Hospital Accreditation:

Joint Commission on Accreditation of Healthcare Organizations' Relationship with Its Affiliate

GAO-07-79: Published: Dec 15, 2006. Publicly Released: Jan 16, 2007.

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Hospitals must meet certain conditions of participation established by the Centers for Medicare & Medicaid Services (CMS) in order to receive Medicare payments. In 2003, most hospitals--over 80 percent--demonstrated compliance with most of these conditions through accreditation from the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission). Established in 1986, Joint Commission Resources, Inc. (JCR), a nonprofit affiliate of the Joint Commission, provides consultative technical assistance services to hospitals. Both organizations acknowledge the need to ensure that JCR's services do not--and are not perceived to--affect the independence of the Joint Commission's accreditation process. GAO was asked to provide information on the relationship between the Joint Commission and JCR. This report describes (1) their organizational relationship, and (2) the significant steps they have taken to prevent the improper sharing of information, obtained through their accreditation and consulting activities, respectively, since JCR was established. GAO reviewed pertinent documents, including conflict-of-interest policies and information about the organizations' financial relationship, and interviewed staff and board members from both organizations, JCR clients, and CMS officials.

The Joint Commission and JCR have a close relationship as demonstrated through their governance structure and operations. The Joint Commission has substantial control over JCR and the two organizations provide operational services to one another. For example, JCR manages all Joint Commission publications, while the Joint Commission provides support services to JCR. Despite the Joint Commission's control over JCR, the two organizations have taken steps designed to protect facility-specific information. In 1987, the organizations created a firewall--policies designed to establish a barrier between the organizations to prevent improper sharing of this information. For example, the firewall is intended to prevent JCR from sharing the names of hospital clients with the Joint Commission. Beginning in 2003, both organizations began taking steps intended to strengthen this firewall, such as enhancing monitoring of compliance. Ensuring the independence of the Joint Commission's accreditation process is vitally important. To prevent the improper sharing of facility-specific information, it would be prudent for the Joint Commission and JCR to continue to assess the firewall and other related mechanisms. The Joint Commission agreed with GAO's concluding observations. CMS did not comment on GAO's findings or concluding observations. Both provided technical comments, which we incorporated as appropriate.

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