JCAHO Standard PI.04.01.01 Joint Commission

¶ … JCAHO Standard PI.04.01.01

Joint Commission on Accreditation of Hospital Organizations Standard PI.04.01.01 is a reasonable standard. The standard is patient-focused, and looks to establish and maintain a protocol for significantly reducing the risk for the patient and the liability for the organization. In requiring the organization to develop the formulas utilizing data elements identified and calculated by the provider, the provider then has a set of data and criteria that exceeds the quality assurance (QA) and quality improvement (QI) processes. The standard also creates a link between the actions of clinical care and the human resource (HR) as part of those processes. This standard assures that a balance is maintained in the changing healthcare organization environment.

Mary Ann Baily, Melissa Bottrell, Joanne Lynn, and Bruce Jennings (2006) succinctly assess the changing healthcare organization environment that the standard helps to steady. They say:

Ethical issues arise in QI because attempts to improve the quality of care for some patients may sometimes inadvertently cause harm, or may benefit some at the expense of others, or may waste scarce health care resources. Ethical issues also arise because some activities aimed at improvement have been interpreted as a form of medical research in which patients are used as subjects. If this interpretation is correct, QI would come under the same complex review and regulatory requirements that have been set up to govern biomedical and other types of research (Baily, Bottrell, Lynn, and Jennings, p. 1)."

The JCAHO standard prevents the delivery of care from deteriorating to the level that deficiencies become a critical issue. The healthcare organization will ostensibly use some level of focused inspection in determining the minimum set of four indicators and the patient care units. In making the selection, the leadership is going to create an initial set of criteria for use in its ongoing collection and analysis of the information that the organization is reporting on: two aspects of patient care that represent potential risk, and two aspects or indicators of HR.

In 2003, Howard University lost its JCAHO accreditation of its graduate training program (McElhatton, Jim, 2003, p. B03). While the loss of accreditation would not prevent the University from building and operating a teaching hospital in Southwest sector of the District, the loss would impact the hospital's ability to receive reimbursement that would help to offset the cost of the teaching hospital. Loss of accreditation means definite federal oversight and review, and no reimbursement from federal programs without accreditation. It is a serious matter for a hospital, and one might expect it to be a serious matter for a teaching hospital.

This is why the standards, and especially standards that give the hospital or healthcare provider an opportunity to identify any deficiencies prior to the JCAHO inspections, which, since 2006, are done without prior notice. Standard PI.04.01.01 helps healthcare providers find the balance that otherwise puts the organization at risk of losing its accreditation, and, for a healthcare provider that receives funding from federal programs, jeopardize the hospital's financial stability.