Joint Commission on Accreditation of Healthcare Organizations

REGULATORY ENTITIESAgencies that Regulate Washington Hospitals ..........................2<strong>Joint</strong> <strong>Commission</strong> on Accreditation ofHealthcare Organizations ..............................................................3Washington Hospital Licensing Standards.................................4Medicare Conditions of Participation ..........................................5Summary of Primary HospitalRegulatory and Accrediting Entities............................................7Other State and Federal Regulations............................................7Local Regulations............................................................................8Summary ..........................................................................................8References ........................................................................................9

2Hospitals must comply with a number of regulations to carry out state andfederal laws. The two primary reasons for health care regulations are theprotection of the health and safety of patients and the government’s major role inpaying for health care, through Medicare and Medicaid programs.In addition to providing a range of health care services, hospitals must obtainmultiple licenses and undergo numerous surveys. For example, a hospital thatoffers acute care, home health care, hospice care and long-term care must have

3separate surveys and a different license for each service. This is in addition tothe hospital’s license and Medicare certification.Trustees should also have an understanding of the cost of complying withregulations. Often, compliance requires the purchase of special supplies, hiringof additional staff, architectural changes to a facility or the provision of servicesthat are costly to maintain.JOINT COMMISSION ON ACCREDITATION OF HEALTHCAREORGANIZATIONSFor decades, hospitals participated in a voluntary self-regulatory process. In theearly 1950s, a program of hospital self-inspection, sponsored by the AmericanCollege of Surgeons, began expanding into the present <strong>Joint</strong> <strong>Commission</strong> onAccreditation of Healthcare Organizations (JCAHO). Originally, the “<strong>Joint</strong><strong>Commission</strong>” surveyed and accredited only hospitals. Today JCAHOaccreditation includes critical access hospitals, pathology and clinical laboratoryservices, home health agencies, behavioral health care services, long-term carefacilities, ambulatory care centers, health care networks and managed care. The<strong>Joint</strong> <strong>Commission</strong> conducts a voluntary survey program of hospitals. A hospitalmust request and pay for a survey.Approximately two-thirds of hospitals in Washington state are accredited byJCAHO. More information about JCAHO accreditation can be found on theJCAHO website, www.jointcommission.orgJCAHO SURVEY AND STANDARDS OVERVIEWA multi-disciplinary inspection team spends at least two days in the hospital.Standards that measure plant safety, medical staff, quality assurance, departmentservices and what the hospital is doing to improve the qualityof its services are used. The <strong>Joint</strong> <strong>Commission</strong> wants to see mechanisms andprocesses in place to ensure that the Board has an oversight role in thecredentialing of the medical staff, quality assurance and continuousimprovements of the care provided by the hospital. The <strong>Joint</strong> <strong>Commission</strong>awards a three-year accreditation to hospitals that meet its standards. In somecases, it makes receiving accreditation part of meeting certain standards betweensurveys. If these standards are not met, conditional accreditation or denial ofaccreditation can result. Costs related to maintaining JCAHO accreditationinclude a fee for the survey itself and expenses related to the cost of training,publications, seminars and consultants.Hospitals that are accredited are automatically eligible to participate in theMedicare program. Accreditation or Medicare certification is required forparticipating in most managed care programs.

4The Governing Board must be an active participant in the accreditation process.The JCAHO standards manual includes specific standards for the governingbody (see appendix). Board members must be familiar with these standards andtheir requirements.Some of these requirements are: Credentialing of the medical staff Board self-evaluation Orientation of new Board members Continuing education for the Board Adopting bylaws Conflict of interest statements Performance improvementThe <strong>Joint</strong> <strong>Commission</strong> wants to see mechanisms and processes in place to ensurethat the Board has an oversight role in the credentialing of medical staff, qualityassurance and continuous improvements of the care provided by the hospital.During the survey, the Board should meet with the survey team. It is importantfor Board members to participate in the exit conference with the team and hearits recommendations. The CEO should supply the Board with the written reportfrom the JCAHO survey along with a plan for carrying out therecommendations. The <strong>Joint</strong> <strong>Commission</strong> is conducting unannounced surveysinstead of scheduled surveys, except for initial surveys. The hospital does notreceive notice of its survey date.WASHINGTON STATE LICENSING STANDARDSHospitals in Washington must be licensed by the state in order to operate.Revised State licensing regulations (246-320 WAC, 70.41 RCW), modeled afterthe JCAHO standards, came into effect in March, 1999. The regulations are nowoutcome-based and streamlined.In Washington state there are separate licensing standards for specialty hospitals,such as psychiatric and chemical dependency facilities.Key sections of the state licensing standards are noted below (see the appendixfor the governance section of the state licensing standards):GovernanceLeadershipManagement of human resourcesMedical staff

