Helps reinforce critical nature
Provides benchmarks

Raises ethical awareness

Initially aligned program with existing JCAHO and committee process to impress org
wide Compliance culture - evolved to coordinate/collaborate process improve efforts

Integrate national pt. safety goals

JCAHO is not helpful, primarily because it does not have specific standards relating to
business compliance (as does, e.g., CARF). JCAHO's failure to adopt compliance
program standards as part of its Leadership section sends a message that compliance is
not important. JCAHO's traditional definitions of sampling sizes (small) is a major
barrier to leadership's willingness to consider more robust and valid sampling for
business compliance.

Comprehensive compliance with all regulations

It is an "audit", the findings can be valuable for compliance related work

Hospital is JCAHO accredited

Provides an organizational environment of compliance with standards

Helpful because of the crosswalk with Medicare Conditions of Participation

Compliance audits can be linked in with existing JCAHO audit processes

Validates standards of Conditions of Participation, ties in Organizational Ethics

Quality of care, addresses many CoP requirements, Privacy/Security stds


Has helped create a compliance culture to build off of for other compliance issues.

Helps validate standards, policies and procedures

Use of Standards in Delegation and clinical record reviews

Overlap of JCAHO and oig

Compliance includes adherence to regulatory, accreditation and professional standards

This is a joke, right?
Familiarization with standards that hospitals must comply with.

Understanding specific standards to ensure that requirements under the compliance
program do not conflict with JCAHO standards

Use of standards

Compliance with JCAHO requirements is no different than compliance with other
regulatory standards.

Only in knowing what their expectations in relationship to compliance issues


Some JCAHO standards overlap with and reinforce compliance functions/goals

Many requirements of JCAHO align perfectly with a compliance program

Helps to focus quality of care issues.

In meeting Conditions of Participation only. Provides this reporting avenue.

Direct link to compliance with Medicare COP

Further support for the integration of compliance planning and risk assessments into all
managers' responsibilities

Structured approach; accepted benchmarks; process driven

Leadership Roles


Helps with understanding the organizations quality initiatives and accreditation goals.

JCAHO/Compliance overlap re: medical record documentation, some areas of CMS

As a Behav. Hlth. facility we participate in CARF accreditation.

Provides practical implementation and adherence to Medicare/Medicaid Conditions of

many ways
some of the same standards apply to compliance

Standards utilized for both quality and compliance

If the question included NCQA, I may have responded differently. When will HCCA be
more inclusive of health plans?

I was not involved with the implementation of our Compliance Program, my predecessor
was. I can only assume that JCAHO had some impact.

Similar standards

Identify areas of clinical deficiencies which may impact general system risks

mandatory nature of JCAHO requirements verses CofP for Medicare

focusing on the specific standards, implementing through policy and process


documentation standards, etc

Requirements more readily accepted by clinical personnel/physicians


provides some guidance

only helpful if views/requirements are in sync with regulatory requirements

using their requirements as a guide

when standards track Conditions of Participation and in quality tracking/indicators

JCAHO requirements parallel nicely with compliance requirements

Helps the awareness and compliance in many ways outside of HIPAA, Medicare etc.

Patient Rights & Patient Safety & Signage requirements

Quality measurement standards are used in compliance program

setting standards

another set of eyes
not helpful, just trying to meet standards

weaknesses and areas in need of improvement

Focuses people; clear standards

Helped improve our policies and procedures

basically it's an effective hammer for getting staff's attention on the importance of
compliance. Anything that follows "JCAHO says" is generally listed to!

Useful guidance in process evaluation.


Deemed status and conditions of participation are the most direct link. Our standards of
conduct also speak to regulatory compliance.

our activities just focused on research

Assists in building awareness of regulatory role in healthcare industry

Provides additional guidance

Helps develop some foundation for rules and regulations

provides justification to audits, monitors, and enforcement activities

because JCAHO standards and compliance cross-over in so many areas, it is another way
that employees are made aware of rules that have to be followed

It is AOA, which helps set the framework for the compliance program.

external guidance

provides additional compliance standards to meet

setting standards

Some Standards are helpful

JCAHO does not have an accreditation program that is ideal for my type of organization

Supports requirement for specific activities

Awareness & structure
Maintaining accreditation is important to the facility


standardization of compliance

linkage to quality of care, sentinel events

Conditions of Participation

I've seldom found the JCAHO standards to be helpful....they are always there....some new
and "better" version.....always changing...always coming from Chicago and costing $ to

We use as a strategy to maintain compliance with COP's

we are doing 'CHAP'

component of risk assessment or vulnerable areas, sets industry stds or benchmarks

Provides another opportunity to highlight the importance of compliance

made sure any guidelines set by JCAHO are covered in Compliance Program

Clear standards, recognized authoritative guidance

guidance and target focus

JCAHO Readiness is more easily grasped than general compliance. We use the concept
as a springboard.

Keeps staff focused on JCAHO Standards and need for complying with standards.

JCAHO is just touching the tip of the iceberg on compliance--they are way behind the 8
ball, a day late and a dollar short of the OIG & AHLA and HCCA

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