The Rev. Susan Wintz on a different way to look at JCAHO

JCAHO is Professional Chaplaincy's Friend

The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) is a much-discussed entity within professional chaplaincy. Perspectives differ from whether interacting with JCAHO is a thorn in the flesh of chaplains or an opportunity to be proactive about the work that we do. This writer takes the latter perspective.

According to the Strategic Plan of the Association of Professional Chaplains, it is part of the responsibility of the Commission on Quality in Pastoral Services to “champion APC representation to JCAHO, the COMISS Network on Specialized Settings, and other professional healthcare organizations.” Over the past three years, this has been done in a variety of ways, and the Commission’s relationship with the Joint Commission has grown to benefit the profession of professional chaplaincy.

I believe that JCAHO is our friend because their standards provide chaplaincy departments with the opportunity to articulate and advocate for the work that chaplains do as members of the interdisciplinary team. They lead us as we develop standards of practice, policies, and other documents similar to those of other disciplines within our organizations. Additionally, they provide us with opportunities to share those documents and engage in dialogue with surveyors and with our interdisciplinary colleagues before, during, and long after the survey itself is completed.

The key, however, is that we have to be proactive. We need to take responsibility for our work by choosing to participate fully in survey preparations rather than attempting to avoid the process. It is essential that we step up to the plate of professionalism and identify the ways in which we are collaborative members of the team rather than attempting to argue that our role is different or unexplainable in clinical language. We need to do the work necessary to prepare documents in line with those of the other discipline and participate in planning meetings. Just as importantly, we need to seek out opportunities to be involved in surveys and speak up to questions asked rather than hiding in our offices or the back of the room.

We also need to be collaborative in how we speak about and engage the Joint Commission. While it is true that stronger language in the JCAHO standards about the role of the clinically trained, professional certified chaplains would advocate even more for our presence within healthcare organizations, we need to be aware that change comes slowly to regulatory agencies. And change IS happening.

The Quality Commission is actively engaged in dialogue with the Joint Commission, and was sought out for input when an article was recently written about how organizations can evaluate their spiritual assessment process. Conversations are occurring regularly about how we can be involved with and contribute to the survey process both locally and nationally as well as articulating more clearly about the role of professional chaplains., This dialogue is mutual and empowering. Advocacy being done by the Quality Commission is taking place for our profession as a whole, not simply for one single cognate group. It is the responsibility of all of us to be proactive, positive, and collegial in our relationships with the Joint Commission and in our conversations with each other. JCAHO truly is our friend.

The Commission on Quality in Pastoral Services is committed to providing various resources to assist professional chaplains in their work. Several resources, including a crosswalk for the 2005 JCAHO Standards for Hospitals, can be found at the website of the Association of Professional Chaplains at http://www.professionalchaplains.org. Click on “Professional Resources” on the left, then on “Reading Room.” Crosswalks for chaplains serving in other areas, including behavioral health and long term care, are being developed by the Commission.

Do you have thoughts about advocacy you’d like to share with your colleagues? Send an e-mail to info@PlainViews.org.