the Medicare program, hospitals must be either accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or federally certified.

Rural hospitals are less likely to seek accreditation through JCAHO than are urban hospitals. During the 10-year period from 1987 to 1996, the proportion of accredited urban hospitals remained fairly steady at 95 percent, while the proportion of accredited rural hospitals decreased from 62 to 58 percent (Brasure et al., 2000). In a survey of rural hospitals, 79 percent of respondents indicated that the cost of accreditation was a major deterrent, but there were other reasons as well: have no need or see no value (19 percent), standards unrealistic for small rural hospitals (16 percent), already surveyed by other agencies (11 percent), and other concerns regarding the JCAHO process (11 percent) (Brasure et al., 2000). In applying for accreditation, hospitals face two types of costs: survey fees paid to JCAHO (direct costs) and expenses associated with preparing for the survey, such as staff time or consultant fees (indirect costs). Recent changes in JCAHO’s hospital accreditation program intended to streamline preparation should decrease the indirect costs somewhat (JCAHO, 2004). In addition, both JCAHO and the American Osteopathic Association have established special accreditation programs for critical access hospitals (Personal communication, K. Patton, July 7, 2004). It is too early to tell whether these changes will attract a sizable number of new entrants to the accreditation process.

As an alternative to accreditation, hospitals can be certified through a review process carried out by state governments. Most rural hospitals have chosen this route. There are no survey fees for certification. Unfortunately, state certification processes are highly variable, and state fiscal constraints often limit the frequency of reviews and the intensity of follow-up activities (Federal Register, 2002).

CONCLUSIONS AND RECOMMENDATIONS

Many aspects of an effective quality improvement infrastructure will be the same for rural and urban areas, but some aspects need to be customized to reflect key differences between rural and urban health systems and environments. In Chapter 1, the committee embraced the overarching objective that rural Americans, like urban Americans, should have access to the full spectrum of high-quality, appropriate health care. The committee also identified a set of guiding principles for operationalizing this overarching objective. These guiding principles recognize that there will be differences in the



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