The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has been a major force in shaping the national approach to quality in the healthcare setting. In 1986, the JCAHO announced that it would establish an “Agenda for Change” designed to improve the measurement of quality. The result is that hospitals now are being held to a new set of standards, creating opportunity, uncertainty, and anxiety. This article is designed as a primer to help epidemiologists and infection control practitioners prepare for JCAHO visits.
The best advice is to start early and work continuously to prepare for a JCAHO visit. Most standards require that compliance be documented for at least 1 year prior to the survey. Several resources are available to assist the epidemiologist (Table).
The Comprehensive Accreditation Manual for Hospital, published annually by JCAHO, is an ideal place to begin preparing for a survey.' The accreditation manual contains standards that hospitals are expected to meet, as well as scoring guidelines and rules for accreditation. All sections that apply to the epidemiologist should be read. In some institutions, the epidemiologist's responsibilities are confined to infection control. In other institutions, the responsibilities have been broadened to include most of the functions described in the accreditation manual. It is helpful to go over each standard individually and consider how compliance will be documented.