The president's quality commission is girding itself to wrestle with some of the slipperiest issues in healthcare today: Who should oversee and regulate healthcare providers? What kind of healthcare work force should we have? What rights and protections should patients expect?
Judging by two days of testimony and debate in Chicago recently, it will be a herculean task to sort out the answers.
The official mandate of the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry is to come up with quality standards and a bill of rights for consumers that everybody-patients, providers, payers and regulators-can live under.
President Clinton created the commission in September 1996. Its co-chairs are Labor Secretary Alexis Herman and HHS Secretary Donna Shalala.
The 32 commissioners have met several times in Washington. They are scheduled to deliver their final report to Clinton in March 1998.
The commission is more than halfway through its statutory lifespan. Its support staff has submitted many informational reports to the commissioners, and chapters of a bill of rights have been drafted. It's still not clear, however, where the group will come down on certain key issues.
"The testimony is very good and worthwhile," said Commissioner Alan Weil, former Medicaid director in Colorado. "But the commissioners need time to just go at it and find out what we really think."
A number of philosophical questions arose during consideration of the subcommittee report on the patient bill of rights.
Donald Berwick, M.D., president of the Institute for Healthcare Improvement, argued for a "visionary" role for the commission.
"If we as a committee can't set out a right as a matter of purpose and vision, then who can?" he said.
Commissioner Peter Thomas, chair of the consumer rights subcommittee, replied that the commission is trying to come up with rights that "are not out in left field but are grounded in the current system."
Commissioner Sandra Hernandez, M.D., former health director of San Francisco, said she thought "any document that allows discrimination in the private marketplace is not worth doing."
But Commissioner Phil Nudelman, president of Seattle-based Group Health Cooperative of Puget Sound, warned against the temptations of idealism. Just a few years ago he lobbied to reform Washington state's individual insurance laws. The result was that insurers withdrew from the state.
After that, Shalala joined the fray. "I think the president wants us to push the edge of the envelope," she said. "He would not have appointed a commission as distinguished as this" if he wanted it simply to reiterate what is possible under existing limitations.
Among the many topics of inquiry, oversight, accreditation and work-force quality got particular attention.
One subcommittee heard testimony from several nurses who described the effects of "the sicker and quicker environment" in hospitals. Mary Foley, a vice president of the American Nurses Association, pointed to the "amazing lack of data" on the impact of reducing nurse staffing levels in hospitals. She said hospitals don't have to reveal "their staffing levels, their mix of nursing staff or their patient outcomes." Too many decisions are being made on a short-term cost-cutting basis, she said, with no regard for patient safety.
The ANA, though, has yet to document a connection between cutbacks in nurse staffing at hospitals and an increase in adverse patient events, aside from anecdotal complaints from nurses. A government commission examined the issue, and in a report released in January 1996 said it couldn't find such a connection, either.
Patty Clark, a registered nurse in Louisville, Ky., described understaffing at Columbia Audubon Hospital. She said she tried to explain the hazards to surveyors from the Joint Commission on Accreditation of Healthcare Organizations, but they didn't take her complaints seriously. The hospital disciplined her for speaking out, she said.
The hospital maintains she was written up because she made an error in documentation of patient care. The National Labor Relations Board has a hearing pending on the dispute (Sept. 15, p. 17).
"Currently, JCAHO is a joke. Every nurse and healthcare worker knows this," Clark said. "To assure the public of quality healthcare in this country, healthcare employees must be free to report adverse conditions."
Commissioner Herbert Pardes, M.D., dean at Columbia University College of Physicians and Surgeons, was "terribly disturbed" by the "dumbing down of the system" of care. "I don't think one can be casual about low morale in a human service enterprise," he said.
The next day, Pardes asked speaker Dennis O'Leary, M.D., president of the JCAHO, whether workers in fact may speak confidentially to surveyors.
Yes, O'Leary said. "We changed our policy six months ago to allow staff at an institution to talk to surveyors in private," he said. In response to lively questioning by commissioners, O'Leary admitted that "there is probably some information we are not harvesting in our survey process." He pledged to open up JCAHO surveys to more kinds of information, although he said he wasn't ready to support statutory protection for whistleblowers inside the accredited organization.
Shalala said the JCAHO ought to consider a public hearing as part of the survey process. O'Leary said he found that "an attractive idea."
In his testimony O'Leary appealed for a widened use of "deemed" status, in which JCAHO accreditation automatically qualifies a provider for Medicare or Medicaid programs. That notion was endorsed by Commissioner Gail Warden, president of Henry Ford Health System in Detroit. The federal government "cannot keep pace with the private sector's ability to promulgate state-of-the-art standards, train and maintain surveyors and adopt technological supports to the survey process," O'Leary said.
The tension between private and public oversight got more scrutiny from other speakers and the commissioners.
Claudia Schlosberg, a lawyer with the National Health Law Program, said patients can't trust the JCAHO to guarantee quality. It isn't publicly accountable or responsive to consumer needs, she said. Private accreditation bodies like the JCAHO are no substitute for public regulation and oversight.