Aninch will, in turn, present a discussion of the psychiatric facility survey process and describe the procedures by which JCAH arrives at a decision as to whether or not to accredit a surveyed facility.

The joint commission on accreditation of hospitals was founded in 1951 as the outgrowth of the hospital standardization program conducted until that date by the American College of Surgeons. JCAH is a private, voluntary organization, chartered in the State of Illinois as a not-for-profit corporation under section 501 (3) of the U.S. Internal Revenue Code.

Its governing authority is a 20-member board of commissioners, the members of which are appointed by the commission's four member organizations, which are the American College of Physicians, the American College of Surgeons, the American Hospital Association and the American Medical Association. The joint commission's corporate by laws recite its purpose and objectives, which are as follows:

(a) To establish standards for the operation of hospitals and other healthrelated facilities and services.

(b) To conduct survey and accreditation programs which will encourage members of the health professions, hospitals and other health-related facilities and services voluntarily to:

(1) Promote high quality of care in all aspects in order to give patients the optimum benefits that medical science has to offer.

(2) Apply certain basic principles of physical plant safety and maintenance, and of organization and administration of function for efficient care of the patient;

(3) Maintain the essential services in the facilities through coordinated effort of the organized staffs and the governing bodies of the facilities.

(c) To recognize compliance with standards by issuance of certificates of accreditation.

(d) To conduct programs of education and research and publish the results thereof, which will further the other purposes of the corporation, and to accept grants, gifts, bequests and devices in support of the purposes of the corporation. (e) To assume such other responsibilities and to conduct such other activities as are compatible with the operation of such standard-setting, survey and accreditation programs.

ACCREDITATION PROGRAM

The joint commission is probably best known for its largest and most visible program, the hospital accreditation program. Since the late 1960's, however, JCAH has been responsive to the rapid growth in the numbers of facilities and programs for specialized patient care by establishing additional accreditation programs.

As early as 1966, for example, JCAH had begun surveying longterm care facilities, and in 1971, this activity was formalized through the establishment of our accreditation council for long term care facilities. Similarly, heightened public awareness of, and interest in, mental health, coupled with our lack of expertise at the time in thoroughly evaluating facilities for physchiatric treatment strongly suggested the need for establishment of a separate accreditation program for these institutions and services.

Thus, the accreditation council for psychiatric facilities was created in 1970, in cooperation with six national organizations with that interest. The number organizations represented upon the council has grown since its establishment to 10, and they are, the American Academy of Child Psychiatry; the American Association on Mental Deficiency; the American Association of Psychiatric Services for Children; the

American Hospital Association; the American Psychiatric Association; the Association of Mental Health Administrators; the National Association of Private Psychiatric Hospitals; the National Association of State Mental Health Program Directors; the National Coalition for Alcoholism Program Accreditation; and the National Council of Community Mental Health Centers.

The council develops standards for the accreditation of psychiatric facilities and programs which are subject to ratification by the JCAH board of commissioners.

These standards are developed in consultation with a wide panel of outside professional and technical experts in the field of psychiatric care. It is particularly important to note here that the process of standards development is dynamic, rather than static.

The accreditation standards for psychiatric facilities, like all JCAH accreditation standards, are under continual scrutiny and evaluation, with a view to revising them as necessary to keep them current with the state of the art and insure that they will prescribe an optimal achievable level of performance for facilities surveyed by the

program.

Utilizing the standards, the program performs onsite visits of psychiatric facilities to determine that substantial standards compliance is, in fact, being maintained. In his presentation, Dr. Wolman will describe the professional background of the survey team members, their training and qualifications, and the survey process itself.

The recommendations of the survey team are returned to the program's Chicago headquarters where they are analyzed and evaluated by central office staff in order to assure consistency with program policy and standards.

The entire survey report is next reviewed by the program's professional staff to assure that the recommendation as to accreditation status of the facility is consistent, and is supportable by the detailed survey findings.

