What it Means To Be Accredited

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO, for short) is one of the main bodies that essentially license hospitals to operate and care for the community. A group of JCAHO reviewers, made up of nurses, physicians, engineers, visit every hospital in this country, without notice on a regular basis. Usually the time frame is every 3 years, though this interval varies based on the reviewers' findings. When JCAHO "comes to town," it takes the work of the entire hospital to make transparent the quality and safety of our operation. The reviewers spend 3-4 days looking at everything from our cafeteria to our power plant, from our Emergency Department to our operating rooms, and from our nurses to our physicians. They look in credentialing and licensing to make sure everything is uptodate. You can imagine how much work this process entails on everyone's part. That being said, I find it a helpful process in that we should always be testing ourselves and our processes to make sure that we are the providing the best care. If we fall short, it is our responsibility not only to identify the shortcoming, but to look at the cause and create a solution. After their 4 day visit, the reviewers from JCAHO renewed our Accreditation. I often say that health care is not about getting a pat on the back or an "A" for effort, because we are talking about lives, however, it is nice to get the positive review of an objective observer.