Providing quality imaging services poses many challenges in today’s competitive, constantly changing health care environment.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) works closely with diagnostic imaging professionals in both inpatient and outpatient settings, freestanding imaging or MRI centers, ambulatory surgery centers, group medical practices, radiation clinics, urgent care centers, hospitals, and many other types of health care organizations.

JCAHO’s ambulatory care accreditation programwhich currently accredits more than 1,400 ambulatory organizations of all typesis designed to help diagnostic imaging organizations integrate performance improvement principles into their daily operations and to improve quality, safety, and outcomes continuously. Accreditation is becoming increasingly important to providers because it demonstrates a public commitment to quality by seeking an outside, independent review of compliance with state-of-the art, optimal standards. In recent years, payors have also started to require accreditation as a method for ensuring quality services.

Accreditation makes good business sense; diagnostic imaging organizations gain a competitive and marketing edge, while the survey process helps providers to do the right things and to do them well. This commitment to continually improve the way care is delivered will support diagnostic imaging providers’ efforts to reduce risk, enhance performance, and acquire contracts with payors.

JCAHO surveyors are health care professionals who have specific knowledge, training, and experience in ambulatory care and diagnostic imaging in particular. During the survey, surveyors will observe activities, interview patients and staff, and review documents to evaluate the degree to which the diagnostic imaging organization meets the standards.

According to Cathie Norins, JCAHO field representative and a regular surveyor of JCAHO’s imaging organizations, “During a survey, surveyors are interested in understanding how’ the organization uses the JCAHO standards to more effectively and efficiently achieve its stated mission. In order to gain this understanding, surveyors spend the majority of their time asking leadership, management, and staff questions about how’ the organization has designed, implemented, and improved its processes.

“Each organization is unique and how it decides to meet the intent of each standardtoday or in the futureis influenced by ever-changing internal and external factors.”

As the nation’s leading evaluator of health care quality, JCAHO has more than 50 years’ experience in improving the quality of care for the American public.


JCAHO’s standards focus on the key safety and quality issues that contribute to good care at diagnostic imaging organizations. Standards cover essential patient care areas such as:

  • patient rights
  • provision of care to patients
  • medication management, as applicable to the organization’s setting and services
  • environment of care
  • infection control
  • leadership, human resources, and performance improvement

The design of the standards was established to meet the unique needs of ambulatory care facilities, but shares a common focus with the other standards JCAHO uses to accredit nearly 17,000 other types of health care organizations.

Accredited organizations have made a commitment to implementing the systems and processes to support quality and to continuously improve performance in the delivery of care and services. Patients who choose to receive their care from accredited health care providers will have a greater likelihood that the care and services they receive will be coordinated among the providers, that outcomes will be enhanced, and that risk for medical errors will be reduced.

This is especially important given that there is no national, comprehensive oversight for diagnostic imaging centers, although some states do require licensure or registration. This does not discount the value provided by accrediting imaging technologies through the American College of Radiology accreditation program, which focuses on image quality and includes an element of peer review. ACR accreditation also serves a role for FDA-required certification of mammography centers. JCAHO believes that accreditation helps to standardize national expectations and leads to improved performance that will meet both health care and consumer demands for quality.

Shared VisionsNew Pathways

Beginning in 2004, imaging professionals will also see a number of significant changes in the JCAHO accreditation process, across all of its accreditation programs, including ambulatory accreditation.

The Shared VisionsNew Pathways” initiative, as it is called, is designed to progressively sharpen the focus of the accreditation process on systems critical to the safety and quality of care. Shared VisionsNew Pathways will concentrate more than ever before on following the experiences of actual patients in a health care organization. By tracing the care of randomly selected patients through an organization, from the scheduling of an appointment through to completion of a imaging study or even a reappointment, ambulatory surveyors will be able to get a look at how JCAHO standards are being put into place to produce good outcomes and reduce risks.

According to Norins, “surveyors are patient advocates. To understand how the organization’s processes are effective and efficient, surveyors follow the patient’s path through the care delivery process of the organization. For diagnostic imaging, the integration and coordination processesassociated with the ordering of the imaging study, to the turnaround time of the final reportare important steps for all patients, all of the time. Surveyors are interested in observing and knowing that current processes in place minimize variations from one patient to another. To ensure this outcome, surveyors seek to understand how organizations design, monitor, and continuously improve their many processes.”

In addition to this “tracer methodology,” other critical elements of the new accreditation process include a major consolidation of existing JCAHO standards, the introduction of a periodic performance review process, and the use of data from multiple sources to guide the on-site accreditation survey. This process shifts the focus from survey “ramp-up” every 3 years to continuous systems improvement by living the standards on a daily basis.

Periodic Performance Review

One of the key components of JCAHO’s Shared VisionsNew Pathways is the focus on encouraging health care organizations to maintain 100% standards compliance, 100% of the time.

The Periodic Performance Review (PPR) is a process that a diagnostic imaging organization and JCAHO will use to gauge the organization’s ongoing standards compliance.

