Wednesday, July 21, 2004

JCAHO hit in GAO report for CMS.

If you can understand the title of this post without a translator, you're a true health-law nerd!

As the Associated Press reports today (courtesy of the Indianapolis Star), the Government Accountability Office (GAO (formerly the "General Accounting Office")) has filed a report that is extremely critical of the performance of the Joint Commission for Accreditation of Healthcare Organizations (JCAHO (formerly the Joint Commission for the Accreditation of Hospitals)) in its role as the designated Medicare accreditation-surveyor for the Centers for Medicare and Medicaid Services (CMS (formerly the Health Care Financing Administration). (The link to the GAO report is probably not a stable address; if it stops working, try here.)

The report includes the following:
JCAHO’s pre-2004 hospital accreditation process did not identify most of the hospitals found by state survey agencies in CMS’s annual validation survey sample to have deficiencies in Medicare requirements. In comparing the results of the two surveys, CMS considered whether it was reasonable to conclude that the deficiencies found by state survey agencies existed at the time JCAHO surveyed the hospital. 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 deficiencies in Medicare requirements. Of these 157 hospitals, JCAHO did not identify 78 percent (123 hospitals) as having deficiencies in Medicare requirements. For the same validation survey sample, JCAHO also did not identify the majority -- about 69 percent -- of deficiencies in Medicare requirements found by state agencies. Importantly, the number of deficiencies found by validation surveys represents 2 percent of the 11,000 Medicare requirements surveyed by state agencies in the sample during this time period. At the same time, a single deficiency in a Medicare requirement can limit the hospital’s capability to provide adequate care and ensure patient safety and health. Inadequacies in nursing practices or deficiencies in a hospital’s physical environment, which includes fire safety, are examples of deficiencies in Medicare requirements that could endanger multiple patients.

The potential of JCAHO’s new hospital accreditation process to improve the detection of deficiencies in Medicare requirements is unknown because the process was just implemented in January 2004. JCAHO plans to move from using announced to unannounced surveys in 2006, which would afford JCAHO the opportunity to observe hospitals’ operations when the hospitals have not prepared in advance to be surveyed. In addition, the pilot test of the new accreditation process was of limited value in predicting whether it will be an improvement over the pre-2004 process in detecting deficiencies. Limitations in the pilot test included that hospitals were not randomly selected to participate; that observers from JCAHO accompanied each surveyor, thus possibly affecting surveyors’ actions; and that JCAHO evaluated the results instead of an independent entity.

CMS has limited oversight authority over JCAHO’s hospital accreditation program because the program’s unique legal status effectively prevents CMS from taking actions that it has the authority to take with other health care accreditation programs to ensure satisfactory performance. For example, requiring JCAHO’s hospital accreditation program to submit to a direct review process or placing the program on probation while monitoring its performance. Further, CMS relies on a measure to evaluate how well JCAHO’s hospital accreditation program detects deficiencies in Medicare requirements that provides limited information and can mask problems with program performance, uses statistical methods that are insufficient to assess JCAHO’s performance, and has reduced the number of validation surveys it conducts.
The AP story provides a little more detail:
Many of the overlooked problems related to fire safety, while others involved substandard care.

In a Texas hospital, a patient died after receiving a double dose of narcotics in the emergency room. A California hospital lacked "a sanitary environment to avoid sources and transmission of infections and communicable diseases and failed to develop a system for ensuring the sterilization of medical instruments," the report said.
Predictably, JCAHO isn't pleased with the report:
Commission President Dennis O'Leary 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," O'Leary said in response to the GAO report.
What the AP story doesn't say (and I can't find it in the GAO report, either) is that in the 20+ years JCAHO has been in the "deeming" business with CMS, a few provisionally accredited hospitals have been denied full accreditation, but no fully accredited hospital has ever lost its accreditation. (If any reader can cite me an example that disproves this statement, I'd love to see it.) Long viewed as a toothless tiger by many in the industry, JCAHO ought to feel the sting of this GAO report. And, as denials go, President O'Leary's face-saving comment that "we're better than that now" isn't much of one.

