JCAHO Regulations

23 04 2010

One could almost say that the purpose for the organization known as JCAHO began with the first error made by a medical provider on a patient and its creation was first practiced in a hospital founded by Dr. Ernest Codman in the early 1900s.  Dr. Codman was employed as a surgeon and continuously and vocally pushed for a cause and effect report on all treatments used on patients and became an outcast through his antics; his convictions eventually leading to his resignation.  He asked board members and fellow doctors alike “for whose primary interest is it to have the hospital efficient: the patient who seeks relief, (or) the public who supports the hospital?”  In that era, the hospital needed to maintain their reputation of infallibility and Dr. Codman believed that the hospital owed a greater debt to making sure that mistakes were examined and prevented from occurring again (Meyer).  In 1951, four independent organizations, each with a goal of preventing errors in medical practice and initiating standards of treatment came together to form a joint organization which would later be renamed the Joint Commission on Accreditation of Healthcare Organizations (JCAHO History).

The organization is now a respected agency, viewed by medical offices and hospitals alike as having the highest standards and receiving a certification from JCAHO is an honor.  Being certified as an institution by the JCAHO is not mandatory for a medical practice, and in fact is noted as being an arduous process (Los Angeles Magazine).  And while not required for operation of a facility, many insurance providers will only approve facilities that have obtained that certification.  To become certified, an eligible facility is inspected by a JCAHO team (consisting of at least one physician, one nurse and one administrator) once every three years to verify that they have met each of over 2000 standards (US Congress 188-189).  Some of the standards are simply requiring a set amount of education and experience for staff in a specific area of the facility, while other standards apply to simply having accountability measures in place for errors made by the staff (JCAHO Requirements).

The JCAHO standards for retention in full can be found in their Standards IM.01.01.01 through 04.01.01, which require hospitals to keep records private, monitor which abbreviations are permitted to be used in records and which must be spelled out, incorporates backup methods for information, and has written policies in place for procedures (JCAHO Self-Assessment).  “Although JCAHO accreditation standards do not explicitly address required media for record keeping and storage … JCAHO requires that all medical records be accurate, accessible, authenticated, organized, confidential, secure, current, legible, and complete” (Dick et al 208).  The standards are written in a manner that permits each institution to create their own methods of achieving compliance.  For example, Standard IM.02.02.01 instructs that the institution should implement “its policy regarding the terminology, definitions, abbreviations, acronyms, symbols, and dose designations permitted for use in the hospital and the abbreviations, acronyms, symbols, and dose designations prohibited from use in the hospital” without specifying any precise terminology permitted by this standard.  This created confusion in many institutions as they understood it to mean they needed to create their own specific list, and as a result, JCAHO is reverting to the previous verbiage for this standard, which states that “the organization uses standardized terminology, definitions, abbreviations, acronyms, symbols, and dose designations”, effective July 1, 2010 (StayAlert!).

The standards for compliance in regards to medical record retention and maintenance are vast, and considering the importance of these documents, the susceptibility to human error and the consequences of errors made with medical records, it only makes sense.  The health and illnesses of an individual are their burden to bear and it is rightly their choice with whom this information is shared; the standards in place to protect those rights and ensure the patient’s privacy are, in my opinion, the most critical of all the standards.  I know all too well the devastation of lost records or incomplete record keeping can have on an individual and a hospital taking the steps to acquire certification to boast their acknowledgement of that importance is something I desire to be a part of as I move into this field.


Work Cited

“History and Archives.” American College of Surgeons. American College of Surgeons, 7 Apr. 2010. Tues. 20 Apr. 2010. <http://www.facs.org/archives/index.html&gt;.

Clark, Jean. “Keep Your Medical Records Ready for a Joint Commission Survey.” Medical Records Briefing 25.1 (2010): 15-16. Jan. 2010. Tues. 20 Apr. 2010. <www.hcmarketplace.com/supplemental/140_sampleissue.pdf>.

“Appendix B: Legal Aspects of Computer-Based Patient Records and Record Systems.” The Computer-Based Patient Record: An Essential Technology for Health Care, Revised Edition. Ed. Richard S. Dick, Elaine B. Steen, and Don Detmer. Washington, D.C.: National Academy, 1997. 200-24. National Academy Press. Web. 23 Apr. 2010. <http://www.nap.edu/openbook.php?record_id=5306&page=208&gt;.

USCUH, ed. “USC University Hospital Honors and Recognition.” Los Angeles Magazine Nov. 2005: 240. Print.

Meyer, Del. Review of A Study in Hospital Efficiency, As Demonstrated by the Case Report of the First Five Years of a Private Hospital by E A Codman, MDDel Meyer, MD, Pulmonary Medicine. 1992. Mon. 19 Apr. 2010. <www.delmeyer.net/bkrev_StudyInHospitalEfficiency.htm>.

“TJC Issues Clarification on IM.02.02.01.” Staylert! Virtual Compliance Administrator. MCN Healthcare, 22 Apr. 2010. Web. <http://www.mcnstayalert.com/index.php?act=alert&id=1757&gt;.

“Our History.” The Joint Commission. 25 Aug. 2009. Mon. 19 Apr. 2010. <http://www.jointcommission.org/AboutUs/joint_commission_history.htm&gt;.

“CSR CHM IM Self-Assessment.” The Joint Commission. The Joint Commission Organization, Nov. 2009. Mon. 19 Apr. 2010. <http://www.jcrinc.com/common/pdfs/csr/forms%20and%20tools,%20newsletters/camh%20self%20assessments/2010%20CSR%20CAMH%20IM%20Self-Assessment%2011-09.doc&gt;.

“The Joint Commission Requirements.” Joint Commission Resources. The Joint Commission Organization. Mon. 19 Apr. 2010. <http://www.jcrinc.com/Joint-Commission-Requirements/&gt;.

The Quality of Medical Care: Information for Consumers. Washington, D.C.: U.S. Congress, Office of Technology Assessment, 1988. Google Books. Congress of the United States, June 1988. Tues. 20 Apr. 2010. <http://books.google.com/books?id=4vnyl8b5qMAC&lpg=PA188&dq=jcaho&pg=PR1#v=onepage&q=jcaho&f=false&gt;.

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