Organizations seeking reaccreditation will receive the PPR tool 15 months after their last triennial survey, and will have 3 months to complete it. Organizations must submit the PPR to JCAHO at the midpoint of the accreditation cycle. Each organization will rate its level of compliance with the standards, and develop a plan of action for areas of noncompliance.

After an organization completes its PPR and submits it electronically over a secured extranet, JCAHO’s Standards Interpretation Group will conduct a telephone interview with the organization to review the PPR and approve any plan of action. The Standards Interpretation Group serves as the primary resource for standards compliance information for health care organizations, JCAHO surveyors, and others.

If the action plan is approved, the organization’s accreditation status is not impacted. At the organization’s next full on-site survey, the surveyor(s) will review the resolution of the plan and its corresponding measures of success. Organizations due for survey in July 2005 will be the first to receive and use the PPR tool. They will receive the tool in October of this year.

For more information about Shared Visions-New Pathways, go to for “Frequently Asked Questions (FAQs) about Shared Visions-New Pathways.” These comprehensive FAQs cover training and communication of the Shared Visions-New Pathways initiative to organizations; how the survey process will change; how JCAHO will communicate changes to organizations; the specific survey components, including the PPR; and other questions that JCAHO has received about Shared Visions-New Pathways.

Also, organizations can learn about Shared Visions-New Pathways by watching free online informational videos with corresponding fact sheets and transcripts. To access the videos, go to , click on Shared VisionsNew Pathways, then Video Information Series. Windows Media Player is required.

Process for Imaging Centers

On-site evaluations are typically conducted by one JCAHO surveyor for 2 days. Two surveyors will be assigned for 2 days for all organizations with greater than 10,000 patient visits annually.

The survey includes interviews with key personnel, observation of the center’s administrative and clinical activity, assessment of the physical facilities and patient care equipment, and review of documentation. The actual agenda is customized to fit the needs and services of each unique organization, and to minimize any interruption with patient care delivery.

Accredited health care organizations have been very clear in their desire to eliminate unnecessary “ramp up” costs and activities prior to survey. This fact led JCAHO to announce recently a switch to unannounced surveys, scheduled to begin in 2006.

While the surveys will be unannounced, JCAHO is not attempting to engage in a game of “gotcha” with accredited organizations. Instead, the move to unannounced surveys is a logical evolution in the new accreditation process, which creates the expectation that diagnostic imaging organizations will be in compliance with all applicable JCAHO standards, all of the time.

With surveys conducted on an unannounced basis, organizations that may be emphasizing major preparations for a survey only once every 3 years will shift to an everyday state of continuous survey readiness. Organizations moving toward this goal will need to work collaboratively across all areas and disciplines to be up-to-date on all applicable standards, troubleshoot areas that present challenges, and resolve issues on an ongoing, timely basis.

Shared VisionsNew Pathways further encourages this transformation by relying on the PPR midway during the triennial accreditation cycle. During the on-site, unannounced evaluation, JCAHO surveyors will work with diagnostic imaging organizations to continually improve systems and operations, further eliminating the need for major presurvey preparations.

Being ready for a survey at any time makes good business sense for diagnostic imaging organizations because it helps them to perform at peak levels and fosters safe, high-quality services. JCAHO also is confident that unannounced surveys will increase consumer confidence in the accreditation process and in accredited organizations, further strengthening the value of accreditation.

JCAHO is announcing the switch to unannounced full surveys far in advance to give organizations a chance to prepare for the new process and to provide for changes in JCAHO infrastructure that supports the survey process. The lead time also allows ample time to work with advisory groups and seek input from accredited ambulatory organizations to make the transition a smooth one. Pilot testing during the coming 2 years will be important in fine-tuning the process, giving JCAHO staff and surveyors insight into real-life issues and concerns at accreditation organizations.


JCAHO has been working diligently to strengthen the accreditation process. The goal has been to make accreditation more consistent, relevant, and focused on important issues specific to each health care organization. Since 1999, JCAHO has asked accredited organizations what it could do to increase the value of accreditation.

Organizations have told JCAHO that the accreditation process should focus on organization-specific, critical care, treatment or services processes and systems, and less on rote assessment of standards compliance. The desire to eliminate costly “ramp up” activities before triennial surveys also was a theme. There were other comments as well, about enhancing the educational aspects of the survey and improving surveyor consistency.

Unannounced surveys and other components of Shared VisionsNew Pathways, along with new electronic applications for accredited organizations and stepped up efforts to provide certification and additional training and support for surveyors, directly address these concerns. These significant changes in the accreditation process promise to present both opportunities and challenges. But the new standards and survey process will focus energy on what is most importantproviding safe, quality care, treatment, or services to the American public.

For more information about JCAHO’s Ambulatory Care Accreditation Program,? call Michael Kulczycki at (630) 792-5290 or send email to [email protected] .

Michael Kulczycki, MBA, is the executive director for the Ambulatory Care Accreditation Program at the Joint Commission on Accreditation of Healthcare Organizations. Kulczycki has more than 20 years of experience in managing and marketing health care organizations and other entities.