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
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.
We are ACHC accredited not JCAHO
Ties in compliance policies with JCAHO requirements
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
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
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
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
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
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
GUIDELINES - EVERYONE UNDERSTANDS THE IMPORTANCE OF JCAHO
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
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
Structured approach; accepted benchmarks; process driven
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
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.
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
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.
provides additional compliance standards to meet
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