JCAHO
For many every day citizens, JCAHO (Joint Commission
on Accreditation of Healthcare Organizations) means virtually nothing.
To physicians, it is a necessary evil. More government regulations in an already over-regulated field. It does not equate to quality of care in most physician's minds, but it is a tool that is used to standardize care, grade hospitals and create havoc to normal functioning. It is a very poor tool in our minds, but it is the system enjoy (or not).
But to hospitals, it has been the gold-standard for accreditation. Without it, the organization could not obtain federal funds through Medicare and Medicaid. It is always a major task to prepare for and pass the accreditation process.
In 2004, Floyd Memorial received a letter stating that our lab would be receiving a preliminary denial of accreditation because of having too many deficiencies during the inspection. This was “briefly” mentioned to the Board and I do mean briefly. We were given assurance by the CEO that the problems would be rectified and it would not affect the hospital. Months went by and nothing else was mentioned until the Board was informed that JCAHO did in fact intend to uphold the preliminary finding and not give accreditation to the hospital.
When questioned why so much time had passed and why we were just hearing about this, the backpedaling, excuses and passing blame immediately began by the CEO. It was always someone else’s fault for his failures. But as always, he made excuses and all of a sudden wanted to dump JCAHO and become accredited with a secondary organization through the American Osteopathic Association that none of us had heard of before. This was called the Healthcare Facilities Accreditation Program (HFAP)
He made comments condemning JCAHO and how they had changed and were all about money. He commented how JCAHO was in hot water with the Federal Government for not being strict enough and accrediting organizations that were later found to have significant problems. There was some truth to these statements, but it only mattered when we were at risk of not being accredited. There was never any mention of even considering switching accreditation organizations until we were failing with JCAHO.
He wanted to appeal the JCAHO ruling which eventually cost the Hospital more than $100,000. The result after all legal challenges remained the same. DENIED ACCREDITATION.
Information obtained from an individual who actually was at the final hearing in Chicago stated the issue was never totally about the Hospital’s standards. The hospital had a good lab and in virtually all other cases, these minor deficiencies would have been allowed to be rectified. But it had evidently become a personal issue. Reportly, some of the evaluators were treated poorly or disrespected and the manner in which the denial of accredtaiton was challenged by the administration seemed to bruise some egos. This was the responsibility of the CEO although it never got talked about. (Sweep it under the rug and don’t talk about it. That way you don’t have to address the “white elephant” in the room. The typical modus operandi)
Too much energy was now being focused on complete overhaul of our accreditation. Employees worked tirelessly to accomplish the enormous task of a new accreditation process all while the CEO continued finding ways to pass blame and take credit for others successes. After all, if we didn’t pass this hospital-wide accreditation process, we would lose Medicare and Medicaid dollars. That could be financial devastation to the hospital especially in the midst of the new Heart Center.
During this fiasco, the CEO had to get the Board to change it’s bylaws as well because they specifically stated we would be accredited by JCAHO. The CEO had to change his personal goals so he could still get his large year-end bonus because it also stated we would maintain JCAHO accreditation.
The County Commissioners were informed about these events, but really didn’t voice any major concerns because the CEO continued to provide the same lip-service, as usual, with blind reassurances and promises.
We now are a hospital no longer accredited by JCAHO but by the American Osteopathic Association.
As a Board Member, I voiced my discontent with the manner in which the situation was handled and the poor communication to the Board by the CEO. I had heard from hospital employees of how some of the JCAHO evaluators were treated and felt early on that the hospital would not be able to overcome the ruling because of this. We were going to be used as an example by JCAHO.
I did vote to proceed with the secondary accreditation because I knew the chances of overturning the JCAHO ruling were slim. The hospital could not afford to lose Medicare and Medicaid dollars.
Does it affect patient care?
Not yet, but that is not the point. Our CEO, with the Board and Commissioners knowledge, failed a major part of running a hospital. Rather than addressing the underlying problem, the issue was once again marginalized and trivialized. How many more events will need to occur before there are enough people to make the changes necessary to have our hospital grow and prosper?
This is another reason to hold Commissioner’s Freiberger and Reisert accountable for their poor decisions. Removing the only physician from the Board was not a good decision. If they really cared about the hospital, the employees, and the community, they would appoint individuals willing to do what is right; not political cronies, personal friends or pressured appointments from the CEO.
on Accreditation of Healthcare Organizations) means virtually nothing.
To physicians, it is a necessary evil. More government regulations in an already over-regulated field. It does not equate to quality of care in most physician's minds, but it is a tool that is used to standardize care, grade hospitals and create havoc to normal functioning. It is a very poor tool in our minds, but it is the system enjoy (or not).