2 comments:

Anonymous said...

Kaiser Fresno (Calofornia) Hospital (Kaiser Permanente / Health Plan) is about to undergo the first in a series of northern California Kaiser Hospital triennial accreditation visits by JCAHO (beginning 9/01/2004). Key staff involved in orchestrating the active concealment of serious patient safety hazards and deficiencies have said that they believe that they have nothing to worry about because:

1) JCAHO is only conducting superficial surveys in 2004, as even the "seasoned" surveyors do not fully comprehend the new "Tracer" process being introduced by JCAHO

2) JCAHO will overlook anything that occurred prior to the days and years that they are on the premises, since they no longer delve into the records of patients who are not present on the actual dates of the survey or Significant Events (incident reports) that they are not told about voluntarily --- allowing massive coverup activities to occur.

3) There has been a massive effort to coach staff over the past two months to learn how to respond to JCAHO surveyors; learnings which are unliikely to be more than superficial and to revert to the norm as soon as JCAHO leaves.
4)Staff have also been screened, and a plan made to help ensure that any staff who would be likely to offer true disclosure to JCAHO surveyors about what has been occurring,in direct violation of JCAHO patient safety and other standards over the past three years, will simply not be available on the dates of the upcoming survey.

5) Massive efforts have been instituted in July and August 2004, to coach physicians, nurses, and other personnel on how to answer JCAHO surveyor questions, involving the memorization of actual "scripts," allegedly based upon insider information derived from sources at JCAHO.

6) Kaiser REGIONAL administrators and in-house consultants have been busy creating documents that did not previously exist, to convince the JCAHO surveyors that patient safety requirements were met in 2001, 2002, and 2003 --- when in fact, this is not true.

7) Quality Department staff have been actively engaged in creating data when it was absent, in an effort to "prove" that all required data was collected and analyzed. Kaiser leaders have convinced the Quality Department staff that they are not really fabricating data, but merely "extrapolating" from what little existed.

8) Everyone has been threatened either directly or indirectly by Kaiser administrators and leaders, that if Kaiser Fresno does not pass the JCAHO survey, that there will be consequences such as terminations and layoffs, due to the financial consequences of a failed or provisional JCAHO accreditation. (Even the unions have bought into this strategy, fearing they could not prevent layoffs.)

9) Most Important: Kaiser officials have been heard claiming that the 2004 JCAHO survey is a "sure thing," because the lead JCAHO Surveyor, Inez Kennemore R.N., happens to be a close friend of Kaiser Northern California's Regional Director of AR&L (Accreditation, Regulation, and Licensing), Cynthia Hartman R.N.; a relationship established when Hartman and Kennemore were both working for JCAHO as surveyors. Hartman was specifically hired by Kaiser to leverage her former relationship with JCAHO to the advantage of Kaiser during future JCAHO surveys.

The GAO findings in regard to the poor performance of JCAHO is of the utmost relevance in regard to the upcoming JCAHO surveys of multiple Kaiser Permanente hospitals throughout northern California. Without adequate pressure brought to bear on JCAHO, it would not be suprising that superficial surveys are conducted, missing entirely or in large part, any serious infractions impacting patient safety and quality-of-care standards. WHATEVER OCCURS IN FRESNO, WILL SET THE TONE FOR ALL OF THE SURVEYS CONDUCTED AT KAISER HOSPITALS IN NORTHERN CALIFORNIA BY JCAHO. --- Kaiser is counting on it!

Anonymous said...

I have written to Dr. O'Leary, president JCAHO, regarding care at a local Kaiser Hospital which I believe is below the standard of care. I would like to collect patient experiences which are also below the standard of care. Dr. O'Leary has never responded to my letters. I believe there is much amiss in the Kaiser organization.
It would be helpful to collect records of poor care. Documentation is essential. Names of the patients can be removed.