Joint Commission on Healthcare Accreditation

The Joint Commission on Accreditation of Healthcare Organizations, known as JCAHO, was the nonprofit accreditor that Memorial Medical Center and most U.S. hospitals hired to inspect them every third year. Its Gold Seal of Approval helped hospitals secure state licensure and reimbursement for treating patients through Medicare and Medicaid. Yet the seal was common, the details of inspection deficiencies were not public, and JCAHO’s standards did not ensure that a hospital’s emergency plans would work when disaster arrived. The account uses Memorial’s Katrina crisis to expose the gap between accreditation on paper and preparedness in practice.

Accreditation and institutional reach

JCAHO’s approval was consequential without being rare. About 99 percent of hospitals achieved the Gold Seal, and accreditation offered a route to licensure and public-program reimbursement. The organization derived most of its revenue from fees paid by the hospitals it accredited. That arrangement placed JCAHO in a position of broad influence, but also made the relationship between accreditor and accredited institution an important part of its structure: hospitals paid for reviews, while the details of deficiencies remained hidden from public view.

Accreditation did not mean that every aspect of a hospital’s operation had been tested under realistic conditions. JCAHO surveyors could identify visible or documentable problems, but serious failures might remain undiscovered until a crisis or a law-enforcement investigation brought them to light. The account describes the organization’s approval as a routine credential rather than an exceptional distinction, and presents its inspections as a limited form of assurance: meaningful for licensing and reimbursement, but not a guarantee that an institution could withstand a compound emergency.

The development of emergency standards

For much of the 1990s, emergency preparedness occupied less than a page in JCAHO’s extensive hospital accreditation standards. Disaster planning was treated as an unglamorous specialty, and hospital leaders often regarded emergency managers as people who interrupted ordinary work with plans and drills. As attacks and other mass-casualty events sharpened concern about threats within the United States, disaster experts urged JCAHO to give hospitals stronger preparedness requirements.

When JCAHO proposed new standards for the new millennium, hospital executives objected that they would amount to an expensive mandate without funding. The standards nevertheless took effect in January 2001, nine months before the September 11 attacks. Their governing board had the power to veto proposals and included representatives of powerful industry organizations, among them the American Hospital Association and the American Medical Association; despite industry resistance, the board recognized the need for better preparation for hospital crises.

The new requirements called for hospitals to establish an incident command system and coordinate their plans with the wider community. That coordination mattered because a hospital could not sensibly plan for flooding in isolation from citywide failures of power and water. But the standards did not specify how realistic an emergency plan had to be. They invited a wide range of interpretations, and surveyors generally did not determine whether a hospital possessed the resources its written plan assumed. JCAHO’s standards exceeded federal requirements, but hospitals wishing to avoid them could seek accreditation from competitors.

The standards’ evidence base was limited as well. Their author, Robert Wise, was not convinced that adopting them would necessarily make hospitals better prepared. He and his colleagues expected to learn from disasters by debriefing affected hospitals afterward, distinguishing plans that worked from those that existed mainly on paper. The approach acknowledged uncertainty, but it also meant that the quality of preparedness could remain untested until a hospital faced an actual emergency.

Memorial’s inspection and the Katrina test

In late May 2005, JCAHO surveyors spent three days examining Memorial, including its stairwell signs and patient records. They identified nearly two dozen areas for required or suggested improvement, a number described as typical. None concerned the hospital’s emergency plans. The inspection could register such matters as missing documentation of informed consent, illegible progress notes and care orders, or an unsecured anesthesia cart containing controlled substances. Emergency planning proved harder to assess before it was needed.

That difficulty was not merely a gap in the surveyors’ attention. Wise acknowledged that there was no good way to test emergency plans rigorously. Memorial’s experience shows the consequence of that limit: a hospital could pass through inspection without the review identifying whether its plans fit together or whether staff could execute them under conditions the plans failed to anticipate. The accreditor did not establish that Memorial was ready for a flooded city, a loss of power, or an evacuation through impassable streets.

Memorial had twenty separate emergency plans, but their existence did not amount to a workable all-hazards system. In the years after Katrina, Wise criticized the plans as disconnected and too numerous for anyone to hold together as a coherent operational guide. In his assessment, Memorial had mistaken documentation that could satisfy accreditation for the substance of preparedness. The problem was especially consequential because the hospital’s own emergency-planning committee had rated its readiness for floods, power outages, and generator failure as good, even though its plans had not prepared it for the crisis that unfolded.

Limits revealed by comparison

The account places JCAHO’s limits within a wider contrast among New Orleans hospitals. Charity Hospital faced flooding, loss of power and essential services, difficult evacuation conditions, and a larger patient population with fewer staff per patient than Memorial. Its workers nevertheless used portable generators to power ICU ventilators and cardiac monitors, maintained routines, and evacuated the sickest patients first. These details do not establish that JCAHO caused the different outcomes. They sharpen the question of what accreditation could establish: a hospital’s documented compliance could not by itself tell a reader whether staff, equipment, leadership, and plans would remain effective in an extreme emergency.

The later critique of Memorial’s plans points to the difference between checking for preparedness documents and evaluating the capacity to respond across overlapping hazards. JCAHO’s standards required incident command and coordination, but left realism and available resources largely unchecked. Its role in the account is therefore not that of a disaster-response agency, but of an accreditor whose broad authority and routine approval process could coexist with serious uncertainty about actual readiness. Katrina made that uncertainty visible at precisely the moment when paper plans were no longer enough.