The next step in the decision process is consideration of the individual facility by the council's accreditation committee, which meets once a month in order to formulate and express its decisions based on the recommendations made during the preceding steps in the decision process. The council accreditation committee's decisions are, in turn, reviewed by the accreditation committee of the board of commissioners which either ratifies them or remands them to the council for further consideration.

This process, although tortuous, is designed to provide for every facility surveyed the fullest possible consideration for accreditation. With respect to those facilities for which to contest such decisions either as to fact or as to the standards upon which the decision is made. Against this backdrop of general information about JCAH and the psychiatric facilities program we would now like to present specific information regarding the subject of the committee's interest, St. Elizabeths Hospital, Washington, D.C., and Drs. Wolman and McAninch will make this presentation on the program's behalf.

Dr. Wolman?

Dr. WOLMAN. Mr. Chairman, I would like to present briefly an overview of the AC/PF accreditation process. Dr. McAninch will present some specifics of the St. Elizabeth survey and accreditation decision.

ACCREDITATION PROCESS

The accreditation process begins with a request from a facility or program for survey. An application form is sent which upon its return permits AC/PF central office staff to determine whether the facility is eligible for survey and its categories of service. It also permits initiation for scheduling and planning for the survey.

A self-evaluation questionnaire is available which offers the facility a means of self-evaluation and provides it with indications of possible deficiencies.

The surveyor's onsite visit is the heart of the process. It is the basis for the firsthand information available to the central office and accreditation committees for their consideration. The onsite survey provides information about the facility's organization, its policies, its provison of treatment, care, and other services to the patient and its documentation of these processes.

The purpose of that survey is to permit a discussion and educational process to take place, as well as to evaluate compliance with the standards. In this connection, the survey team meets with the facility's administrative and medical staffs, as well as with major department heads, in the course of the survey.

Primary, but not exclusive concerns of the onsite visits are the environment, safety, and quality of medical care and patient management. The survey includes a review of a random sample of medical records, a followthrough on patient care, and review and examination of the facility buildings and grounds.

An information interview is conducted immediately prior to the beginning of the survey. This interview permits anyone who believes he has important information about the facility's compliance with accreditation standards to present it to the survey team.

SURVEY FINDINGS AND RECOMMENDATIONS

At the end of the survey, the survey team reports its findings and recommendations to the representatives of the facility's governing body, administration, and staff at a summation conference. This conference actually may be viewed as the first step in the appeal process, since facility representatives are provided the opportunity to correct or rebut the reported findings of the surveyors.

If the recommendation is for nonaccreditation, the facility or program is afforded due process through the appeal mechanism. The facility can request an interview with staff. The results of that interview then are considered by the council accreditation committee.

If the committee still recommends nonaccreditation, the facility can. request a hearing before an appeals hearing board which is composed of individuals selected by the board of commissioners and which cannot have on it the individuals who surveyed the facility, or members of the council accreditation committee that recommended the nonaccreditation decision. The panel's recommendation is then sent to the board's accreditation committee for ratification.

If the decision is still for nonaccreditation, the facility may appeal directly to the board of commissioners less those members who served

on the accreditation committee that made the previous decision. The decision of the board is final.

I would like to add a word about the qualifications of the surveyors participating in this process. Surveyors are selected on the basis of experience and knowledge in the areas of mental health. They are psychiatrists, administrators of mental health facilities, or other mental health professionals.

They undergo several days of training and orientation with emphasis on the standards and their interpretation. As a part of the training they are sent as observers on surveys along with experienced surveyors. Next they participate as a part of a survey team after which they are considered ready to survey independently.

Mr. McAninch will now present information relevant to our survey of St. Elizabeths Hospital.

Dr. McAninch?

SURVEY OF ST. ELIZABETHS (1975)

Dr. MCANINCH. Mr. Chairman, based on accreditation procedures. just outlined, a team of four surveyors conducted an on-site visit of St. Elizabeths Hospital on September 8 through 11, 1975. All of the surveyors were psychiatrists by profession.