5Management of informationImproving organizational performancePatient rights and organizational ethicsInfection control programRegulations for the range of services a hospital provides, such aspharmaceutical, diagnostic, inpatient and outpatient and specialized careManagement of environment for care (assures a safe environment forpatients, staff and visitors)Design, construction review and plan approvalFacility requirements (for clinical, non-clinical and specialized services areas)All Washington state hospitals participate in the state licensing survey processwhich occurs every 18 months for non-JCAHO hospitals. JCAHO accreditedhospitals are surveyed by the state once every 3 years because the JCAHOaccreditation survey substitutes a licensing survey. Once the survey is complete,the Board should receive a copy of the findings along with recommendations forcorrection of any problems.MEDICARE CONDITIONS OF PARTICIPATIONThe Medicare Program is the primary source of health care payment for thenation’s and state’s elderly population. Medicare is a federal programauthorized by Title 19 of the Social Security Act (also see finance chapter).Hospitals that participate in the Medicare program must be certified.In order to be Medicare-certified, a hospital must comply with the MedicareConditions of Participation. These conditions set forth the standards for healthcare provided to Medicare beneficiaries in the hospital setting.If a hospital meets the standards for Medicare certification, this qualifies thehospital for participation in the Medicaid program. The hospital is not requiredto undergo an additional survey to qualify to participate in the Medicaidprogram.The Medicare Conditions of Participation contain requirements regarding thegovernance and administration of hospitals, patient’s rights, quality assuranceand utilization review, required and optional services and requirements forstaffing. The Conditions of Participation require the medical staff be composedof physicians and allow the Governing Board to appoint other practitioners tothe medical staff. All patients in a Medicare-certified hospital must be under thecare of a physician and a physician must be on call 24 hours a day. The hospitalmust have nursing services on a 24-hour basis, and all nursing care must beprovided or supervised by a registered nurse (RN). Critical Access Hospitals donot have to be open 24-hours a day and seven days per week, they may staff with

6mid-levels, and do not always need an RN if they receive a state licensurewaiver.There are several services that Medicare-certified hospitals must either providewithin the facility or make available through a contractual or consultingarrangement. These include:Pharmaceutical servicesDiagnostic radiology servicesClinical lab servicesDietary servicesThe Conditions of Participation establish standards for optional services forMedicare-certified hospitals. These include surgery, anesthesia services,outpatient services and rehabilitation, nuclear medicine and respiratory care.Medicare-certified hospitals are not required to provide emergency medicalservices, but must have written policies appraising, treating and referringpatients needing emergency care. Standards for the physical environment arenot as stringent as the facility requirements in the state’s Hospital LicensingStandards.SURVEY PROCESSThe Washington State Department of Health conducts Medicare certificationsurveys under a contract with the Centers for Medicare & Medicaid services,www.cms.gov/. Each year a few randomly selected hospitals that are JCAHOaccredited undergo a validation survey while non-JCAHO hospitals usuallyparticipate in a Medicare Certification Survey. The Medicare certification andthe hospital licensing surveys are generally conducted at the same time. Thehospital is notified of the date that its Medicare survey will occur.The only time a hospital survey is unannounced is when the Department ofHealth has received a complaint.

