JOINT COMMISSION PROHIBITS REFORMATTED
OR REWRITTEN QUALITY ASSESSMENT DOCUMENTATION
OAKBROOK TERRACE, Ill., May 11 /PRNewswire/ -- The board of commissioners of the Joint Commission on Accreditation of Healthcare Organizations has ruled that previously prepared quality assessment records cannot be rewritten or reformatted in any way to satisfy Joint Commission requirements. Documents determined to falsely represent quality assessment activities in a health care organization could lead to loss of accreditation, suspension from the accreditation process for one year and referral to appropriate state and federal government agencies. The policy is effective immediately.
"The new policy reasserts the Joint Commission's long-standing requirement for good faith participation in the accreditation process and clarifies what actions will be taken when substantive allegations of falsification are brought to our attention," said Dennis S. O'Leary, M.D., president of the Joint Commission.
Organizations that apply for an accreditation survey agree to the terms set forth in the "General Administrative Policies and Procedures" section of the accreditation manuals. These include "good faith and frank participation by the (organization) in the survey process."
"The new policy was developed to safeguard the integrity of the accreditation process," O'Leary said. "We intend to rigorously enforce this policy."
The need for the new policy is based on an increased number of complaints received by the Joint Commission relating to falsification of quality assessment documents. Documentation is one mechanism for demonstrating a health care organization's compliance with the Joint Commission's national standards for health care quality. The Joint Commission is currently reviewing approximately two dozen cases of alleged falsification.
Effective July 1, 1992, the Joint Commission will require written certification by an organization's governing board chairman, chief executive officer and chief or president of the medical or professional staff that all organization personnel have been instructed to provide accurate and fully truthful information. The certifiers will also be required to state that these instructions have been followed to the best of their knowledge. Receipt of the certification by the Joint Commission will be required within 10 days of the survey and the survey report will not be released until the certification is received.
The policy defines falsification "as the redrafting, reformatting, content deletion or fabrication, in whole or in part, of any document provided by an applicant or accredited organization to substantiate compliance with Joint Commission standards." Materials prepared for "summarizing or otherwise explaining original documents may be submitted to the Joint Commission, so long as these materials are properly identified and dated, and are accompanied by the original document."
"Whenever the Joint Commission is reasonably persuaded that an organization has submitted falsified documents in seeking to achieve or retain accreditation, it shall immediately take appropriate action which will, under usual circumstances, be a decision not to award accreditation or a decision to remove the accreditation award from an accredited organization," according to the policy. When disciplinary action has been taken, the Joint Commission will notify responsible federal and state government agencies.
"By prohibiting reformatting and rewriting, we hope to remove the temptation and opportunity to embellish and even falsify quality assessment documentation," O'Leary said. "The policy makes it clear how seriously we take this issue and should send a strong and appropriate message to all participants in the accreditation process," he added.
Founded in 1951, the Joint Commission on Accreditation of Healthcare Organizations is a private, not-for-profit organization that evaluates and accredits more than 5,400 hospitals as well as 3,600 other health care organizations that provide home care, mental health, ambulatory care, and long term care services.
Policy concerning fraudulent preparation of documents.
Information provided by an organization that is seeking accreditation is a critical component of the Joint Commission's assessment of organization performance. The accuracy and veracity of that information is essential to the integrity of the Joint Commission's accreditation process. Such information may be verbal in nature, may be obtained through direct observation by Joint Commission surveyors, or may derive from documents supplied by the organization to the Joint Commission. The Joint Commission insists that each organization seeking accreditation engage in the accreditation process in good faith. Failure to participate in good faith, including but not limited to falsification of any document used to evaluate compliance with Joint Commission standards, may be grounds for a decision not to award accreditation or a decision to remove the accreditation award from an accredited organization.
1. For purposes of this policy, falsification is defined as the redrafting, reformatting, content deletion or fabrication, in whole or in part, of any document provided by an applicant or accredited organization to substantiate compliance with Joint Commission standards.
2. Falsified documents must never be submitted by an organization to the Joint Commission in the accreditation process. Any efforts to do so will be construed as a violation of the organization's obligation to engage in the accreditation process in good faith.
3. Notwithstanding the foregoing, additional materials prepared by the organization for the purpose of summarizing or otherwise explaining original documents may be submitted to the Joint Commission, so long as these materials are properly identified and dated, and are accompanied by the original documents.
4. At the time of, or within ten (10) working days following completion of, a full survey or focused survey, each organization is required to submit to the Joint Commission a signed Certification that attests to the accuracy and veracity of the documents provided to the Joint Commission to substantiate compliance with Joint Commission standards. The Certification is to be signed by the chief executive officer, the chairperson of the governing body and the chief of the medical (or Professional) staff (for those accreditation programs which require such staffs). In the case of a written progress report, the signed Certification is to accompany the submitted progress report.
5. No accreditation award or survey report will be released to an organization until the Joint Commission has received a properly signed Certification from the organization.
6. Whenever the Joint Commission has cause to believe that an accredited organization may have falsified documents which have been used to substantiate compliance with Joint Commission standards, the Joint Commission shall conduct an appropriate evaluation of the situation which shall include, except as otherwise authorized by the President, an unannounced on-site survey of the organization. Such a survey will use special protocols that are designed to address both the alleged document falsification and the degree of actual organization compliance with the standards that are the subject of the allegation.
7. Whenever the Joint Commission is reasonably persuaded that an organization has submitted falsified documents in seeking to achieve or retain accreditation, it shall immediately take appropriate action which will, under usual circumstances, be a decision not to award accreditation or a decision to remove the accreditation award from an accredited organization.
8. Any organization that is subject to a disciplinary action in the context of item 7 above shall also be the subject of appropriate notification by the Joint Commission to responsible federal and state government agencies.
9. Whenever an organization becomes not accredited on the basis of document falsification, the organization shall be prohibited from participation in the accreditation process for a period of one year unless the President, for good cause, waives all or a portion of this waiting period.
/CONTACT: Stephen L. Davidow, 708-916-5635 for Joint Commission on Accreditation of Healthcare Organizations/ CO: Joint Commission on Accreditation of Healthcare Organization ST: Illinois IN: HEA SU:
SH -- NY068 -- 8684 05/11/92 13:31 EDT