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JCAHO gives four hospitals preliminary denial of accreditation

Accreditation Connection, July 11, 2005

Four of five hospitals in the Lovelace Sandia Health System in Albuquerque, NM received preliminary denial of accreditation from the JCAHO on June 30, according to the Albuquerque Journal. The fifth facility earned full accreditation in January.

A preliminary denial doesn't strip the health system of its current accreditation.

System executives say they plan to appeal the decision, which cited 17 standards where the JCAHO found the group of four hospitals to be noncompliant. These citations included documentation, communication, physical structure or equipment, governance, and human resources.

The four hospitals that received preliminary denial of accreditation should not have been surveyed as one entity, according to the JCAHO's policy, says Arturo Delgado, interim director of public relations at Lovelace Sandia Health System. "The health system is working with the JCAHO in an appeals process to clarify the recommendations for improvement (RFIs) and to provide information that shows the hospitals should not have been surveyed as one system," Delgado said in a statement to Accreditation Connection.

Historically, when the hospitals were part of the St. Joseph's system, they were surveyed as one system because the structure and function was as one hospital with multiple campuses.

Albuquerque Regional Medical Center, a component of the health system, submitted its accreditation application listing four hospital sites and a hospice as its locations of care, Mark Forstneger, media relations specialist at the JCAHO, told Accreditation Connection. Under the JCAHO's Tailored Survey Policy, this application met the criteria for both organizational integration and functional integration, and so it was evaluated with one survey, one survey report, and one accreditation decision. The organizational and functional integration criteria are listed on page APP-3 of the 2005 Comprehensive Accreditation Manual for Hospitals.

If at the end of the appeals process, the JCAHO determines the preliminary denial stands, the hospitals will ask to be resurveyed. At that resurvey, each facility will be surveyed separately, Delgado said. 

Reach the original story through this link, a paid feature for nonsubscribers to the Albuquerque Journal.

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