Using thresholds to monitor dietetic services: the JCAHO 10-step process for quality assurance

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the licensing and governing agency for the evaluation of health care services. The JCAHO has developed a 10-step process to assist health care organizations in establishing appropriate quality assurance programs. The 10-step process guides the practitioner through problem identification, monitoring, evaluation, reporting, and problem resolution. Dietitians at 20 hospitals ranging in size from 125 to 1,538 beds were surveyed to obtain threshold designations used to monitor 19 dietetic services indicators in their quality assurance program. A threshold, usually designated as a percentage, corresponds to a numeric measurement. For example, a threshold of 90% would indicate that one unacceptable finding in 10 findings would meet the threshold designation for a particular indicator. The survey designated five threshold ranges--100%, 99%-90%, 89%-80%, 79%-70%, and 69%-50%--as well as the responses "no threshold set" and "not monitoring." A cumulative analysis of responses revealed that use of the five threshold ranges was reported with the following frequency: 100% threshold--16% (60 of 380) of responses; 99%-90% threshold--40% (154 of 380) of responses; 89%-80% threshold--6% (21 of 380) of responses; 79%-70% threshold--2% (7 of 380) of responses; 69%-50% threshold--1% (6 of 380) of responses; and no threshold or not monitoring--35% (132 of 380).