HEALTH-SYSTEM EDITION
BUSINESS/MANAGEMENT

Shunning JCAHO, some hospitals take another route

West Shore Medical Center in Manistee, Mich., is one of a handful of U.S. hospitals not accredited by the Joint Commission on Accreditation of Healthcare Organizations. Clinical pharmacy coordinator Ron Villamaria likes it that way. He was part of a team that helped West Shore meet the latest quality guidelines set up by the International Organization for Standardization, ISO 9000, and win its certification.

"It was a chance for us to be on the cutting edge of quality improvement," Villamaria said. "If every medical institution could actually meet ISO 9000, our healthcare system would be a lot more effective, a lot safer, and a lot less expensive."

Dorsey Sullenger is pharmacy director at Madison Memorial Hospital in Rexburg, Idaho, which has also replaced JCAHO accreditation with ISO 9000 certification. "With JCAHO, you have to toe its mark whether you're a 50-bed community hospital or a 500-bed tertiary care center," he said. "Under ISO, you can decide what fits your facility to improve your quality of care."

ISO 9000 is a mystery to most U.S. hospitals, said Celeste Nair, chair-elect of the American Society for Quality's healthcare division. But ISO 9000 certification has replaced national healthcare accreditation standards in most of the rest of the world. Fewer than 40 U.S. hospitals have been ISO 9000-certified against more than 40,000 institutions worldwide. "The word just hasn't gotten out in this country," she said.

The two organizations tackle quality from different perspectives. JCAHO sets and enforces specific clinical care standards by focusing on specific procedures, such as verifying patient identification three times. ISO 9000 sets quality performance standards by focusing on specific outcomes, such as reducing the number of misidentified patients.

Each organization sets its own quality goals based on local strengths and weaknesses, Sullenger explained. Certification means the organization has created a quality improvement system, is using it, and can demonstrate objective improvement in target measures, such as med errors, physician callbacks, or incomplete admissions data. "You must show you've taken corrective action and it actually worked," he said. "It forces me, as a pharmacist, to live quality standards on a daily basis. With JCAHO, you have a major cram session, then forget it for the next 30 months."

Tom Bishop, Madison Memorial's performance improvement director, has a list of ISO-based improvements. The average time it takes the hospital to receive payment has dropped from 140 days to less than 80. The number of outside vendors has been cut from six to one. "That's millions of dollars from cleaning up our procedures," he said. On the pharmacy side, "we've started counting all interventions on physician drug orders, not just errors that made it to the floor." The new intervention numbers are convincing doctors that computerized order entry is good for their patients, not just a time-saver for pharmacy, he said.

Even JCAHO has positive words about ISO 9000. "ISO, as a quality management system, goes into more depth than JCAHO in many areas," said senior VP Paul Schyve. "What many have come to conclude, including we at JCAHO, is that these two systems can be complementary to each other." Translation: ISO 9000 certification works.

"JCAHO has taken several ISO standards and practices into its medication management chapter," said Kasey Thompson, director, Center on Patient Safety at ASHP. "JCAHO has an active committee to incorporate ISO standards and concepts."

ISO certification is also less expensive. Both West Shore and Madison Memorial reported that costs associated with ISO certification were about one-third those for JCAHO accreditation.

But ISO has its drawbacks. It can be difficult to convince health professionals that the same standards that help build better cars can help improve medical care. The problem is linguistic. ISO refers to products, processes, and outcomes, while health care thinks of services, care delivery systems, and providers.

The biggest problem is reimbursement. JCAHO accreditation means near-automatic qualification for most payment systems. ISO certification does not. Most ISO-certified institutions either continue JCAHO accreditation or seek state accreditation to meet reimbursement requirements. But that could change.

Medicaid agencies in some states are pushing the Centers for Medicare and Medicaid Services to give ISO certification the same status as JCAHO accreditation, Bishop said. CMS already requires Medicare contractors to hold ISO 9000 certification or a similar third-party validation for their in-house quality improvement programs. "The ISO process benefits us more than the JCAHO process," he said. "It's just a matter of time until CMS sees the reality."

Fred Gebhart

 

Fred Gebhart. Shunning JCAHO, some hospitals take another route. Drug Topics Nov. 17, 2003;147:HSE44.