JCAHO Awards UCSF Full Accreditation Following Survey

June 17, 2004
News Office: Carol Hyman

The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) national standards for health care and safety awarded UCSF Medical Center and its home care services full accreditation.

JCAHO evaluators, concluded following their comprehensive five-day survey of UCSF hospitals, ambulatory practices and the UCSF Home Care program, that UCSF Medical Center met all of its criteria for providing quality health care, and that no recommendations for improvement would be necessary.

According to JCAHO, only 17 percent of hospitals received accreditation with full standards compliance in 2003.

"It really doesn't get any better than that," said medical center CEO Mark Laret, addressing a group of faculty and staff who had gathered to hear the results of the survey. "They (JCAHO evaluators) survey hospitals that are smaller than some of our individual units," he continued. "This just reinforces the fact that our staff and faculty here are absolutely tremendous."

Such a distinction does not come without a great deal of effort and hard work by many people. Manager training sessions were held twice monthly for several months. Managers in turn spent a portion of each day training and quizzing staff in JCAHO "hot topics," conducting rounds and reviewing charting. Medical staff and house staff also attended training sessions, and all faculty and staff were asked to review a 100-page comprehensive guide to JCAHO compliance.

Laret explained that because they were not making any recommendations, the JCAHO surveyors really didn't have much to say at their final meeting. They did make many positive comments about staff and faculty throughout the survey. For example, during the leadership interview on the last day of survey, an evaluator said, "We are more impressed today with your organization than we were on the first day due largely to the staff interaction and cooperation we received."

Another evaluator commented: "The UCSF mission is alive and well in leadership and among the staff," while another added: "I am a richer person for having lived amongst you for a week."

Laret also took a moment to acknowledge the nursing department. "They were especially scrutinized," he said, "and they did an amazing job."

Founded in 1951, JCAHO is dedicated to improving the safety and quality of the nation's health care through voluntary accreditation. JCAHO's on-site survey of UCSF Medical Center occurred in late May.

To earn and maintain accreditation, hospitals must arrange for an onsite JCAHO review at least every three years to evaluate the organization's performance in areas that affect patient care. JCAHO officials then decide whether to award accreditation based on how well the organization met JCAHO standards. JCAHO is an independent, not-for-profit organization governed by a board of physicians, nurses and consumers. JCAHO evaluates the quality and safety of care provided by nearly 16,000 health care organizations, and sets the standards by which health care quality is measured in America and around the world.