Doctors demand more input on hospital standards

Delegates call on the Joint Commission to give physicians earlier notification about proposed changes and to revise rules that unintentionally could harm patients.

By Kevin B. O’Reilly — Posted Dec. 4, 2006

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In the short term, the Joint Commission on Accreditation of Healthcare Organizations should reconsider recent proposals that are not good for medicine, the AMA's House of Delegates said at its policymaking meeting in November. In the long run, the commission should do more to communicate with and consider physicians' viewpoints in its standards-setting process, doctors said.

AMA delegates raised concerns that the Joint Commission's process is too obscure, too unwieldy and too slanted toward hospitals and the government.

"JCAHO is being used as a tool by the government to take over the practice of medicine through the hospitals," said David McKalip, MD, a St. Petersburg, Fla., neurological surgeon and alternate delegate for his state society.

Most significantly, the AMA wants the Joint Commission to notify doctors' groups six months before it adopts or modifies standards. Most field reviews of proposed revisions now last six to eight weeks, far too short a time according to delegates. For example, only 155 doctors participated in a recent Joint Commission field review on proposed revisions to a medical staff governance standard that the AMA said poses a grave threat to physician autonomy in hospitals.

At other times, physicians believe their views go unheeded. A standard requiring pharmacists to review any first-dose medication was adopted in spite of physicians' complaints that it was impractical and could create more harm than good by exacerbating emergency department wait times.

Joint Commission communication should be timely and occur in both print and online, and JCAHO standards should "be made available to any licensed physician without hindrance," the house said in policy it adopted. Also, the Joint Commission should establish a special channel to allow physicians to provide feedback about standards or programs adversely affecting doctors' practice, delegates said.

William E. Jacott, MD, the Joint Commission's special adviser for professional relations and a former AMA trustee, said the group has stepped up its physician communication efforts.

"We are doing a lot," Dr. Jacott said, noting that he is contacted nearly every day by an individual doctor or a physician group on commission matters. In the past year, the Joint Commission has begun sending relevant standards that are up for field review to physician organizations, and for several years hospital chiefs of staff have received the standards.

"We used to only send standards for field review to the accredited organization and if the physicians got a look at it, it was just pure luck," Dr. Jacott said. "We give all this information to physicians and physician organizations and they don't disseminate it, but JCAHO gets blamed for not talking to physicians in Blackduck, Minn."

Moving from a two-month field-review process to a six-month doctor-notification time frame "would really slow us down," added Dr. Jacott, who served as an AMA JCAHO commissioner for 10 years. "I don't see that changing. ... Six months is unrealistic. You make new standards to help increase quality and patient safety, and to just keep delaying it doesn't make a whole lot of sense."

About quality, or control?

While none of the AMA delegates who spoke out on the Joint Commission disputed the importance of making strides in quality or patient safety, many said specific standards undermine physician autonomy without an accompanying benefit to patients.

Drawing particular criticism were the Joint Commission's proposed -- but not yet approved by the JCAHO board -- revisions to Standard MS.1.20, which deals with medical staff governance.

"This is a do-or-die situation for all of you," New York allergist and immunologist Lewis D. Yecies, MD, a member of the Organized Medical Staff Section governing council, told his fellow delegates. Existing AMA policy on what should be included in medical staff bylaws is, he added, "not being adhered to by these recommendations from JCAHO."

The debate between doctors and hospitals about proposed revisions to Standard MS.1.20 centers on what components of governance must be included in medical staff bylaws -- and therefore voted on and approved by physicians -- and what can be addressed in the administrative rules, regulations and policies that hospital boards and medical executive committees decide. Also, courts are more likely to view medical staff bylaws as binding contracts.

"This has been a volatile issue in some local jurisdictions and some hospitals where medical staff autonomy has been trampled on," said Ron Davis, MD, AMA president-elect and one of the Association's seven representatives on JCAHO's 29-member board of commissioners.

Robert A. Wise, MD, Joint Commission vice president of standards and survey methods, said it is fine if an organization wants to include in its medical staff bylaws everything the AMA believes should be there, but that JCAHO only requires elements that are directly linked to quality and patient safety.

"Issues like credentialing and privileging clearly do relate to patient safety," Dr. Wise said. "But when you get into things like dues or legal representation, it is a stretch."

The resolution on MS.1.20 that the AMA house adopted said such elements are "integral" to medical staff self-governance and directed the AMA's JCAHO commissioners to introduce preferred language to the full board.

