Are Joint Commission Safety Rules Really Backed by Evidence?

Alok S. Patel, MD


November 16, 2022

This transcript has been edited for clarity.

You have a coffee at the nurses' station, you put it down, and suddenly, someone says, "Hey, the Joint Commission is coming by. Watch out for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) — put your coffee down over there at that specific table." It's 2 feet away.

The coffee cup on the table rule had me thinking. On midnight rounds, I asked a charge nurse exactly what the Joint Commission looks at. The nurse told me that the JCAHO pays attention to everything from patient charts to cleanliness, lines, flushes, and expiration dates on medicines. Apparently, they're big on expiration dates. I get it. The Joint Commission plays a crucial role when it comes to setting safety standards, but are their rules and regulations backed by evidence?

First, what is the Joint Commission? They're a nonprofit that provides accreditation for healthcare institutions and sets safety standards. In order to get their gold seal of approval, a healthcare facility needs to have an onsite visit by one of the thousand people who works in their surveyor force. They provide accreditation for hospitals, nursing care, home care, behavioral health care, ambulatory care centers, and labs.

Accreditation is technically optional, but institutions that have their badge of approval are eligible for federal reimbursement from Centers for Medicare & Medicare Services (CMS). Also, it doesn't look too great if a healthcare institution isn't accredited. Naturally, hospitals spend a large amount of time and money to fulfill all their requirements.

Out of curiosity, I began looking online for some of the requirements and I ran into this study published this past June in The British Medical Journal titled, "The Evidence Base for US Joint Commission Hospital Accreditation Standards: Cross Sectional Study." The press release had an even catchier title: "Hospitals Bound to Patient Safety Rules That Aren't All Backed by Evidence."

The researchers at Northwestern University looked at rules set forth by the Joint Commission. They found that only six of 20 were backed by solid evidence. The team looked at R3 reports, which stands for requirement, rationale, and reference, and the actionable standards associated with them. In other words, something like pain assessment or patient documentation would have specific requirements within a report and then references to support the standards.

They assigned Oxford evidence quality ratings, grading recommendations, assessment, development, and evaluations, and determined if the recommendations were completely, partially, or not at all backed by the research. Well, this is one of the first studies to show that the Joint Commission has standards or rules that are not necessarily backed by evidence.

Now, this doesn't mean that the actual recommendations are far out in left field. In fact, two of the recommendations that got a grade D for evidence are as follows:

  • The critical access hospital analyzes data collected on pain assessment and pain management to identify areas that need change to increase safety and quality for patients.

That sounds solid. Here's the other one:

  • The critical access hospital identifies opioid treatment programs that can be used for patient referrals.

Clearly, both of these are important. The authors openly say they're not critical of the Joint Commission's mission, their value, and their importance, and state that "The Joint Commission standards are important and often extremely helpful in making healthcare very safe and in reducing medical errors."

Perhaps, the standards and the checklist behind these recommendations need to be evaluated because they take a large amount of time and resources to follow.

That's what the authors want to see done — that the standards set forward by the Joint Commission are supported by evidence and that there's transparency in the data. If there is no evidence, there should be a clear, written justification for that standard. The authors also suggest that some standards could be on a weighted scale rather than all or nothing.

I agree with the need for transparency. It is surprisingly difficult to look up the specific requirements for new standards or the checklist. You can look up exciting new R3s, such as one measure to reduce healthcare disparity.

If you try to go and find the compliance standards for a critical access hospital, you'll have to pay $350 to look at it. Well, unless you buy a bunch, then you get a bundled deal. Thanks so much for the savings, Joint Commission.

Again, this is not meant to be overly critical of the Joint Commission. They work to ensure patient safety. I think about them every time we do a procedural "timeout." I also saw that they're working with the White House on social determinants of health data collection. It's pretty solid.

They are cognizant of what's changed during times of COVID-19. For example, there's a set of requirements that go beyond CMS standards, appropriately called "above and beyond requirements," and they're going to evaluate these to see if they're truly necessary.

Here's the reality: Not every hospital has the same ability, resources, and funding to make sure that every single box is checked. Therefore, we have to make sure that the boxes are all necessary.

What do you all think? Who out there has some thoughts about the Joint Commission? Prior to my nursing station coffee cup drama, I never really took a deep dive into all the requirements.

For anyone who's involved in hospital administration or leadership, this is naturally important for you, and you're probably way more well versed about this than me or other hospital staff. I want to hear from you.

Alok S. Patel, MD, is a pediatric hospitalist, television producer, media contributor, and digital health enthusiast. He splits his time between New York City and San Francisco, as he is on faculty at Columbia University/Morgan Stanley Children's Hospital and UCSF Benioff Children's Hospital. He hosts The Hospitalist Retort video blog on Medscape.

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