OIG report spurs JCAHO changes in accreditation surveys, oversight
Reports cite significant deficiencies, weaknesses in hospital oversight
A July report blasting HCFA, the Joint Commission, and state accreditation agencies for failing to ensure quality care and patient safety in hospitals has already triggered major changes in the way quality directors will do their jobs, including more frequent and unannounced surveys, random selection of records for review during those surveys, and publication of new performance measures, most probably on the Internet.
On July 20th, the Office of Inspector General (OIG) of the federal Department of Health and Human Services released four final inspection reports assessing the key roles played by the Health Care Financing Administration (HCFA), the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), and state survey and certification agencies in overseeing hospital quality. The reports, the results of a two-year study, will impact your day-to-day job. The bottom line for hospitals: The survey process will change significantly in the near future, with more frequent and more unannounced inspections.
"This development doesn’t surprise me," says Patrice L. Spath, ART, of Brown-Spath Associates in Forest Grove, OR. "I am only speculating, but these reports seem to be an indication of HCFA moving in a direction for hospitals in which they have already been moving in nursing homes and home health agencies."
Jo Surpin, president of Mediq Consulting Group in Pennsauken, NJ, agrees that the OIG’s findings were not surprising. "As health care becomes deregulated in other areas, particularly with most states no longer having certificate of need and other protective mechanisms, licensure and certification become much more important. They are the only vehicles left to protect patients." (See articles on certificate of need in Hospital Peer Review, November 1998, pp. 197-206.)
Spath says she would have preferred that the OIG concentrate on the state surveys that aren’t getting done. "These reports mean more to non accredited hospitals than to those surveyed by the Joint Commission. It’s the nonaccredited hospitals that have a real problem." Those facilities need to have more surveys and more stringent consistency from state to state. "It is really a mess out there," she says. In Spath’s view, hospitals not surveyed by the Joint Commission are in more of a crisis than those that are. "There’s a hospital in Wyoming that hasn’t been surveyed in nine years. The problem is, some states have problems getting money to do those surveys." (See more of Spath’s comments in article on p. 144.)
Overall, the reports of the OIG’s Office of Eval u ation and Inspections conclude that while HCFA’s current system of oversight — a combination of private accreditation and state certification — has strengths, it also has deficiencies that warrant serious attention. The agency, say the reports, does little to hold either JCAHO or state survey agencies accountable for their performance.
HCFA responded quickly and positively to the reports by presenting a detailed hospital oversight plan that incorporates OIG’s recommendations as well as a strategy for hospital performance measurement. HCFA’s reform efforts focused on three areas:
• An upcoming revision of the conditions of participation (CoP) for hospitals that participate in Medicare and Medicaid programs will clearly define safety priorities such as medication errors and surgery mix-ups. Final CoPs are expected to be completed by fall 2000.
HCFA has directed state Peer Review Organi za tions to develop new evidence-based quality measures that will provide benchmarks for hospitals. Under development are three performance measures: the rate of beta-blockers prescribed for patients hospitalized following myocardial infarction, mortality rates following surgery, and infection rates following surgery.
HCFA is endeavoring to provide more information to consumers and is coordinating a pilot project that is developing and distributing performance data so patients can compare quality of care among hospitals.
JCAHO’s deemed status is in peril
As administrator of Medicare, HCFA relies primarily on two types of external review to ensure hospitals meet the minimum requirements for participating in Medicare: accreditation by private entities, mainly JCAHO, and Medicare certification by state government agencies. By federal law, hospitals accredited by JCAHO are deemed to meet the Medicare hospital CoPs. About 80% of the 6,200 hospitals participating in Medicare are accredited by JCAHO; about 20% are certified by state agencies.
The OIG report states, "[T]he granting of this unique [deemed] status should not be for perpetuity, without accountability for performance." HCFA can now review the deeming authority when validation survey results reach a certain disparity rate. The OIG reports call for the agency to periodically assess whether JCAHO’s performance continues to warrant its unique deeming authority and to report its conclusions to Congress.