But to hospitals, it has been the gold-standard for accreditation. Without it, the organization could not obtain federal funds through Medicare and Medicaid. It is always a major task to prepare for and pass the accreditation process.
In 2004, Floyd Memorial received a letter stating that our lab would be receiving a preliminary denial of accreditation because of having too many deficiencies during the inspection. This was “briefly” mentioned to the Board and I do mean briefly. We were given assurance by the CEO that the problems would be rectified and it would not affect the hospital. Months went by and nothing else was mentioned until the Board was informed that JCAHO did in fact intend to uphold the preliminary finding and not give accreditation to the hospital.
When questioned why so much time had passed and why we were just hearing about this, the backpedaling, excuses and passing blame immediately began by the CEO. It was always someone else’s fault for his failures. But as always, he made excuses and all of a sudden wanted to dump JCAHO and become accredited with a secondary organization through the American Osteopathic Association that none of us had heard of before. This was called the Healthcare Facilities Accreditation Program (HFAP)
He made comments condemning JCAHO and how they had changed and were all about money. He commented how JCAHO was in hot water with the Federal Government for not being strict enough and accrediting organizations that were later found to have significant problems. There was some truth to these statements, but it only mattered when we were at risk of not being accredited. There was never any mention of even considering switching accreditation organizations until we were failing with JCAHO.
He wanted to appeal the JCAHO ruling which eventually cost the Hospital more than $100,000. The result after all legal challenges remained the same. DENIED ACCREDITATION.
Information obtained from an individual who actually was at the final hearing in Chicago stated the issue was never totally about the Hospital’s standards. The hospital had a good lab and in virtually all other cases, these minor deficiencies would have been allowed to be rectified. But it had evidently become a personal issue. Reportly, some of the evaluators were treated poorly or disrespected and the manner in which the denial of accredtaiton was challenged by the administration seemed to bruise some egos. This was the responsibility of the CEO although it never got talked about. (Sweep it under the rug and don’t talk about it. That way you don’t have to address the “white elephant” in the room. The typical modus operandi)
Too much energy was now being focused on complete overhaul of our accreditation. Employees worked tirelessly to accomplish the enormous task of a new accreditation process all while the CEO continued finding ways to pass blame and take credit for others successes. After all, if we didn’t pass this hospital-wide accreditation process, we would lose Medicare and Medicaid dollars. That could be financial devastation to the hospital especially in the midst of the new Heart Center.
During this fiasco, the CEO had to get the Board to change it’s bylaws as well because they specifically stated we would be accredited by JCAHO. The CEO had to change his personal goals so he could still get his large year-end bonus because it also stated we would maintain JCAHO accreditation.
The County Commissioners were informed about these events, but really didn’t voice any major concerns because the CEO continued to provide the same lip-service, as usual, with blind reassurances and promises.
We now are a hospital no longer accredited by JCAHO but by the American Osteopathic Association.
As a Board Member, I voiced my discontent with the manner in which the situation was handled and the poor communication to the Board by the CEO. I had heard from hospital employees of how some of the JCAHO evaluators were treated and felt early on that the hospital would not be able to overcome the ruling because of this. We were going to be used as an example by JCAHO.
I did vote to proceed with the secondary accreditation because I knew the chances of overturning the JCAHO ruling were slim. The hospital could not afford to lose Medicare and Medicaid dollars.
Does it affect patient care?
Not yet, but that is not the point. Our CEO, with the Board and Commissioners knowledge, failed a major part of running a hospital. Rather than addressing the underlying problem, the issue was once again marginalized and trivialized. How many more events will need to occur before there are enough people to make the changes necessary to have our hospital grow and prosper?
This is another reason to hold Commissioner’s Freiberger and Reisert accountable for their poor decisions. Removing the only physician from the Board was not a good decision. If they really cared about the hospital, the employees, and the community, they would appoint individuals willing to do what is right; not political cronies, personal friends or pressured appointments from the CEO.
posted by Anonymous at 5:42 AM
3 Comments:
How is it, again, that we are better than Jewish hospital? I keep reading more and more reasons not to ever trust Floyd!
Please do not equate accreditation with overall quality, compassion and care. FMHHS has excellent nurses, techs and staff and give quality care and in my opinion, better than any other local hospital.
Could things improve?
Yes, but probably not until there is change in leadership. Your county commissioners are accountable for this problem.
This yet another example of the willingly uninformed silent majority having it's future quality of life bandied away for political/corporate gain by the few.
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