Download Hospital Regulation Roots

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In 1905, Ernest Codman, MD, first
described the “end result idea.”
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In 1913 the American College of
Surgeons (ACS) was founded to improve
the quality of care of surgical patients by
establishing standards for surgical
education and practice.
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These early efforts gave birth to a
hospital standardization program, but
the results of the 1918 field trials were so
shocking they were suppressed and
destroyed.
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In 1917 only 89 of 692 met these
standards. By 1950, 3200 hospitals met
the standards of care.
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In 1951 unresolved quality concerns
sparked a formal relationship between
four healthcare organizations.
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ACS, AMA, AHA, and the American
College of Physicians collaborated to
form the Joint Commission on
Accreditation of Hospitals, now known as
the Joint Commission on Accreditation
of Healthcare Organizations.
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In 1965, Congress passed the Social
Security Act enacting Medicare.
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This legislation also contained a provision
that if a hospital had earned JCAH
accreditation that the hospital was
“deemed” to be in compliance with
most of the Medicare conditions to
participate.
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Accreditation is an internationally
recognized process through which
healthcare organizations are able to
improve the safety and quality of
services delivered to patients.
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The focus of accreditation is to help
organizations understand what they are
doing well and what opportunities are
available for improvement.
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Joint Commission standards address the
organization’s level of performance in
key functional areas.
› patient rights
› patient treatment
› medication safety
› infection control
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The standards focus on setting
expectations for an organization’s actual
performance and for assessing its ability
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In addition to accreditation, JCAHO
certifies programs.

Certification is earned by programs or
services that may be based within or
associated with a healthcare
organization.
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A JCAHO accredited medical center
can have certified programs or services

The JCAHO is governed by a 29-member
Board of Commissioners that includes
physicians, administrators, nurses,
employers, a labor representative, health
plan leaders, quality experts, ethicists, a
consumer advocate, and educators.
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The present accreditation programs
offered by JCAHO include ambulatory
care, behavioral health care, critical
access hospitals, home care, hospitals,
laboratory services, long term care and
office-based surgery.
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Every type of organization accredited by
JCAHO has a manual that is customized
to fit the scope of services offered by the
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The manuals for hospitals are quite large and contain
the following areas:
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Emergency Management
Environment of Care
Human Resources
Infection Prevention and Control
Information Management
Leadership
Life Safety
Medical Staff
Medication Management
National Patient Safety Goals
Performance Improvement
Provision of Care, Treatment, and Services
Record of Care, Treatment, and Services
Rights and Responsibilities of the Individual
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A JCAHO survey is tailored to the facility
and consists of
› Care delivered to patients
› Verbal and written documentation provided
to JCAHO
› On-site interviews and observation
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These site visits occur every 18 to 39
months, can be unannounced, and
include a team of surveyors who spend
about a week learning the specific
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JCAHO does not issue monetary fines.
A non-compliant review by JCAHO may
lead to non-accreditation.
JCAHO may perform "unannounced"
inspections but not always.
JCAHO requires written follow-up reports.
JCAHO requires written policies and
procedures.
JCAHO covers patients, visitors, and staff
safety.
JCAHO uses performance oriented criteria
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In response to patient safety concerns,
JCAHO introduced National Patient Safety
Goals. This is a part of the evaluation
process.
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The patient safety goals for hospitals
include
› improve the accuracy of patient identification
› improve the effectiveness of communication
among caregivers
› improve the safety of using medications

In 1999, patient safety became a major
area of focus. The Institute of Medicine
released a report stating that between
44,000 and 98,000 people die each year
from medical errors.

Rather than individual error, the report
said the problem is caused by faulty
systems and processes, and other
conditions that lead people to make
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FDA – Food and Drug Administration –
drug approvals, drug safety information,
and providing information about
medication errors.
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AHA – American Hospital Association –
voice of hospitals and health systems in
Washington.
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AMA – American Medical Association –
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Every state has a law that describes how
medicine will be practiced within the
state.
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This Act usually establishes the medical
board for the state and protects the
health and safety of the public.

This board establishes the licensure
standards, credentials, and sanction
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How does law relate to medicine?
Tort law- (intentional) a patient can sue a
physician for medical or physical injury
caused by the physician or the physician’s
employee
Battery (unlawful touching)- no procedure can
be performed without a patient’s consent:
offering an arm to a phlebotomist to allow a
blood draw is implied consent.
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HIPAA – Health Insurance Portability and
Accountability Act; this is an example of
legislation passed by congress.
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Improves the portability of health
insurance, combats fraud, abuse, and
waste in healthcare, promotes the
expanded use of medical savings
accounts, and simplifies the
administration of health care insurance.
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JCAHO’s philosophy concerning patient
safety is that No adverse event should
ever occur anywhere in the world if the
knowledge exists to prevent it from
happening.
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Patient safety solutions are defined as
“any system design or intervention that
has demonstrated the ability to prevent
or mitigate patient harm stemming from
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JCAHO is not a body that enforces
regulatations; however, they promote
safety and quality patient care through
the accreditation process.
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JCAHO exists to improve standards of
care. Through programs and surveys,
medical standards of care are
constantly improving.