Report may focus your next quality studies
For now, continue to do the right thing’
An alarm may sound for many quality professionals as they acquaint themselves with the four reports in which the Office of Inspector General (OIG) challenges the Health Care Financ ing Administration (HCFA), the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), and state survey and certification agencies in overseeing hospital quality. Others may perceive the new recommendations as pretty much business as usual with just a few new twists. Whatever your initial reaction, the experts say, "Don’t panic."
Patrice L. Spath, ART, of Brown-Spath Associ ates in Forest Grove, OR, gives this advice to quality professionals: "Do the right thing, and continue to do the right thing — measuring and improving quality." She says the new federal mandates will likely affect the focus of the studies done by quality managers. "HCFA may focus our improvement activities. We may have less latitude to pick and choose what is important. Rather than us saying that we think we need to do a project on reducing patient falls, for example, HCFA might tell us we need to do that."
An ongoing issue among states is whether Joint Commission accreditation should replace state accreditation. Some state agencies find it cost-effective to contract with JCAHO to conduct their accreditation surveys. But others see a benefit in having two bodies doing the accrediting, with JCAHO focusing on some factors and the state focusing on others.
"When the two surveys are complementary, that’s good, but not when they’re redundant," says Jo Surpin, president of Mediq Consulting Group in Pennsauken, NJ. "Providers find it difficult to understand why they have to be subjected to two costly reviews. The reality is that the Joint Commission has gotten away from some of the more routine standards that state agencies have always focused on, and looks instead at the more broad-based quality issues. Quality has relevance and importance in terms of issues that hospitals are facing now, particularly as managed care penetration increases. But if HCFA develops benchmarks that have to be adhered to by both JCAHO and state agencies, that is a positive development."
State surveys vary significantly from state to state, and these experts say there’s no standardization or accountability. The frequency of surveys and quality of the surveyors depend on what funding the state has. "States have to have money to do surveys every three years," says Spath. "There’s a lot of pressure right now for states to shift their funding to nursing home surveys because of public concern. Where’s HCFA going to get the funding to give states more money to do more surveys? And what recourse have they against states if they don’t do surveys?"
Oversight necessary to protect patients’ rights
No one would dispute that surveys are functions that should be performed. It’s the only way to protect patients and assure quality care. But as it stands, a lot is left to the discretion of the states and how they administer programs. Many in the industry would agree that the situation as it currently exists is not satisfactory; it varies too much by state.
Surpin says the impact of the OIG reports will be both good and bad. "Anything that will ultimately require more regulatory oversight is always burdensome and expensive," she says. "There is a lot of overlap and redundancy between JCAHO and the state agencies, but in some areas there is no oversight at all." She says that is always going to be an issue unless there are consistent guidelines to follow.
"The issue is variability by state," she says, "and that’s what the OIG is getting at. Some states are very good at doing certification and reviews, and others don’t have the resources to do them in an appropriate way."
How ORYX fits in
Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, says HCFA’S new marching orders won’t have much effect on JCAHO’s ORYX project. "The new evidence-based HCFA measures probably won’t impact ORYX that much," she says. "Probably some hospitals have selected those measures already. The only issue I have is that those HCFA measures primarily address the Medicare population, where the JCAHO measures look at all patients and their processes." Some of the ORYX measures are based on the Medicare Provider Analysis and Review Files data, but the initiative covers all patients, whereas the HCFA measures look primarily at Medicare patients.
"I hope HCFA’s performance measures will be complementary to JCAHO’s," says Surpin.
"The Joint Commission probably would like this to work in sync with its ORYX project," comments Spath. "It’s too soon to say, but either the federal government is saying that it has measures it’s been testing for many years and is going to impose those measures on hospitals, or HCFA and the Joint Commission collaborated on the measures all along — HCFA wrote the regulations to match JCAHO’s measures." She says she thinks HCFA is aware that the confidentiality of data that go to the Joint Commission is not protected by federal statute, and HCFA is trying to acquire that information so it can become more accessible to the public.
The new survey path OIG is recommending shouldn’t be too startling to the Joint Commis sion. "That’s essentially where JCAHO is going with its ORYX initiative," Spath points out. "What JCAHO eventually wants is to have performance data as a piece of the accreditation decision," she continues. "Right now, the accreditation process relies upon a facility having a process in place to collect information, and the answer to that factors into accreditation decisions. JCAHO’s goal with ORYX is to use that data to make a judgment about accreditation.
"The Joint Commission should be pleased to see this latest move," Spath says. "Its new core measures look somewhat like the areas covered by the new HCFA measures."
Collegiality under fire, but standards needed
Looking at the entire hospital review system, the OIG report takes aim at what it calls a shift toward a collegial mode of oversight, with its hallmarks of education and quality improvement, rather than a regulatory mode, which focuses on investigation and enforcement of minimum requirements. According to Surpin, we don’t need more regulation, but there should be a common set of standards to which everyone adheres. "I didn’t take the OIG findings to mean that necessarily we need additional regulatory oversight," she says. "It’s that what’s in place is not being adhered to. It’s about the administration of the standards already in place. We should have a minimum set of standards that should be adhered to equally across all hospitals in the country. There’s too much variability in administering those standards on a state-by-state basis. That’s the issue."
