JCAHO’s one concession: Will start doing truly unannounced surveys
Despite OIG’s criticism, Joint Commission unlikely to change its ways
Sensing blood in the water following the release of a four-part government report decrying the sorry state of hospital accreditation, critics of the Joint Commission on Accreditation of Healthcare Organizations are pushing harder than ever for fundamental change in how the commission does its work. But if Joint Commission officials are worried, they aren’t showing it: Weeks after the release of the Health and Human Services’ Office of Inspector General’s (OIG) damning report, the commission has changed virtually nothing, with one exception. The organization says it intends to implement totally unannounced surveys as part of the small percentage of random surveys it conducts.
Paul Schyve, MD, senior vice president at the Joint Commission, says, "It’s fair to say" that the Joint Commission isn’t likely to launch many new initiatives in direct response to the OIG report, which was released July 20. "What we’ve done is look at what we were already working on and compare those things to the OIG recommendations," Schyve says. "For each of the recommendations, we were able to identify something that we’re working on. We had already identified all of the issues the OIG has identified and are working in our way to address those issues." (One OIG recommendation, random pulling of records, started several months ago. See related story, p. 151.)
The Joint Commission’s critics say its tepid response to the OIG report is consistent with its historical unwillingness to bend to outside forces. "For lo these many decades, the Joint Commission has ridden through one [presidential] administration after another, but those changes didn’t have much of an impact on what JCAHO is doing. Nothing seems to have an impact on what JCAHO is doing," says Sidney Wolfe, MD, director of the Health Research Group at Public Citizen in Washington, DC, a consumer advocacy group. "They have plans and have said they have all these new things in the offing. They’re always saying that, but what is it that they’re really doing?"
In the wake of the OIG report, the Joint Com-mission has moved decisively to change only one policy — to make its "random, unannounced surveys," which account for 5% of all the surveys it conducts, truly unannounced. Although the change happened after the release of the report, it was in the works long before that and not a direct response to OIG criticism, Schyve says.
In the past, Joint Commission surveyors gave hospitals at least 24 hours warning before showing up to conduct an "unannounced" survey, so that the hospitals could make sure appropriate personnel were in place to answer questions during the survey process. Schyve admits, however, that there were problems with the old policy. "Quite frankly, while you didn’t know for sure if you were going to get [a random survey], you did know a couple of things," he says. "First, if you were going to get one, you’d get it at about the 18-month mark because they occurred in the middle of the cycle. So you knew when to worry about it. Second, we focused those surveys on areas that, as a whole, organizations had had difficulty with the previous year. So you knew what the surveyors were likely to focus on."
Because the random, unannounced surveys were, in fact, announced on short notice and predictable in certain ways, they limited the ability of surveyors to uncover certain things "going on in the organization that maybe even the hospital was not aware of," he says.
With the policy change, no notice will be given whatsoever before a random survey commences, Schyve says. Surveyors will simply walk in, show their credentials, and get to work. Also, instead of always taking place at the 18-month mark, random surveys can occur anywhere from nine months to 30 months into the triennial survey cycle. They won’t occur sooner than nine months because many organizations remain in contact with the Joint Commission anyway for the first several months after a scheduled survey in an effort to address specific recommendations. "During that time period, we already know something about what’s going on in the organization," he adds.
The content of the unannounced surveys will also change to become less predictable, Schyve notes. While the surveys will continue to focus in part on certain predetermined areas, such as credentialing, the surveys will devote more time to issues specific to the organization being surveyed. "For example, what were the areas where they had Type 1 recommendations [in their previous survey]?" he asks. Surveyors will also pay more attention to complaints received about the organization as well as sentinel events.
Wolfe, for one, says he is not impressed by the Joint Commission’s decision to amend its policies for random surveys. "They make it sound as though a major victory has been won for people who think hospitals should be regulated, but all that’s happened is they’ve stopped lying," Wolfe says. "Now the so-called unannounced inspections are really going to be unannounced. Fine, but that doesn’t do anything about the other 95% of surveys, which will continue to be announced weeks or months in advance."
Joint Commission spokeswoman Janet McIntyre says her organization has no plans right now to increase the percentage of random, unannounced surveys beyond 5%.
Although the Joint Commission hasn’t made wholesale changes as a result of the OIG report, some industry observers remain concerned that it is creeping toward becoming more of a regultory body and abandoning its traditional collegial approach toward hospitals. Richard Wade, senior adviser for communications at the Chicago-based American Hospital Association (AHA), says he is particularly disturbed that industry groups were largely shut out of the decision-making process that led to the policy shift on unannounced surveys.
"We had been talking to the Joint Commission all along about how you implement this — if you reduce notice to four hours or 16 hours or whatever," he says. "We even put together a special advisory committee at the request of the Joint Commission to be a sounding board for the different proposals." The Joint Commission had also agreed to consult liaisons from state hospital associations in coming up with a new unannounced survey policy, Wade adds. "But the Joint Commission didn’t avail themselves of those two mechanisms. We had also been led to believe there might be a pilot test of this before it was implemented," but that didn’t happen, either. "We were very disappointed with the process," he says.
Schyve stresses that the Joint Commission will attempt to preserve its traditional collegial and education-oriented approach, while at the same time serving effectively in a regulatory capacity. "We want to have a collegial approach to help the organization get better," he says. "And we also want to have a regulatory approach that says, Look, if somebody really isn’t doing the right thing or refuses to do the right thing and harms patients, we have the ability to act.’ We need a balance between those approaches."
Schyve compares the Joint Commission to a general practitioner, with hospitals as its patients. "We would want our doctor to take a collegial approach to help us do better," he says. "But we would also expect our doctor do whatever was necessary to get a true, accurate picture of our physical functioning. If I thought my physician was superficial in his or her evaluation of me or was making a superficial diagnosis, I’d soon go to another physician."
Wolfe notes, however, that most patients aren’t attempting to hide their condition from their doctors. He suggests a different example. "What if the police announced to the burglar community, or any community of people considering breaking laws, that they’re going to show up a month from now, but until then you can do whatever you want? And when they do show up, they’re only going to want to look at certain things, and you can pick out what those things are? That’s very collegial."
Most experts argue, however, that the collegial vs. regulatory issue, which is at the heart of the OIG report, isn’t so simple. Judy Homa-Lowry, RN, MS, CPHQ, president of Homa-Lowry Healthcare Consulting in Canton, MI, and an occasional consultant with the Joint Commission’s consulting arm, says there are ways to achieve an effective balance between the two approaches when conducting surveys. "The Joint Commission has the job of making sure patient care standards are in place," she says. "That doesn’t mean surveyors can’t be helpful, educational, and consultative, but their primary role needs to be ensuring that the standards are adhered to."
Wade adds that how the Joint Commission ends up handling the collegial vs. regulatory debate could affect the very future of voluntary accreditation. "If the Joint Commission continues to appear to the public and the government as being weak and ineffectual, then somebody will get the idea that it ought to be replaced with something completely regulatory in nature," he warns. "But if they go too far the other way, then hospitals will lose the desire to be supportive and cooperative with the Joint Commission as a quality improver. It’s going to be a delicate balancing act."
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