The Science Journal of the American Association for Respiratory Care

1996 OPEN FORUM Abstracts

JCAHO In Acute Care

Richard M. Ford, BS, RRT Wednesday, November 6, 1996

Although not required by law, facilities that serve as providers of health care are clearly disadvantaged in terms of public image, competitiveness, and the ability to secure funding without JCAHO accreditation. Facilities not accredited by JCAHO must undergo a more enforcement-focused inspection by the Health Care Financing Administration to receive and maintain their Medicaid and Medicare funding. There are over 5,200 acute care hospitals that seek the JCAHO "Seal of Approval" who have demonstrated they are well managed and strive to provide excellent patient care. The standards that the JCAHO addresses in its accreditation of hospitals, as well as the survey process, have recently undergone major changes. Prior to 1994 the standards were focused on how well specific staff members or departments fulfilled their duties. In 1994, however, the JCAHO unveiled its "performance driven, cross functional" standards and introduced a multi-disciplinary approach to the survey process that focused on how well bedside providers work together to improve organizational performance. Respiratory care departments in the past were accustom to playing a key role in the accreditation process through department inspections and interviews. The respiratory care department continues to play a key role in the new survey process, however, the focus is not on an inspection of the department, but a series of JCAHO conducted hospital leadership team interviews as well as visits to patient care units in which bedside staff directly participate in the survey. Both RC management and staff directly participate in these elements of the survey. While it remains important to insure written department specific medical staff approved policies exist that clearly define the RCP role, methods, equipment and techniques employed in the delivery of care, equal efforts must be made to prepare staff for direct discussions with the JCAHO surveyors. Planing and staff training have become the most important considerations for the respiratory care department to contribute to JCAHO accreditation. Respiratory care departments utilizing multi-disciplinary patient driven protocols, who have ongoing programs for staff development, who insure mechanisms are in place to communicate care plans, who's leadership is actively involved in multi-disciplinary efforts to improve organizational performance, and who's staff demonstrate their value in patient care will find they have significantly contributed to insuring a "passing grade" from JCAHO surveyors.

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