How Good Is the Evidence Base for Joint Commission Mandates? Spoiler Alert…

August 22, 2022

Written by Gabby Leonard

Spoon Feed
A review of actionable standards set forth by the Joint Commission in 2018-2019 showed that the majority of required changes were only partly, or not at all, supported by quality evidence.

Why does this matter?
More than 22,000 healthcare facilities in the U.S. depend on accreditation by the Joint Commission (aka Joint Commission on Accreditation of Healthcare Organizations or JCAHO) to receive reimbursement from Medicare/Medicaid or, in some states, for hospital licensure. Up to 1.7% of annual operating costs for healthcare facilities are spent on accreditation adherence. High standards matter, but are the JCAHO metrics evidence-based?

Extraordinary claims require extraordinary evidence
The Joint Commission sets forth actionable standards that are required changes intended to promote patient safety and quality care. These standards are scored by site reviewers to determine compliance with regulations from the Joint Commission, which impacts accreditation. This cross-sectional study of the 2018 Joint Commission R3 reports (requirement, rational and reference) evaluated 20 required or revised actionable standards divided into 76 distinct components supported by 47 references.

Two independent investigators classified the degree to which each reference supported the actionable standard. Importantly, interrater reliability was substantial (0.73). They found that 72% (34/47) of references were low quality evidence (level 4 or 5). Only 30% (6/20) of actionable standards were completely supported by references; notably, 5/6 of these references were assigned a GRADE D* strength of recommendation score. 30% (6/20) of actionable standards were partly supported by references and 40% (8/20) were not supported by references.

This raises concern that the majority of required actionable standards set forth by the Joint Commission are not supported by high quality data. Authors offered suggestions for improvement to prevent regulatory fatigue and wasted time and resources: transparency about high quality evidence that may not have been referenced, enforcing fewer actionable standards that are based on higher quality of evidence, and changing required actions to suggested recommendations.

*Editor’s note: GRADE D means, “recommendation is based on very low quality evidence, and any estimate of effect is very uncertain.” To quote Dr. Gordon Guyatt on GRADE, “In terms of Quality of Care, strong recommendations are considerations. Weak recommendations are not, because the right thing to do differs from patient to patient.” It seems JCAHO can do better. Enough said. ~Clay Smith

Source
The evidence base for US joint commission hospital accreditation standards: cross sectional study. BMJ. 2022 Jun 23;377:e063064. doi: 10.1136/bmj-2020-063064.