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Untangle the scoring process for JCAHO standards

Accreditation Connection, January 14, 2005

While assisting the JCAHO with the development of its new Shared Vision-New Pathways, the JCAHO's standard review task force discovered that many organizations misinterpret the accreditor's standards, further complicating and confusing compliance efforts.

A member of that task force, Claude (Bud) Pate, REHS, director of clinical operations effectiveness for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, advises medical staff leaders frustrated with the JCAHO's "unreasonable" standards to take a closer look at the standard. That which is upsetting you may not be on the books.

The elements of performance (EPs) associated with each standard are the key to pinpointing just what the JCAHO requires in regard to your medical staff policies and procedures. In addition to understanding the EPs listed beneath each standard, it's important to understand how they are scored, says Pate.

Category A EPs are generally scored based on the presence (2 points) or absence (0 points) of a process (e.g., a policy or guidelines). Many category A EPs require 100% compliance, which means that just the presence of the process alone isn't enough.

Category B EPs are similar to category A EPs except that they deal with the development of the policy or guideline. A policy or process that follows all good process design principals is scored 2 points, those with some but not all good process design principles are scored 1, and those lacking good design principles are scored 0. As with category A EPs, some EPs in this category require 100% compliance.

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