sion). Approximately 77 percent of the approximately 7,000 Medicare participating hospitals have received Joint Commission accreditation. The remaining 1,600 hospitals that are not accredited are, for the most part, small rural institutions with 50 or fewer beds (see Chapter 5 in this volume and Chapter 7, Volume II for an extensive discussion of the evolution of the Joint Commission’s accreditation process).

The accreditation manuals for each type of facility are designed for hospital use in self-assessment and for the Joint Commission to use for on-site surveys. For hospitals in “substantial compliance” such a survey occurs every three years. Scheduled at least four weeks in advance, the survey is conducted by a physician, nurse, and administrative surveyor over a three-day period using explicit scoring guidelines. After a concluding educational exit interview, the facility may receive full accreditation or may be notified that accreditation is contingent on its carrying out a plan of correction. A hospital with contingencies may submit written evidence or may undergo a return site visit. It may then may be fully accredited or, in due course, nonaccredited.

In 1981, the Joint Commission replaced their prescriptive, structure-oriented standards and numerical audit requirements with a standard requiring ongoing, facility-wide monitoring of care. Monitoring was intended to permit the identification of problems and ways to improve the delivery of care and to promote solutions to any problems identified. Nevertheless, structural standards designed to prevent problems and to ensure the capacity of the hospital to operate safely are still in effect. Three such areas of emphasis include (1) a standard specifying that the governing body is to hold the medical staff responsible for establishing quality assurance mechanisms, (2) medical staff standards requiring regular review, evaluation and monitoring of the quality and appropriateness of services provided by the medical staff, and (3) a standard calling for the establishment of coordinated hospital-wide quality assurance activities.

In addition to the Joint Commission, accreditation for ambulatory facilities can also be sought on a voluntary basis from the Accreditation Association for Ambulatory Health Care (AAAHC), for HMOs from the National Committee on Quality Assurance (NCQA), and for home health agencies from the National League for Nursing (NLN) through its Community Health Accreditation Program. To date nonhospital providers have sought accreditation infrequently. These accrediting organizations, however, have become increasingly active, and some states, such as Pennsylvania and Kansas, have determined that these accrediting groups are acceptable to provide external review for HMOs.

Strengths

Standards for accreditation are publicly available. If the standards are unambiguous, and if reviewers are consistent in applying them, then infor-



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