Hospitals that fall under the glare of public scrutiny after allegations of poor patient care have more to worry about than blaring headlines. After the cameras and reporters leave, in steps the Joint Commission.
As a number of high-profile hospital incidents illustrate, inspectors from the healthcare accrediting agency appear within days at the hospitals' doors, seeking answers to what went wrong.
The question hospitals have is this: Are surveyors there to help or to grab publicity for the Joint Commission on Accreditation of Healthcare Organizations, which is under contract with the government to monitor hospital care?
In recent years, such institutions as the University of Kansas Medical Center in Kansas City, Dana-Farber Cancer Institute in Boston, and University Community Hospital in Tampa, Fla., have all gotten visits from the JCAHO after newspapers publicized patient-care accidents.
Last week, prestigious Rush-Presby-terian-St. Luke's Medical Center in Chicago was added to the list after allegations about its heart transplant program appeared in the Dec. 12 issue of the Wall Street Journal.
The article alleged that inappropriate procedures were performed under pressure from hospital administrators who wanted to push up the volume of transplants done by the 816-bed teaching hospital. Six days after the story broke, JCAHO surveyors were crawling all over the transplant department.
"What our evaluation will do is identify any weaknesses that do exist in patient care and management processes," said Richard J. Croteau, M.D., JCAHO vice president of accreditation services, speaking generally about the agency's inspection policy.
After a highly publicized patient accident, the JCAHO dispatches a special team to find out whether a so-called "sentinel event" has occurred. The JCAHO defines a sentinel event as "an unexpected occurrence, involving death or serious physical or psychological injury or risk thereof."
At Rush, public relations director Carolyn Reed said: "We're more than willing to cooperate fully with the Joint Commission, and that's all we want to say at this time." Reed said the hospital was confident the Joint Commission would find everything in order.
The role of the JCAHO in such instances has at times been called into question. So have its motives.
Often, state and federal health regulators conduct their own investigations of what went wrong. In that case, hospital executives wonder, what value does a JCAHO inspection add to the mix, particularly if a hospital has just passed a regularly scheduled survey? While some hospital officials who have lived through the nightmare say their hospitals are better off for the experience, many feel betrayed by an organization whose board is controlled by provider groups and whose accreditation services they voluntarily pay for.
"Those are precisely the questions we're trying to answer," said Lance Helgeson, publisher of Inside the Joint Commission, a newsletter.
In the newsletter's July 29 issue, Helgeson described an adverse medical incident at Anne Arundel Medical Center in Annapolis, Md., and the JCAHO's response.
The hospital had been fully accredited in 1992 with no Type I recommendations, which are the most serious infractions of the JCAHO quality assurance standards.
"In April 1995, four months after the hospital discovered the error on its own, the JCAHO paid an unannounced visit and lowered Anne Arundel's accreditation status to conditional, despite the fact that the hospital had already corrected the deficiencies it found," Helgeson wrote. The JCAHO later restored the hospital's full accreditation status.
Likewise, a follow-up visit by surveyors to Illinois Masonic Medical Center in Chicago after a highly publicized series of patient accidents elicited an angry denunciation of the agency's tactics and motives from the hospital's late president, Gerald Mungerson (See graphic, p. 16).
In a letter to the
JCAHO board, Mung-erson said, "To characterize them (JCAHO surveyors) as hatchet men/women would be kind. They made us feel as if this was the worst hospital they had ever set foot in."
In April 1995, the JCAHO decided to revoke the accreditation of University Community Hospital in Tampa after it was disclosed that a surgeon at the hospital amputated the wrong leg of a patient two months earlier. About a year before to the incident, which received national media attention, the hospital received a near-perfect score on its JCAHO accreditation survey.
In a letter to MODERN HEALTHCARE, University's President and Chief Executive Officer Norm Stein suggested that the incident at the hospital gave the JCAHO a vehicle to improve its "image and credibility problems." The hospital appealed the JCAHO's decision and got its full accreditation status back.
In September, however, and partly in reaction to criticism that its actions appeared punitive and publicity-hungry, the JCAHO changed its policy.
Now, when sentinel events occur, the JCAHO places hospitals on "accreditation watch" while surveyors examine what went wrong and what can be done to prevent similar mistakes. Previously, such sentinel events could lead to "conditional accreditation," which is tantamount to probation.
The JCAHO launched its conditional accreditation program in 1989 after it was the subject of a Wall Street Journal expose that criticized the agency for accrediting hospitals with serious quality problems. Prior to the program, the names of hospitals with quality problems were confidential, and they maintained their full accreditation status while they cleaned up their acts.
