JCAHO Standard PI.04.01.01 Joint Commission

In 2003, Howard University lost its JCAHO accreditation of its graduate training program (McElhatton, Jim, 2003, p. B03). While the loss of accreditation would not prevent the University from building and operating a teaching hospital in Southwest sector of the District, the loss would impact the hospitals ability to receive reimbursement that would help to offset the cost of the teaching hospital. Loss of accreditation means definite federal oversight and review, and no reimbursement from federal programs without accreditation. It is a serious matter for a hospital, and one might expect it to be a serious matter for a teaching hospital.

This is why the standards, and especially standards that give the hospital or healthcare provider an opportunity to identify any deficiencies prior to the JCAHO inspections, which, since 2006, are done without prior notice. Standard PI.04.01.01 helps healthcare providers find the balance that otherwise puts the organization at risk of losing its accreditation, and, for a healthcare provider that receives funding from federal programs, jeopardize the hospitals financial stability.

The hospital reports leadership on the data collection and analysis of the standard on an annual basis. This is an organization friendly standard, because it gives the hospital or healthcare provider a lot of choices in selecting the criteria by way of units and indicators. The hospital is able to establish the formula for assessment, and to collect and analyze the data that supports its QI from one JCAHO inspection, to the next. This is a win-win standard for patients, and the organization.



Baily, M.A., Bottrell, M., Lynn, J., & Jennings, B. (2006). The Ethics of Using QI Methods to Improve Health Care Quality and Safety. The Hastings Center Report, 36(4), 1+. Retrieved November 6, 2008, from Questia database: http://www.questia.com/PM.qst?a=o&d=5017243091

Howard Unfazed by Accreditation Loss. (2003, November 19). The Washington Times, p. B03. Retrieved November 6, 2008, from Questia database: http://www.questia.com/PM.qst?a=o&d=5002036972.


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