The survey team compared the existing conditions of the physical plant and service delivery system (s) with the approved AC/PF standards. As is our practice, corrections made in response to recom mendations made in conjunction with our 1974 survey were noted as part of this survey.

The survey team based its judgment as to the level of compliance of St. Elizabeths Hospital largely on a multiplicity of items pertaining to the quality of patient treatment as noted in the fundamental principles section of the Accreditation Manual for Psychiatric Facilities.

This manual contains nine fundamental principles, compliance with which is considered important in order for accreditation to be attained or retained. These are as follows:

Principle I.-The primary functions of any psychiatric facility shall be to diagnose and treat persons with psychiatric disorders, to restore them to an optimal level of functioning and to return them to the community.

Principle II.-The psychiatric facility shall acknowledge the dignity and protect the rights of all of its patients.

Principle III.-The psychiatric facility shall have a competent staff whose members subscribe to ethical and professional standards.

Principle IV.-A psychiatric facility shall not exclude any person from receiv ing services, or from membership on the governing body or medical staff, or from employment on the basis of race, creed, sex, or national origin.

Principle V.-The psychiatric facility shall integrate its services with other community resources and shall be responsive to community needs.

Principle VI.-The psychiatric facility shall have clearly delineated purposes and goals reflected in its written policies, procedures and organization plans. Principle VII.-The psychiatric facility shall promote a climate that makes possible the establishment of significant relationships among staff, patients and their families.

Principle VIII.-The activities of the psychiatric facility shall be conducted in accordance with the law and with accepted standards for clinical practice and human dignity.

Principle IX.-The psychiatric facility shall be organized so as to perform its functions and accomplish its goals.

With the exception of principle IV, varying degrees of noncompliance were found with respect to all.

ADVERSE ACCREDITATION RECOMMENDATION

AC/PF central office review of the survey reports and related supportive materials submitted by the survey team resulted in an adverse accreditation recommendation which was concurred in by the AC/PF accreditation committee and then ratified by the accreditation committee of the board on November 11, 1975. Noncompliance in areas affecting patient safety was instrumental in the nonaccreditation decision.

On January 28, 1976, representatives of St. Elizabeths Hospital met in an informal interview with AC/PF central office staff to discuss any questions raised by the letter of recommendations forwarded to St. Elizabeths Hospital on November 28, 1975.

Corrections were noted subsequent to the onsite visit. There were still major areas of noncompliance, particularly those affecting patient safety and treatment. The accreditation committee of the board reaffirmed its nonaccreditation decision on April 16, 1976.

APPEAL PANEL

On May 5, 1976, St. Elizabeths Hospital formally requested that an appeals hearing panel meet to review the nonaccreditation decision. The appeals hearing panel was conducted on June 11, 1976. Members of this panel were knowledgeable about the standards and accreditation process and were persons who had had no prior review of these materials or association with the accreditation decisions pertaining to St. Elizabeths Hospital.

The quality of treatment planning and its implementation and the environmental and safety deficiencies affecting the general quality of patient treatment were of major consideration in the appeals hearing panel's recommendation. The panel ratified the decision of the accreditation committee, and subsequently the panel's ratification was itself ratified by the executive committee of the board August 14, 1976. Mr. Chairman, this concludes the prepared segment of our presentation. As was indicated earlier, however, we would be pleased to respond to the committee's questions.

The CHAIRMAN. Thank you very much.

I yield to the gentleman from the District, Mr. Fauntroy.

REASONS FOR NONACCREDITATION

Mr. FAUNTROY. Thank you, Mr. Chairman. I have several questions for any member of the panel. In the first instance in your judgment, are the primary deficiencies at St. Elizabeths Hospital those most directly responsible for nonaccreditation, do they relate to budget, or some other factors?

In other words, would additional funds solve the institution's accreditation problems?

Dr. MCANINCH. The major problems were in areas having to do with environmental, patient safety, patient treatment, particularly as it pertains to documentation of the kinds of treatment rendered, the