Friday, July 23, 2004
One of the most stressful times around a hospital is when the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) makes their triennial visit. Medical staffs have many more meetings, administrators stay busy teaching the staff to recite the "mission statement" on demand and the maintenance crews stay busy painting everything. It is felt by many to be annoying and intrusive. The surveys are tolerated mainly for two reasons: 1. Medicare funding is dependent on passing a survey and 2. It promotes patient safety. While the former is most assuredly true, the same cannot be said about the latter. From MSNBC: Hospital inspectors miss 'deficiencies'.
The private organization that clears hospitals to receive Medicare payments missed most problems later identified by state inspectors, potentially compromising patient safety, congressional investigators said Tuesday.It seems that while JCAHO can determines if a hospital participates in Medicare or not, the Center for Medicare Services (CMS) is forbidden by statute to set the conditions for JCAHO approval. CMS contracts with various state agencies to provide validation of JCAHO's methodology. From the GAO report (PDF):
The Joint Commission on Accreditation of Healthcare Organizations, made up mainly of health professionals, failed to find 167 of 241 serious deficiencies in a survey of 500 hospitals that were reviewed between 2000 and 2002, the Government Accountability Office said. The agency, Congress investigative arm, was formerly called the General Accounting Office.
JCAHOs pre-2004 hospital accreditation process often did not identify either hospitals with serious deficiencies or the individual serious deficiencies found by state survey agencies through CMSs validation program. In a sample of 500 JCAHO-accredited hospitals, state agency validation surveys conducted in fiscal years 2000 through 2002 identified 31 percent (157 hospitals) with serious deficiencies; of these, JCAHO did not identify 78 percent (123 hospitals) as having serious deficiencies. For the same validation survey sample, the majority of the serious deficiencies state survey agencies identified but JCAHO did not were in the physical environment COP category, which covers fire safety and prevention.In referring to the tables the percentage of "serious" deficiencies missed by JCAHO that were found by the state inspectors are falling, from a high of 85% in 2000 to 61% in 2002. Most of the issues were physical plant related:
Of the 167 serious deficiencies identified by CMSs validation program from fiscal year 2000 through 2002 but not detected by JCAHO, 87 were related to a hospitals physical environment, which includes life safety code standards on fire prevention and safety.Not surprising since I have yet to meet a fire Marshall or a building inspector on a JCAHO survey team. But JCAHO gets low marks on patient-care related items as well. The first column is the number of events found by state inspectors, the second column is those that JCAHO missed:
So deficiencies were found in things that are the big targets of a JCAHO survey : QA, nursing services and medical records. They did do well on "medical staff" issues, which from personal experience has a heavy emphasis on the credentials process.Physical environment 107 87
Quality of care
Anesthesia services 3 2
Discharge planning 2 2
Emergency services 2 2
Food and dietetic services 5 4
Governing body 16 7
Infection control 15 9
Laboratory services 1 1
Medical record services 7 4
Medical staff 10 1
Nursing services 17 10
Organ, tissue, and eye procurement 5 5
Outpatient services 1 1
Patients rights 10 9
Pharmaceutical services 14 9
Quality assurance 18 8
Radiologic services 1 0
Rehabilitation services 1 1
Respiratory care services 1 1
Surgical services 5 4
Total quality-of-care COPs 134 80
The folks at JCAHO do not take kindly to the findings:
Commission president Dennis OLeary said his group made sweeping changes to the accreditation process earlier this year. In our view, it is irresponsible to alarm the public using statistics that have little meaning, OLeary said in response to the GAO report.This is a reference to the "new" survey procedures. The GAO is reserving judgment:
The potential of JCAHOs new hospital accreditation process to improve the identification of serious deficiencies is unknown because it is too soon after its January 2004 implementation for a meaningful evaluation; in addition, JCAHOs testing of the new process was limited. CMS has not had the opportunity to complete its validation program for 2004 to determine whether JCAHO surveyors using the new process are missing serious deficiencies later identified by state agency validation surveys. While unannounced surveys, which are planned for implementation in 2006, have the potential to improve the detection of serious deficiencies, other features of the new process that JCAHO did not test before implementation may have imitations that could affect the potential of the new process to identify problems with patient care. JCAHOs pilot test of the new process had limitations, including using a ample of hospitals that volunteered for the pilot instead of using a random sample and self evaluating the results instead of using an independent entity.
So what does this mean?
Life will become more difficult for JCAHO. There will be pressure on congress to pass a law to give CMS a greater role in determining JCAHO's priorities and methodology. JCAHO may be able to put it off for a few years given the fact they have changed the way they conduct a surveys and the initiation of unannounced visits in the next few years. I am sure that those results will be scrutinized.
Either to comply with, or to avoid increased government involvement the JCAHO surveys will become more intrusive. They will start crawling through basements, counting lightbulbs at emergency exits while maintaining their constant vigilance of documentation of pain as the fifth vital sign and the elimination of QHS and QD as approved abbreviations.
And since we all know what rolls downhill, this will put additional pressure on medical and nursing staffs of hospitals. With the advent of unannounced visits the hospital will essentially be at an "at war" footing at all times.
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