Trident University International
Module 1 Case Assignment
MHM 522 Legal Aspects of Health Administration
Dr. Andrew Thurman
Hospital accreditation is not the same as licensure or certification. Licensure is required to operate as a hospital and overseen by state government officials. Certification affords hospitals to participate in federally funded Medicare and Medicaid programs. Accreditation is defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve.” (Raik, ...view middle of the document...
In the United States the standard for hospital accreditation is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which per the website states they accredits over 19,000 health care organizations and programs in the United States. JCAHO’s goal is to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment and services. (JCAHO, 2011) In addition to JCAHO, The National Committee on Quality Assurance (NCQA) is a private, 501(c) (3) not-for-profit organization established by health maintenance organizations for the purpose of self-regulation through a program of voluntary accreditation. (NCQA, 2011)
As discussed earlier, licensure is required for a hospital to operate as such, however accreditation is not mandatory. Hospitals that are not accredited are not deemed to meet the Medicare Conditions of Participation, which would forfeit hospital certification. There are those health care professionals that believe that accreditation should be mandatory, and those that do not. Cornelia Sack, et al recently conducted a cross sectional study of inpatient satisfaction in the field of cardiology and found that in the field of cardiology, “successful accreditation is not linked with measurable better quality of care as perceived by the patient and reflected by the recommendation rate of a given institution. Hospital accreditation may represent a step towards quality management, but does not seem to improve overall patient satisfaction. (Sack, et al. 2010)
The other side of the fence believes that mandatory accreditation would set standards across the board that would increase patient safety and quality of care. Delegates at a seminar on Accreditation of Hospitals organized by the Confederation of Indian Industry (CII) agreed that once accreditation becomes widespread, said as consumer awareness grows, hospitals would not only have to demonstrate a commitment to quality care but also provide comparisons with other hospitals.
Weaknesses Inherent in the Healthcare Accreditation Process
Any system designed to create standards will inherently have weaknesses. Healthcare accreditation is no different. Per the Joint Commission International website, the average fee for a hospital full survey in 2010 was $46,000.00. (Joint Commission International, 2010) This fee creates a barrier for rural hospitals that are unable to afford accreditation. According to the case study, Quality Oversight: Why Are Rural Hospitals Less Likely To Be JCAHO Accredited? “The cost of JCAHO accreditation is the major deterrent to seeking accreditation for most rural hospitals.” (Brasure, Stensland, & Wellever, 1999)
The cost associated with accreditation is not the only possible weakens. Since hospital licensure is required and managed by state...