7SUMMARY OF PRIMARY HOSPITAL REGULATORY AND ACCREDITINGENTITIESStandardWashington StateHospital LicensingStandardsMedicareConditions ofParticipationJCAHOAccreditation(all hospitals inWA state must belicensed)(required if ahospital desires totreat Medicarepatients)(voluntary selfregulation)Agency/organizationWashington StateDepartment ofHealthCenters forMedicare &Medicaid Services<strong>Joint</strong> <strong>Commission</strong>on Accreditationof Health CareOrganizationsSurveyEvery 18 months;if the surveyoccurs in the sameyear as a JCAHOsurvey, thehospital mayrequest anexclusionEvery 3 years;MedicareCertification canbe obtained via avalidation survey(for JCAHOaccreditedhospitals)Surveys areperformed everythree yearsOTHER STATE AND FEDERAL REGULATIONSThe Washington State Department of Health is involved in many hospitalactivities including hazardous waste management, construction and remodelingof facilities, infection control practices, medical device reporting, gathering andcompilation of health statistics, reporting of births, inspection of radiographicmachines, inspection of clinical laboratories and communicable diseasereporting.The Department of Social and Health Services (DSHS), www.wa.gov/dshs/,monitors the care provided to patients in nursing homes and long-term care

8facilities. Staff conduct unannounced, on-site inspections on a regular basis andinvestigate complaints.Workers' compensation in Washington state is regulated by the Department ofLabor and Industries. Its sets the fee schedules for physicians, x-ray, anddiagnostic tests for hospital outpatient fees and sets what is called the Percentageof Allowed Charges (POAC) for self-insured hospitals to pay.Nongovernmental hospitals come under the jurisdiction of the U.S.Occupational Health and Safety Administration for the prevention of job-relatedaccidents and illnesses. All hospitals must comply with federal requirementsrelated to non-discrimination on the basis of age, sex, race, national origin,religion and handicap.A special area of concern for hospitals is the requirements of the Americans withDisabilities Act. Hospitals must be fully accessible for visitors, employees andpatients. All hospital services must be accessible. This means that informationmay need to be available in Braille or large type, and by telecommunicationdevices and sign language.Physicians, nurses, radiological technologists, nursing home administrators,pharmacists, social workers, respiratory therapists, physical therapists, dietitiansand physicians assistants must be licensed or certified by state boards before theycan practice in their fields.LOCAL REGULATIONSHospitals are also subject to local regulations including local building codes, firesafety regulations, food sanitation codes and zoning regulations. In urban areas,compliance with these regulations can be costly and complicated. In some ruralareas, the effect of these regulations is minimal.SUMMARYTrustees need to have an understanding of regulatory agencies and theimportance of compliance with their regulations. A special challenge of theBoard is to respond to this oversight in a positive and cost-effective manner.

9REFERENCESBailey, Charles, General Counsel, THA-The Association of Texas Hospitals and Health CareOrganizations, Austin, TX, January, 1998.Brown, Fletcher, Shareholder, Davis & Wilkerson P.C., Austin TX, January, 2006.Claymon, Jennifer, Associate, Davis & Wilkerson, P.C., Austin, TX, January, 2006.DSHS (AASA) website, www.wa.gov/dshs/index.htmlGriffith, Richard and Dewey Johnson, Texas Hospital Law, Austin, TX: Butterworth LegalPublishers, 1990.Health and Safety Code, Vol. 1 and 2, Titles 1 to 5, Vernon’s Texas Codes Annotated,St. Paul, MN: West Publishing Co., 1992 and 1998 supplement.Hospital Licensing Rules, 25 TAC 133; Psychiatric Hospital Licensing Rules, 25 TAC 134.<strong>Joint</strong> <strong>Commission</strong> on Accreditation of Healthcare Organizations, 2006 Comprehensive AccreditationManual for Hospitals: The Official Handbook, Oakbrook Terrace, IL, 2006.McGuire, Catherine, Mary Walker, and Deborah Molsberry, Rural Hospital Models andRecommendations for Their Implementation, Austin, TX: Health Care Options for RuralCommunities, August, 1993.Reed, Kevin, Shareholder, Davis & Wilkerson P.C., Austin, TX, January 2006.Suiter, Brenda, Director, Rural and Public Health, Washington State Hospital Association,Seattle, WA, September 2006..Sjoberg, Elizabeth, Staff Attorney, THA-The Association of Texas Hospitals and Health CareOrganizations, Austin, TX, January, 1998.Wagner, Carol, Director, Patient Safety, Washington State Hospital Association, Seattle, WA,September 2006.