Objective. To evaluate the evidence upon which standards for hospital accreditation by The Joint Commission on Accreditation of Healthcare Organizations (the Joint Commission) are based. Design. Cross sectional study. Settings. United States. Participants. Four Joint Commission R3 (requirement, rationale, and reference) reports released by July 2018 and intended to become effective between 1 July 2018 and 1 July 2019. Interventions. From each R3 report the associated standard and its specific elements of performance (or actionable standards) were extracted. If an actionable standard enumerated multiple requirements, these were separated into distinct components. Two investigators reviewed full text references, and each actionable standard was classified as either completely supported, partly supported, or not supported; Oxford evidence quality ratings were assigned; and the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) was used to assess the strength of recommendations. Main outcome measure. Strengths of recommendation for actionable standards. Results. 20 actionable standards with 76 distinct components were accompanied by 48 references. Of the 20 actionable standards, six (30%) were completely supported by cited references, six were partly supported (30%), and eight (40%) were not supported. Of the six directly supported actionable standards, one (17%) cited at least one reference of level 1 or 2 evidence, none cited at least one reference of level 3 evidence, and five (83%) cited references of level 4 or 5 evidence. Of the completely supported actionable standards, strength of recommendation in five was deemed Grade D and in one was Grade B. Conclusions. In general, recent actionable standards issued by The Joint Commission are seldom supported by high quality data referenced within the issuing documents. The Joint Commission might consider being more transparent about the quality of evidence and underlying rationale supporting each of its recommendations, including clarifying when and why in certain instances it determines that lower level evidence is sufficient.
Commentaire du Dr Marius Laurent (PAQS)
- On attendrait en principe que les standards imposés par les organismes de certification (« accréditation » ailleurs qu’en France) s’attachent à argumenter leur existence par des arguments solides. Il s’agit d’injonctions faites à des hôpitaux et à des équipes hospitalières, qui ont un caractère obligatoire. Les guidelines publiées dans les journaux médicaux, qui ne sont que des recommandations, répondent pour leur part à des critères stricts de qualité, codifiés en fonction de la qualité des preuves qu’ils invoquent (codification Grade). L’analyse du niveau de preuve qui sous-tend les standards de la Joint Commission for Accreditation of Health Organizations (la « HAS » américaine) est globalement décevante. Les standards sont soutenus par des références, mais sur les 75 composants de ces standards publiés, 13 ne le sont pas, la moitié des autres ne s’appuient que sur des preuves faibles (des avis d’experts par exemple). L’effet de standards qui ne s’appuient pas sur des preuves solides n’est que peu ou pas étudié ; il n’en va pas de même pour les guidelines dont on sait que leur durée de vie est limitée, et que des éléments probants à leur encontre, apparus après leur rédaction, existent parfois déjà au moment de leur publication. On sait qu’abandonner et faire abandonner des recommandations n’est pas chose aisée et prend parfois de nombreux mois. Il n’existe pas de raisons de penser que la suppression ou la modification d’un standard soit plus aisée, et laisse moins de traces, potentiellement dangereuses. L’article plaide pour plus de rigueur dans la rédaction des standards de certification, et plus de transparence dans leur justification.
Ibrahim SA, Reynolds KA, Poon E, Alam M. The evidence base for US joint commission hospital accreditation standards: cross sectional study. Br Med J 2022;377:e063064. Doi : 10.1136/bmj-2020-063064.