Spath also questions a return to a regulatory mode of oversight. "I don’t know if any inspection or survey process actually yields better patient care — whether the addition of more regulation necessarily yields better quality," she says. She notes that HCFA is riding on public fear about the quality of care when it is better than it ever has been, and that politicians routinely create a crisis and then present the public with a savior.
"The perceived crisis now is quality of patient care, but that crisis was created by the federal government," she says. "Now HCFA is coming in and saying, We’re going to save you. All we need is another bazillion dollars to do it.’
"The quality of the process of health care in this country is one of the best in the world," Spath says. "It got there, yes, because of money, but also because of oversight by the Joint Commission. The concept that we need to return to a more regulatory environment seems out of date. VA hospitals and other federal institutions such as military facilities are approved by JCAHO, but also have regulatory oversight by the federal government. Is their quality of care better than that at hospitals that don’t have that regulatory oversight? No. Adding that regulatory piece is not necessarily ensuring that the quality will be better. More regulation doesn’t result in better patient care."
Public accountability, on the other hand, she says, could yield better quality. "Because car manufacturers are sued for substandard products," she says, "they are very careful to make sure their products measure up. They have been held publicly accountable for a quality product." The OIG report, in recognizing the efficacy of this means, directs HCFA to increase public disclosure of the performance of hospitals, the Joint Commis sion, and state agencies. At a minimum, HCFA should post more detailed information on the Internet, states the report.
Increased expenditures of time and money will be the chief fallout from the report’s recommendations for quality professionals, Spath thinks. "This adds one more thing that quality directors have to be concerned about," she says. "Added regulation and public accountability come with a cost. More dollars will have to be spent to meet new regulations at a time when funding to hospitals is being cut. This is a rough time to put additional burdens on hospitals."
How to proceed
Spath reiterates her advice to quality professionals to continue doing the right thing. "Measure and constantly improve quality. New mandates may cause you to focus your attention on areas where you didn’t intend to focus it. When you set your quality improvement goals for the upcoming year, they may have to be related to certain topics. But if you have good-quality patient care, it shouldn’t matter what charts surveyors pull. If you have good-quality patient care, it shouldn’t matter if they walk in tomorrow unexpectedly for an inspection."
She says the biggest frustration quality managers have now is that a lot of things they are doing seem to have no meaning, and increased oversight may be adding one more meaningless piece to what they are already doing.
"HCFA has been given a lot of power recently by Congress," says Spath. "The agency is riding on its successes in fraud and abuse in billing practices." She says this is one more example of the federal government moving the industry toward where they wanted it to be back when proposals for national health care were introduced: total control by the federal government. Spath reminds us that these spates of reforms are cyclic. Hospitals have moved from a prescriptive requirement to a flexible requirement.
She says, "We went from Thou shalt do surgical case review’ and Thou shalt do 20% chart review’ to a mandate to Improve the quality of care of your surgical patients. You define how you will do that.’ The IRS form does not say, Fill this out however you want, as long as you meet the intent.’ The IRS is prescriptive because in order to measure something you have to have defined standards. The federal government has realized that without some prescription it is hard to ensure that certain processes are in place. CoPs are prescriptive — they tell us to have the history and physical on the medical record within 24 hours."
It is easier to train a surveyor to check for specifics like those than to check for how well staff are working together as a team and how well they are prioritizing. "JCAHO had influence in promoting flexibility in the new CoPs," says Spath, "but even JCAHO has moved lately toward more prescription because they realize it’s hard for a surveyor to see how you’re doing when there’s no clear definition of what you’re supposed to do."
ORYX is a good example, she says. The initiative requires hospitals to pick whatever measures are important to their facility and pick whatever vendor suits their needs. "But we get inaccurate, unmeaningful data because of that," she says.
HCFA cannot be accountable to the public when the regulations become so flexible no one can measure them. "HCFA says it has directed state Peer Review Organizations [PRO] to develop new evidence-based quality measures that will provide benchmarks for hospitals," says Spath. "The agency says it is now relying on PROs to be the watchdogs, but the PROs have moved to a collegial mode, too."
PROs are involved in comparative data studies for hospitals at the state level — cesarean rates, beta-blocker usage, and so on — with their Cooper ative Cardiovascular Project and other initiatives. They present benchmarks and challenge hospitals to improve their numbers. These nonprofit organizations have been around since the early ’70s as an oversight arm for HCFA at the state level.
Spath concludes that collegial’ doesn’t really describe the trend of JCAHO. "Flexibility’ describes it better. The OIG would have us move back toward a more prescriptive model because there’s no other way to have a standard process in place. The ideal would be to reach a happy medium between flexibility and prescription."
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