The expose prompted a congressional investigation of the JCAHO, which has "deemed status" with the Medicare program. Hospitals that are accredited by the JCAHO automatically qualify for the Medicare program without going through a separate inspection by federal health regulators. Despite the article and investigation, the JCAHO maintained its deemed status but began launching a series of initiatives aimed at improving its hospital oversight activities and making the results of those activities public.
Here is how the new accreditation watch process works, according to Paul Schyve, M.D., the JCAHO's senior vice president: An incident comes to the attention of the JCAHO's complaint unit through media stories, patient letters, employee or physician complaints or hospital self-notification.
The JCAHO also uses a newspaper and magazine clipping service to learn about alleged cases of improper care.
If the report appears credible, it is forwarded to the executive vice president of accreditation operations, Charles Bair. In consultation with senior staff, he determines whether it meets the definition of a sentinel event. If so, staff makes the hospital's chief executive officer aware the JCAHO is looking into the matter and intends to visit.
"That usually occurs within a few days. We schedule it as quickly as we can," Schyve said.
The on-site visit has two purposes: To ascertain the facts of the event, and to consider whether the organization "could be reasonably construed to have had control over the circumstances that led to the event," according to the JCAHO policy.
"The word is `could' not `should,' " Schyve pointed out. "The question is not what they should have done, but is there something they could have done?" The JCAHO doesn't want to place blame or apportion responsibility, according to Schyve. Rather, it wants to examine systems and processes that may underlie what happened.
If the surveyor finds a sentinel event occurred, the organization is asked to do a "root-cause analysis" within 30 days and to submit a report to the JCAHO. It retains its previous accreditation status but is placed on accreditation watch. Conditional accreditation has been dropped because it was perceived as punitive and it made everybody too defensive, Schyve said.
There is one key difference. Under the old policy, the accreditation committee, which is a group composed of outside hospital and medical experts, determined whether hospitals were conditionally accredited or put on probation. In the replacement policy, the JCAHO's staff determines whether to place hospitals on accreditation watch.
Like the conditional accreditation program, the names of hospitals put on accreditation watch are public, although the survey information that led to the determination is not.
Since September, seven hospitals have been placed on accreditation watch. One has since been removed. The agency will keep a database to learn what kinds of errors are cropping up most frequently, and how hospitals change their processes to avoid them.
The JCAHO is not in a position to question medical judgments, Croteau underlined.
"We don't second-guess their medical decisions. We evaluate the process by which they reach those decisions," he said.
Two hospitals that went through wrenching patient-care incidents in 1995 thought the JCAHO played a constructive role in the aftermath.
Dana-Farber Cancer Institute was placed on conditional accreditation after a patient died from a quadruple overdose of chemotherapy drugs. The JCAHO issued a report in spring 1995; the hospital was in compliance by fall and received accreditation with commendation-the highest level of accreditation possible-at its triennial survey in June 1996.
"Dana-Farber without exception believes that having the Joint Commission here helped," said Jim Conway, chief operations officer.
The hospital made fundamental and wide-ranging changes in policies and procedures, and now intends to make the study of medical errors part of an applied research program, he said.
Conway advises hospital executives not "to get into combat with regulatory agencies, be it the Joint Commission or HHS. The Joint Commission can be extremely effective in helping organizations figure out what happened and how to improve."
The JCAHO fully accredited University of Kansas Medical Center in August 1993. But in May 1995, the Kansas City Star revealed that the facility was admitting patients for heart transplants but rejecting most of the donor hearts for administrative or nonmedical reasons.
The JCAHO's visit a month later resulted in a series of recommendations for the heart-transplant program.
However, the university decided not to resume transplanting hearts, so the recommendations were moot.
At the post-incident visit, said Tom Valuck, M.D., KU's associate hospital administrator, "The surveyors were pleasant and fair. That's the way they always are, at least in my experience."
But he did not find all the recommendations necessarily appropriate or useful. "I don't think hospitals ever agree with the recommendations they get on a survey, quite frankly," he said.
Meanwhile, Rush executives reacted vigorously last week to contradict the Wall Street Journal report.
In an open letter dated Dec. 16, Leo M. Henikoff, M.D., Rush president and chief executive officer, said the article contained "many inaccuracies and serious omissions of important facts." Rush reiterated its threat to sue the Journal for defamation, but at deadline had yet to do so.