DOH/JCAHO Announce Joint Hospital Survey Agreement

Albany, November 7 --- In a continuing effort to reduce the burden of state regulations, improve the ability of the state to quickly respond to patient complaints and ensure the highest quality of care in New York's hospitals, State Health Commissioner Barbara A. DeBuono, M.D. today announced that the State Health Department has reached agreement on a pilot project with the Joint Commission on the Accreditation of Healthcare Organizations for a collaborative survey process for hospitals in the state.

"This initiative, part of Governor Pataki's 16-point health care regulatory reform agenda, would eliminate duplicative reviews of hospitals, and place the state's investigative emphasis on areas that really need our attention," said Dr. DeBuono. "The collaborative survey process was the result of an effort by the administration, the Joint Commission, industry representatives and health care consumers to reduce regulatory burdens on the hospital industry.

"It recognizes our commitment to making our survey and investigation process more efficient while ensuring that, even during the transition to a deregulated hospital reimbursement environment, hospitals continue to provide the highest quality of care," said Dr. DeBuono. "It will also enable Health Department staff that have been working on these surveys to focus their attention on more quickly responding to patient complaints and facilities that need immediate attention."

The pilot project enables hospitals to voluntarily participate. The state, with the permission of the subject hospital, can accept the findings of the Joint Commission accreditation survey in lieu of conducting a routine survey of that hospital. The findings of the Joint Commission survey will be considered by the Health Department in determining the necessity, if any, for follow-up surveys to be done by the state.

With the collaborative agreement, quality of hospital patient care and patient safety projections will be enhanced. Through the information sharing relationship, the Joint Commission will be ensuring implementation of corrective action in situations where the State Health Department had identified systemic concerns. Further, if a hospital chooses not to participate, they will have their routine survey performed by the State Health Department.

"The Joint Commission welcomes the opportunities afforded by this major new public sector/private sector partnership," said Dennis O'Leary, M.D., President, Joint Commission. "For many years, over 90 percent of New York's hospitals have participated in our accreditation process. It is certainly timely now to merge our efforts with those of the Department of Health in serving the quality oversight needs of the citizens of the State of New York."

"By sharing information and eliminating duplication we can streamline our review process and reduce onerous requirements, allowing hospitals to also allocate their resources to their most important function -- providing high quality patient care," said Dr. DeBuono.

The pilot will be conducted from Nov. 1, 1996 to June 30, 1997. At its conclusion, an evaluation of the project will be conducted. Approximately 33 hospitals in New York State are due for Joint Commission accreditation surveys during this period. At this time, 20 hospitals have received invitations to participate in the pilot; ten hospitals have volunteered to be part of the joint survey. They are:

  • Bellevue Hospital Center -- Manhattan
  • Jamaica Hospital -- Queens
  • Lawrence Hospital -- Westchester County
  • Mary McClellan Hospital -- Washington County
  • Staten Island University Hospital -- Staten Island
  • Clifton Springs Hospital and Clinic -- Ontario County
  • Union Hospital -- Bronx
  • Lakeside Memorial Hospital -- Monroe County
  • Victory Memorial Hospital -- Brooklyn
  • St. Clare's Hospital -- Manhattan
Through the collaborative process, the Health Department will invite hospitals scheduled for a Joint Commission survey to elect to participate. At that time, the Health Department, in accordance with applicable confidentiality provisions, can share data with the Joint Commission pertaining to systemic concerns at participating hospitals. After each survey is completed, Joint Commission will then provide the Health Department with the final accreditation reports and hospital performance reports pertaining to hospitals in New York State at the same time it submits the reports to the hospitals. These reports will be reviewed by the Health Department for a determination on the need, if any, for follow-up survey activity. As is current practice, the reports will be available to the public under the State Freedom of Information Law.

With this initiative, the Health Department has completed most of the 16 regulatory reforms it originally proposed, and continues to work on the remaining issues.

Contact: Robert Hinckley, Director, Public Affairs (518) 474-7354
New York State Department of Health Posted 11/18/96