The Federal Requirements for JCAHO Accreditation

The Joint Commission on Accreditation of Healthcare Organizations sets a standard for patient care in health care programs and facilities. JCAHO---a private non-profit organization---largely sets its own standards and checks for medical facility compliance with Medicare rules and regulations. The Center for Medicare Services (CMS) has legal oversight over JCAHO's Medicare criteria because CMS has elected to take JCAHO's certification as proof of compliance. In other words, a facility does not have to be JCAHO accredited to be Medicare compliant, but it does have to be compliant to receive JCAHO accreditation.
  1. Ten Quality Measures

    • When performing an accreditation, JCAHO is required to collect data from hospitals in 10 areas of quality measurement and in turn report these to CMS: acute myocardial infarction, heart failure, surgical care, pneumonia, nursing sensitive, outcomes and complications, cardiac surgery, patient experience, pediatric asthma and outpatient measures. JCAHO looks for high enough performance, or in some cases lack of problems and what it calls "sentinel events," which mark egregious errors or compromised patient care.

    Patient Surveys

    • CMS worked with JCAHO on adding patient surveys to the accreditation process. The resulting Hospital Patient Perspectives on Care Survey, which solicits patients' views, comments and ratings on their hospital experiences, is now standard to a JCAHO hospital visit and survey. Patient survey contents include medical care quality, customer service, clinician-patient interaction, cleanliness of facility and more.

    Common Language

    • To ensure that CMS could rely on JCAHO reporting, the two organizations developed a Specifications Manual for National Hospital Quality Measures which contains common terminology. This way, when JCAHO evaluates a hospital and speaks of different areas of quality, strengths and weaknesses, it can be interpreted easily by Medicare. As a result, CMS is able to ensure JCAHO reports are equivalent to Medicare standards.

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