Letting hospital choose records for review
Key findings of the study:
• Although Joint Commission surveys help to reduce risk and to foster improvement in hospital care, they are unlikely to detect substandard patterns of care or individual practitioners with questionable skills. Quick-paced, tightly structured, and educationally oriented, the surveys provide little opportunity for in-depth probing of hospital conditions or practices. "Rather than selecting a random sample," states the report, "surveyors tend to rely on hospital staff to choose the medical records for review."
• Though state investigations offer a timely, publicly accountable way to respond to complaints and adverse events, the agencies rarely conduct routine, not-for-cause surveys of nonaccredited hospitals. In 1997, only half of nonaccredited hospitals had been surveyed within the three-year industry standard. In some cases, nonaccredited hospitals, typically in rural areas, have gone as long as eight years without a survey. Other than when a review is triggered by complaints or adverse events, nonaccredited hospitals receive little external review. Unlike nursing homes and home health agencies, there is no statutory requirement for a mandated minimum survey cycle for hospitals.
• Overall, the hospital review system has been shifting toward a collegial mode of oversight, focusing on education and improved performance and away from a regulatory mode of oversight entailing investigation and enforcement of minimum requirements. The Joint Commission, the dominant force in external hospital review, has led that shift. Both the collegial and regulatory approaches have value, but as the system increasingly tilts toward the collegial mode, it could result in insufficient attention to regulatory approaches intended to protect patients from poor care.
• HCFA does little to hold JCAHO and state agencies accountable. It obtains limited information about their oversight activities and provides little feedback about their overall performance. In dealing with the Joint Commission, HCFA is "more deferential than directive." HCFA should gather more timely and useful performance data and strengthen mechanisms to provide performance feedback and policy guidance to both the Joint Commission and state agencies.
• Public disclosure plays a minimal role in holding JCAHO and state agencies accountable because little information is made available to the public on the performance of either hospitals or the external reviewers. HCFA should increase public disclosure of the performance of hospitals, the Joint Commission, and state agencies by posting detailed information on the Internet.
The ball is in HCFA’s court
The OIG recommends that HCFA exert leadership in addressing the shortcomings by steering the hospital review processes toward a balance between the educationally oriented approaches of JCAHO and the enforcement-oriented techniques used by state agencies. HCFA also should hold both the Joint Commission and the states more fully accountable for their performance in reviewing hospitals, the oversight office says. Specifically, states the OIG, HCFA should negotiate with the Joint Commission to:
— make the "accreditation with commendation" category more meaningful or abolish it;
— determine the appropriate minimum cycle for conducting surveys of nonaccredited hospitals;
— conduct more unannounced surveys;
— introduce more random selection of records into the survey process;
— provide surveyors with more context about hospitals they are surveying;
— determine year-to-year survey priorities;
— conduct more rigorous review of hospitals’ continuous quality improvement efforts;
— enhance surveyors’ ability to respond to complaints during surveys.
In a response to the OIG’s report, Dennis S. O’Leary, MD, president of the Joint Commission, stated that JCAHO is committed to the following efforts:
— greater focus on consistency in the accreditation process;
— new toll-free consumer complaint hotline;
— emphasis on reducing the risk of adverse events;
— increased emphasis on continuous compliance with standards;
— introduction of standardized performance measures into the accreditation process;
— randomized selection of medical records, credential files, and personnel files for review during surveys;
— establishment of a Public Advisory Group to build closer working relationships with patients and those who advocate on their behalf;
— drilling down or focusing in during surveys on areas of current concern, such as Y2K issues.
(Editor’s note: The four reports are available at the OIG Web site at www.os.dhhs.gov/oig. Click on the "What’s New" link to access the reports: The External Review of Hospital Quality: A Call for Greater Accountability, OEI-01-97-00050; The External Review of Hospital Quality: The Role of Accreditation, OEI-01-97-00051; The External Review of Hospital Quality: The Role of Medicare Certification, OEI-01-97-00052; The External Review of Hospital Quality: Holding the Reviewers Accountable, OEI-01-97-00053.)
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