VA Health Care:

Compliance with Joint Commission Accreditation Requirements Is Improving

HRD-92-19: Published: Dec 13, 1991. Publicly Released: Dec 13, 1991.

Additional Materials:


Office of Public Affairs
(202) 512-4800

Pursuant to a congressional request, GAO examined: (1) Department of Veterans Affairs (VA) medical centers' compliance with the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) standards in 1990 compared with their compliance in 1989 and that of non-VA hospitals for both periods; and (2) VA central and regional office oversight activities.

GAO found that: (1) from July to December 1989, compliance scores varied widely among VA regions, primarily because some VA regions and medical centers did a better job of preparing for JCAHO surveys than others; (2) although VA maintained that the problems cited by JCAHO represented a lack of documentation and did not reflect the quality of care its medical centers were providing, without such documentation there was no evidence that appropriate procedures were being followed or that the facilities had the capability to provide quality care; (3) the way medical centers prepared for accreditation surveys was inconsistent among regional VA offices; (4) VA compliance with JCAHO standards improved from a score of 70 in 1989 to a score of 79 in 1990; (5) despite improvements in VA medical centers' compliance scores, they still scored significantly lower than non-VA hospitals in such areas as blood usage review, surgical case review, and surgical and anesthesia services; and (6) although VA has sufficient quality assurance mechanisms in place to ensure positive performance in JCAHO surveys, effective implementation of quality assurance systems requires the active, coordinated involvement of VA central office, regional offices, and medical centers.