When inspectors investigate serious adverse events at hospitals, they should keep a tight focus on patient-care quality issues, and disclosing the investigation results to administrators and accreditation agencies, a review from HHS' inspector general's office concluded.
In particular, inspectors should also do a better job of communicating the exact nature of their investigations to hospital administrators, while also taking care not to disrupt any ongoing efforts begun internally by hospitals to address the deficiencies being investigated.
Those were among the key recommendations in a 49-page report titled Adverse Events in Hospitals: Medicare's Responses to Alleged Serious Events released Nov. 1 by HHS Inspector General Daniel Levinson's office.
The report is one of several that have followed a 2008 study by the inspector general's office that estimated as many as 25% of all Medicare beneficiaries were harmed during hospital stays in October of that year, including 13% that involved a prolonged hospital stay, permanent harm, life-sustaining intervention or death.
Although the recommendations in the latest report are addressed to the CMS, the message is equally intended for review by state inspectors. The Social Security Act requires the CMS to contract with state investigators to look into allegations of improper care or treatment that could result in a citation to the hospital for not complying with Medicare's conditions of participation rules.
“The complaint process, therefore, represents a key part of the CMS' patient-safety system because it is a potential resource for identifying and responding to adverse events,” the report says.
One of the key recommendations in the report is, when inspectors come in to assess a healthcare provider's compliance with Medicare's conditions of participation after a complaint of an “immediate jeopardy,” they should limit their investigative focus exclusively to the incident itself and Medicare's quality assessment and performance-improvement condition.
That conclusion was based on the results of an intensive study of 95 incidents that resulted in immediate jeopardy complaints being filed against hospitals. Those are the most serious events, requiring inspections within two days. The five most common types of immediate jeopardy never-events were sexual assaults, medication errors, physical abuse by staff, restraint problems and suicide, the study found.
Auditors concluded that even though half of the inspections included evaluations of between two and seven Medicare conditions of participation, fewer than half of the inspections included a review of Medicare's quality-related conditions of participation.
Central to this condition of participation “is the idea that the hospital should take responsibility for improving its performance rather than relying on the survey process and the threat of punitive actions,” inspector general's auditors wrote.
A response from the CMS said the agency will increase the prominence of quality conditions of participation in its inspections following immediate-jeopardy complaints and explore ways to improve its communications with accrediting agencies following inspections.
Although such inspections could be a source of feedback for hospitals on ways to improve quality, inspectors are not always forthcoming with information. Of the 95 hospitals surveyed for the report, 16 reported that they first learned of the complaint when state agency inspectors arrived at their facilities.
Hospital staff “had trouble” identifying the exact nature of the complaints in 27 of the incidents, and in three cases, administrators said they never did find out why inspectors had arrived.
About two-thirds of hospitals had already begun reviewing the incidents internally by the time inspectors began their surveys, and in some cases administrators said the state inspectors actually delayed their own responses to the incidents, such as staff training. But at the same time, hospitals said they appreciated how the inspectors' presence added urgency their own reviews.
The inspector general's office noted that accreditation experts with the Joint Commission received notice of only eight of the 88 incidents that took place at hospitals it accredited. In a response, the CMS said it notified the commission of 28 of 88 events at hospitals accredited by the Joint Commission.
