HCFA on track to beef up oversight of hospitals
July 26, 1999 5 minutes read
HCFA on track to beef up oversight of hospitals
Agency eager to correct major deficiencies’ cited in four-part Inspector General report
The Health Care Financing Administration (HCFA) isn’t wasting any time addressing the "major deficiencies" and "significant weaknesses" detailed in the Department of Health and Human Services’ Office of Inspector General’s (OIG) four-volume report on the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and state agencies. That report was released last week following an exhaustive two-year examination by the OIG (see Special Alert, "HHS IG blasts JCAHO’s oversight of hospitals; reforms coming," July 20, 1999).
Congressional sources say the OIG’s report is also likely to breathe new life into recent legislation introduced by Rep. Pete Stark (D-CA), the ranking Democrat on the House Ways and Means Health Subcommittee, that would make major changes in the accreditation process (see related story, below).
Eager to counter the litany of shortcomings outlined in the report, HCFA has already completed a not-yet-public "detailed action plan" to follow the four-point action plan included in the report. HCFA spokeswoman Michelle Robinson confirms that HCFA’s new Conditions of Participation (COP) will be released this fall but added that it is "still very much in draft form." She also says there is "no timetable for the development of performance measures because that is still very much in a preliminary phase." According to Robinson, many of the performance measures will be derived from the Peer Review Organization (PRO) quality improvement projects currently underway.
HCFA’s Hospital Quality Oversight Plan or action plan lays out four broad objectives:
One is "improving oversight of the JCAHO’s activities." Specifically, the agency says it will consider supplementing or replacing current validation surveys with observation surveys that would be conducted concurrently with the accreditation survey. These surveys, Robinson adds, should look at both the JCAHO onsite performance and the ability of the hospital to meet COPs.
Addressing yet another OIG criticism, HCFA says it will "work with the JCAHO to set its annual survey priorities" for the Commission’s surveys. "If HCFA were to work with the JCAHO today," Robinson says, "HCFA’s priorities would be to focus on medication errors, complications from medical errors and patient falls."
Also included in HCFA’s preliminary blueprint for JCAHO are these items:
-More unannounced surveys.
-More random selection of records.
-More "contextual information" about hospitals provided to surveyors.
-More rigorous assessments of hospitals’ internal continuous quality improvement efforts.
-Greater capacity of surveyors to respond to complaints within the survey process.
A second objective is to "strike a balance between both the quality improvement approach and the regulatory approach to hospital oversight." The agency says the preamble to the final COP will make it clear the agency does not plan to abandon its regulatory role. While founded in a "collegial approach," says HCFA, "JCAHO performs onsite surveys, which may serve as the basis for regulatory actions."
The agency says it will also make it clear that it views Peer Review Organizations that operate "in a largely penalty-free environment" —and not JCAHO — as its agent to advance the quality of care in the hospital environment, "even though the JCAHO considers itself as having a similar role."
According to HCFA, future data-driven systems of hospital quality oversight will foster both "quality improvement activities" and "the enforcement of minimum quality standards." The agency adds that it is committed to publishing data on hospital performance. But Robinson says there is no anticipated timetable for posting information on the Internet or elsewhere.
HCFA says it will also redesign the survey data system — OSCAR — either by linking it to JCAHO’s accreditation survey data system or expanding it to include data on JCAHO data survey results, complaints, sentinel events and performance measures.
The agency’s final objectives are to re-evaluate its oversight of state agencies and develop clear criteria for their performance and also to establish a more frequent survey cycle for non-accredited hospitals.
JCAHO responds
How quickly the Joint Commission will move to implement each of these measures is still open to question. "I know the Joint Commission is working very hard to change some of the accreditation process," says the New Jersey Hospital Association’s Judy Finlin. She points specifically to the continuous survey readiness process, which has now been tested in several states. "That is another way to determine whether the process works or doesn’t work," she says. "Instead of coming in once every three years, they come in and look at part of it every quarter."
"One of the complaints everybody has about periodic survey processes is that everybody ramps up when they know they are going to be looked at, and then things slack off in the interim," adds Finlin.
On that point, JCAHO is likely to provide little resistance, according to JCAHO spokeswoman Janet MacIntyre. The Joint Commission currently performs an on-site evaluation at a minimum every three years. "Most often there is some sort of follow-up in between," she adds. "But it isn’t enough that when the Joint Commission comes on-site for that three-year evaluation that everything is in compliance. We want to see some documentation and some evidence to back it up."
Likewise, MacIntyre says JCHAO plans to introduce randomized selection of medical records, credentials files and personnel files for review.
According to MacIntyre, JCAHO also supports standardized performance measures. But like her counterparts in the hospital community, she says this area is extremely complex. The Joint Commission started introducing performance measures "with the idea of getting everyone on the same track," she explains. But she adds that JCAHO’s overly broad measures have weakened that system. "We have allowed a lot of flexibility, and let hospitals choose from a very large pool of measures which things they want to measure and collect data on," she concedes.
That is going to change, she warns, so that the Commission can make meaningful comparisons. "Right now you can’t," she flatly says. "You may have 300 hospitals that have all decided they are going to measure C-sections but they may measure them in different ways."
MacIntyre says there is no current timetable for implementation of these measures, but adds it will likely takes place "over the next few years." The Joint Commission recently announced some of the initial areas that will be examined but specific measures have not yet been selected.
She says the Joint Commission is also "taking a hard look" at adverse events. "The IG actually cites the way the Joint Commission is handling this in their report," she notes. According to MacIntyre, JCAHO is encouraging accredited facilities to notify the Commission when adverse events occur in order to share that information with other facilities and reduce risk.
Other measures already under way include a new toll-free consumer complaint hotline and the establishment of a Public Advisory Group. MacIntyre says the Commission is looking for up to 20 people from a variety of organizations.
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