Chapter 7, from which much of the information in this chapter was taken. Options covering the Conditions of Participation program, and their respective implications, considered by the committee in developing its conclusions on the certification and accreditation of hospitals are delineated in the Volume II chapter.)

The Joint Commission is a private nonprofit organization governed by a board with 21 representatives of hospital and medical associations and 3 public representatives. The American Medical Association (AMA) and the American Hospital Association (AHA) each appoint 7 members.

About 5,400 hospitals are accredited by the Joint Commission, about two-thirds of which are in metropolitan areas. Of the 5,388 currently accredited, 36 percent are facilities of fewer than 100 beds, 55 percent 100 to 499 beds, and 9 percent 500 or more beds (Joint Commission, personal communication, 1989). Another 1,600 hospitals are certified by state inspectors to meet the federal Conditions of Participation. Most certified hospitals are small and located in nonmetropolitan areas; they usually do not wish to pay the expense of accreditation and often do not feel the need for the stamp of approval that accreditation implies because they are the only hospitals in their areas.

Although one is governmental and the other private, both the Health Care Financing Administration (HCFA) (as the administrative branch within DHHS responsible for the Medicare program) and the Joint Commission are regulatory in their approach. Each attempts to assure quality of care by influencing individual and institutional behavior. As in any regulatory system, quality assurance in health delivery organizations has three components (IOM, 1986). First, standards have to be set that relate to quality of care. Second, the extent of compliance of hospitals with the standards must be monitored. Third, procedures for enforcing compliance are necessary.

STANDARDS AND CONDITIONS

Historical Background

The current federal standards for hospitals participating in Medicare are presented in the Code of Federal Regulations as 24 “Conditions of Participation,” containing 75 specific standards (Table 5.1). Another regulation automatically permits hospitals that meet the Medicare Conditions of Participation to participate in Medicaid. The Health Standards and Quality Bureau (HSQB) of HCFA is responsible for administering and enforcing the Conditions of Participation. In addition to overseeing the Medicare accredited and certified hospitals, HSQB enforces separate sets of Conditions of Participation for over 25,000 other Medicare providers. The actual compli-



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