"We are working in medical staffs to take back control of medicine in our hands, and we are losing," Florida's Dr. McKalip said.

Dr. Davis said that with less than half of the JCAHO board consisting of physician commissioners, "it is an ongoing struggle to ensure that Joint Commission standards are fair and appropriate."

The second recent JCAHO action that drew fire from delegates is the proposed Standard MM.4.10, which calls for a pharmacist to sign off on the first dose of any prescription to prevent adverse drug events.

Stephen K. Epstein, MD, an alternate delegate for the American College of Emergency Physicians, said that EDs would need pharmacists available at all hours to comply with the standard.

"There are 114 million ED visits a year," Dr. Epstein said. "We have much better uses of our time and resources given the fractured emergency system today. We need pharmacy review for the more complicated cases, not the simple UTI I'm sending home."

Other delegates argued that reviewing every medication could add to the six- to eight-hour wait times patients face in some emergency departments. Making the waits longer could cost patients' lives, they said.

On this matter, the Joint Commission has opted for a compromise, proposing a retrospective review of ED first-dose drug orders within 24 hours. The standard should be open to doctors' comments by year's end.

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A JCAHO primer

An overview of the Joint Commission on Accreditation of Healthcare Organizations:

What it does: Accredits 15,000 hospitals, nursing homes, home health and hospice care services, ambulatory surgery centers, long-term care, rehabilitation and laboratory facilities. The Joint Commission also sets standards for accreditation that ultimately affect physicians.

When it formed: 1951, as the Joint Commission on Accreditation of Hospitals, by the AMA, Canadian Medical Assn., American College of Physicians and American Hospital Assn.

Where it's located: Headquartered in Oakbrook Terrace, Ill., about 20 miles west of downtown Chicago; satellite office in Washington, D.C.

Why it exists: Provides deeming authority for Medicare certification; health care organizations use accreditation as a marketing tool, and the accrediting process may lead to quality and patient safety improvements.

How it functions: A 29-member board of physicians, nurses, a consumer advocate, administrators, employers, a labor representative, health plan leaders, quality experts, ethicists and educators governs and has the final word on standards; a 1,000-person staff surveys organizations for compliance.

SOURCE: Joint Commission on Accreditation of Healthcare Organizations

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Standard controversies

The Joint Commission recently proposed standards that drew criticism from the AMA. Here's what the House of Delegates had to say:

Medication reconciliation

What the commission proposed: Standard MM.4.10, as proposed, says prescription orders for nonurgent or high-risk drugs (risk to be determined by each individual organization) must be reviewed by a pharmacist before the first dose is given to a patient. Emergent or low-risk drugs must be retrospectively reviewed by a pharmacist within 24 hours of the order being given. An earlier version of the standard did not make the retrospective review exception.

What the AMA said: The house adopted a resolution directing the AMA to advocate within JCAHO to change Standard MM.4.10 "so that medication administered in a hospital setting does not require first-dose review by a pharmacist." The AMA resolution does not distinguish between emergency and nonemergency settings or the riskiness of the drug prescribed.

Medical staff governance

What the commission proposed: Standard MS.1.20, as proposed, allows organized medical staff to delegate to medical executive committees the authority to adopt rules and regulations. The rule would allow the MEC to propose medical staff bylaws directly to the hospital's governing body.

What the AMA said: MS.1.20 should be changed to reflect the fact that the elements below are "an integral part of the medical staff bylaws":

  • Application, reapplication, credentialing and privileging.
  • Fair hearing and appeal processes.
  • Selection, election and removal of medical staff officers.
  • The clinical criteria and standards that manage quality assurance and improvement, and utilization review.
  • Criteria and processing for privileging.
  • Qualification for appointment.
  • The structure of the medical staff.
  • The duties and privileges of medical staff categories.
  • The right to develop and adopt medical staff policies, procedures, rules and regulations.
  • The medical staff's right and ability as a group to retain and be represented by independent legal counsel at the medical staff's expense.
  • The right and ability to assess dues and to use the dues as the medical staff sees fit.

The house also said medical staffs should be self-governing and should develop voting rules and a mechanism to review periodically all new rules and regulations.

Source: Joint Commission on Accreditation of Healthcare Organizations; American Medical Association resolutions

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External links

Joint Commission on Accreditation of Healthcare Organizations (link)

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