QI pros cast wary eye on OIG recommendations
Random reviews OK; regulatory mode troubling
As a quality manager, you can expect some important job changes in the wake of the Office of Inspector General’s (OIG) recent report of a two-year study on weaknesses in the nation’s hospital review system. Recommenda tions from the study are aimed at the Health Care Financing Administration (HCFA) and the Joint Commis sion on Accreditation of Healthcare Organiza tions (JCAHO). The report chastises HCFA and JCAHO for falling short on their responsibility for the inpatient safety of Medicare beneficiaries by allowing loose accountability from hospital reviewers.
The recommendations call for a shift toward a regulatory approach to oversight activities. This worries quality professionals who have painstakingly laid the foundations of "safe organizational cultures." Such environments design or refine systems to minimize errors in patient care. Less emphasis is placed on blame and punishment of individuals. If the recommendations are adopted in a strict sense, oversight activities could have a less "collegial" style than they’ve had in recent years.
Probable result: More maintenance chores
OIG’s call for more random inspection of records during surveys carries fewer philosophical implications. The sources who discussed this provision with QI/TQM agree that while it could mean more work in the short term, it will probably settle into a series of maintenance chores in the long run.
Within days after the OIG report hit the streets, JCAHO modified its policy on random unannounced surveys as follows:
• Effective Jan. 1, 2000, organizations will receive no advance notice (instead of the current 24 hours) for surprise visits.
• Visits may occur nine to 30 months following the triennial full survey.
• The scope and focus of the review will depend on recommendations made during the previous triennial survey, known sentinel events, and other information regarding the organization’s performance.
(See September QI/TQM’s cover story, "OIG’s blast of JCAHO/HCFA hospital surveys raises the bar for QI directors," for coverage of the key recommendations in the report.)
The recommendation for a shift away from JCAHO’s recent educational tone toward a focus on problems alarms many quality managers. The report notes, "A collegial mode of oversight is one that focuses on education and improved performance. It emphasizes a trusting approach to oversight, rooted in professional accountability and cooperative relationships. A regulatory mode focuses on investigation and enforcement of minimum requirements. It involves a more challenging approach to oversight, grounded in public accountability." The report goes on to say: "As the system increasingly tilts toward the collegial mode, however, it could result in insufficient attention to investigatory efforts intended to protect patients from questionable providers and substandard practices."
This troubles many QI specialists who are crusading to change punitive attitudes toward clinical and administrative mistakes. In some organizations, these quality professionals have won the support of senior managers in the drive to bring errors out into the open as opportunities for systems improvement.
While calling the report "a thoughtful piece of work," Jennifer Daley, MD, is concerned about the impact of a knee-jerk shift toward a regulatory mode of inspection. Daley wears several hats, including director of the Center for Health System Design and Evaluation, Institute for Health Policy, at Massachusetts General Hospital/ Partners HealthCare System and associate professor of medicine at Harvard Medical School.
"We need a modest mid-course correction," she advises, "not a swing all the way back to a regulatory approach. There is already a general movement in hospitals toward making the medical environment more safe — a culture of safety, if you will."
(For further perspectives on institutional responses to patient care errors, see QI/TQM’s July 1999 cover story, "Bare-bones resources’ effects on safety, best practices worry clinicians.")
Whether the recommendations actually materialize into more punitive climates for clinical or administrative mistakes will depend on how individual institutions implement them, suggests Mara Fellhoelter, director of quality and resource management at White Memorial Medical Center in Los Angeles. "If we allow it to, the recommendation will result in a more punitive environment. When you get cited on something, it will take discipline to use a process improvement approach instead of taking the easier course of singling out a person. It’s easier to censure somebody than to say, What was the process that allowed them to make an error?’"
Punitive environments often flourish when top managers insulate themselves. Removed from an understanding of the complexities of patient care and support services, leaders can fall into thinking that censure of individuals is the most effective way to correct mistakes. Maureen Bisognano, executive vice president and chief operating officer at the Institute for Healthcare Improvement in Boston, notes, "I am worried that a more inspection-oriented approach [from external reviewers] will thwart improvement." While hopeful that institutions can build openness about systemic problems that breed errors, she observes, "the only way to work this is for senior leaders to become part of uncovering problems in order to fix them, not to punish people. But [the shift] has to start at the top."
Increased attention to regulations could hamper the rational apportionment of scarce health care resources, warns Fellhoelter. "The more prescriptive reviewers become, the more institutions end up auditing things that are not critical to their hospitals. For example, if you’re in a hospital that performs very few surgeries, you might have to put extra resources into auditing surgical wound infections when it’s not critical to your operation."
While random reviews and unannounced surveys will demand more continual attention from quality managers, the result will be higher quality overall, notes Daley. "It’s like, when you know your mother-in-law is coming, you clean the house. But if you don’t know when your mother-in-law might drop in, you keep your house in order all the time. With random surveys, quality managers might have the same amount of work over three years as they would have over a few months when they know a survey is coming."
Drop-in surveys could be gifts
The technology for real-time documentation is there, contends Bisognano. She adds, however, that many of us are crisis-oriented, especially when it comes to accreditation surveys. In her experience as a hospital CEO, Bisognano admits that she never arrived at the Japanese view of the review process as an ever-present gift of knowledge and opportunity for improvement. Our industry has yet to make that shift, she opines. "When we know an inspection is due, we tend to rely on heroics. We pull people off of projects in the months before the visit and heave a sigh of relief afterward — and then go back to business as usual. It’s time for us to abandon the heroics!"
We have much to learn from manufacturing industries, many of which treat inspection readiness as routine business, suggests Bisognano. "It requires a constant tension around improvement," she notes. We might borrow the "the walk of shame" concept, as it’s called in manufacturing circles. It’s nothing more than a senior leader taking a patient’s footsteps through a stay at the facility, or following a nurse through half of a shift.
That sort of front-office-to-front-line connection could nurture a realistic balance of quality care and regulatory compliance — a balance Fellhoelter fears could get lost in the wake of this shake-up. "As resources dwindle," she argues, "all of us are working pretty lean. It could drain our resources even more if we feel compelled to audit our compliance with all the minor state regulations."
And, as one expert points out, all oversight agencies need to make sure they are promulgating the best and latest processes. Mary R. Grealy, chief Washington counsel for the Chicago-based American Hospital Association, writes in her response to the Inspector General’s report: "HCFA needs to create a more dynamic process to ensure that their standards do not lose relevance. . . . For example, they are still requiring an outmoded Life Safety Code of 1985, even though the field has moved, including JCAHO, to the current state of the art in life safety as recognized in the 1997 code."
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