Why is Larned State Hospital accredited by JCAHO?

1.    What is JCAHO?

        JCAHO, The Joint Commission of Accreditation of Healthcare Organizations, is a nationwide not for profit organization. JCAHO’s purpose is to evaluate a healthcare organization’s patient care outcomes by routinely visiting that facility and comparing its outcomes with established standards. JCAHO issues accreditation determinations based on the organization’s level of compliance with these standards.

2.    What are JCAHO standards?

JCAHO standards are guidelines for achieving “quality” patient care. These standards include:

• The rights of patients.
• The provision of care, including assessments and treatments.
• The assurance of a safe environment for patients and employees.
• The quality of patient care.
• The management of patients’ records.
• The organizational responsibilities of leadership and staff.

JCAHO visits healthcare organizations every three years to evaluate the standards. Typically 3 or 4 surveyors conduct the survey, which can last up to 4 days. Surveyor activities include visiting patient care units and interviewing staff. Starting in 2006, these visits are unannounced.

3.    What does JCAHO accreditation mean for Larned State Hospital?

        Our organization actively works to maintain JCAHO accreditation because this:

• Enhances community confidence of our services..
• Offers an objective evaluation of our performance.
• Provides a “report card” to the public.
• Stimulates our quality improvement efforts.
• Aids in professional staff recruitment.
• Serves as a staff education tool.
• Helps our efforts to meet certain Medicare certification requirements.

4.    How is JCAHO focusing on patient safety?

       A 1999 Institute of Medicine (IOM) Sentinel Report helped to trigger a nation-wide focus on patient safety. The report, “To Err is Human, Building a Safer Health System,” indicates that up to   98,000 deaths per year are related to medical errors. JCAHO’s response has been to implement new patient safety standards and goals for hospitals.

• Patient Safety Teams at Larned State Hospital conduct monthly audits and educate unit staff on the National Patient Safety Goals.

• The hospital has a number of safety reporting processes in place including a Report Line #4594, email link: Report Email Address, and the use of Incident and Medication Variance Report forms.
• If these avenues don’t bring resolution to safety concerns, JCAHO can be contacted by employees and the public by calling: 1-800-994-6610.
• JCAHO call also be contacted by email at:  complaint@jcaho.org
• JCAHO policy forbids accredited organizations from taking retaliatory actions against employees who report concerns to JCAHO.