Skip to main content Back to Top


Rural, Small Hospitals Face JCAHO Challenges

Donna Young

For small and rural hospitals endeavoring to meet the new medication management standards set by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), one of the most difficult challenges is finding space for a class 100,000, or International Organization for Standardization class 8 cleanroom—a controlled work area for mixing sterile preparations, said Thomas R. Jacobsen, pharmacy director at Feather River Hospital, a 101-bed facility located at the foothills of the Sierra Mountains in Paradise, California.

"We're landlocked," he said, speaking about the location of the pharmacy in the hospital.

Hospitals seeking accreditation must comply with the United States Pharmacopeia (USP) general chapter 797, or "Pharmaceutical Compounding—Sterile Preparations," beginning July 1.

Jacobsen has encouraged his health-system's administrators to install a cleanroom in the pharmacy, but now, he said, he has the force of JCAHO behind him.

But, Jacobsen added, he still has the problem of no extra space in which to build a cleanroom.

Meeting the other infection-control requirements of USP chapter 797, including donning gowns, gloves, and shoe and hair covers, will not be as challenging as the physical plant changes and costs associated with building a cleanroom, he maintained.

To free up space for a cleanroom, Jacobsen said, he plans to move his outpatient pharmacy to a different location in the hospital, move his office, and "cannibalize the bathroom."

Space issues also pose challenges for small hospitals in meeting requirements when the facility lacks 24-hour pharmacy service.

Under JCAHO's new standards, pharmacies that are not open 24 hours per day, seven days per week, and do not have an automated storage and distribution device accessible outside of the pharmacy must provide a sufficiently stocked night cabinet or have a limited area of the pharmacy in which a supply of certain medications is stored that can be accessed by nursing supervisors when the pharmacy is closed.

The medication management standards forbid access to the full pharmacy after hours by anyone other than a hospital's pharmacists, according to JCAHO.

George Hatfield, pharmacy director for Island Hospital, a 42-bed facility 90 miles north of Seattle, Washington, in Anacortes on Fidalgo Island, said he was fortunate because his pharmacy's long, narrow floor plan has made it easy to add a partition between the front and back ends of the room to make a night pharmacy.

Once the pharmacy's redesign is complete, the nurse supervisor will be able to access a limited supply of drugs by entering through a back door at the back of the pharmacy, he said. The front of the pharmacy, where most of the drugs are stored, will remain secure at night.

"Preparing the night pharmacy was a bit of a challenge, but I agree that this is probably safer to have a part of the pharmacy that's really set up for the nurses with drug safety in mind," Hatfield said.

Another problem faced by many small and rural hospital pharmacies that do not have 24-hour service is the requirement that a pharmacist must remain on call to answer any questions or in case a medication is needed that cannot be prepared or accessed by a nurse supervisor.

In rural areas, an on-call pharmacist may have to travel many miles at night to get to the hospital.

Jacobsen is worried that if the on-call pharmacist is called into the hospital more than once a night, it will be difficult for that person to work his or her shift the next day, which could eventually lead to the pharmacist becoming burned-out.

Feather River Hospital has five pharmacists on its staff, he said, with some of those pharmacists living at least 30 miles outside of Paradise.

It took Jacobsen 14 months to recruit the most recent pharmacist who joined his team-even though his hospital was offering one of the highest-paid salaries in the state, he said.

Debra Cowan, pharmacy director at Angel Medical Center, a 55-bed facility in Franklin, North Carolina, said that a big concern for her hospital was ensuring that nursing units had segregated, uncontaminated areas for nurses to prepare i.v. solutions.

The hospital has also focused on making sure that all nurses are adequately trained in proper aseptic techniques and their competency is tested and documented, she added.

Angel Medical Center hired a nurse educator who used a video produced by the American Society of Health-System Pharmacists about aseptic techniques as a teaching tool for nurses, Cowan said.

Although not an easy task to complete, one tool that has helped Cowan's pharmacy identify areas that need work before the hospital undergoes its onsite survey is JCAHO's Periodic Performance Review (PPR) self-assessment, which the hospital completed in April.

After completing the PPR, hospitals are required to develop plans of actions for any area in which they were not in compliance with JCAHO standards and identify measures to assess the effectiveness of the plans.

"My to-do list is a monster now," Cowan said.

DeeAnn Wedemeyer Oleson, pharmacy director and diabetes education instructor at Guthrie County Hospital, a 25-bed critical access hospital in rural West Central Iowa, noted that hospitals are not required by the Centers for Medicare & Medicaid Services (CMS) or any other government agency to be accredited by JCAHO.

In fact, she added, most of Iowa's hospitals are not JCAHO accredited.

According to Scott McIntyre, government relations director of communications for the Iowa Hospital Association (IHA), only 42 of the 116 hospitals in the state are accredited by JCAHO.

"What makes Iowa different is that the vast majority of the hospitals are very small," Wedemeyer Oleson said.

JCAHO accreditation for many small hospitals is "very unrealistic," she said, "because of the cost involved to be accredited and also because the standards are so many times very, very difficult to achieve because you don't have the kind of money that you do in the larger facilities. You don't have the staffing, and that becomes a big player when it comes to the medication-use standards. A lot of the things that JCAHO requires are just things that the small hospitals can't [do] or find it difficult to achieve."

The hospital is inspected by Iowa's Department of Inspections and Appeals, Wedemeyer Oleson said, which only requires hospitals to meet "minimal standards" to participate in Medicare programs.

Guthrie County Hospital also achieved Critical Access Hospital (CAH) status in 1999.

CAH facilities receive Medicare payments of 101% of cost for inpatient, outpatient, and "swing bed" care.

More than 50 Iowa hospitals have been approved by CMS as CAH facilities, IHA's McIntyre said.

The advantage of achieving CAH status, Wedemeyer Oleson noted, is that hospitals are not reimbursed based on diagnosis-related group, but are reimbursed based on the actual cost of providing care.

"And so your reimbursement rates are much, much higher," she said.

Iowa has "the lowest Medicare reimbursement in the country," she added. "For some hospitals, [CAH status] is the difference between surviving and not surviving. For us, it's not only improved our financial status, but it allows us to provide some services that we have not been able to provide in the past. It is important."

But, Wedemeyer Oleson said, CAH standards are also "extremely minimal" in comparison with the requirements of JCAHO's medication management standards.

The downside to not seeking JCAHO accreditation, she noted, is that she does not have the medication management standards to "back me up" when confronting medical staff about eliminating dangerous abbreviations.

Even though her health system has implemented a policy regarding the elimination of certain abbreviations, Wedemeyer Oleson said that one physician refuses to comply.

"If I had been JCAHO accredited, it would have helped me," she said.