Employees of Columbia/HCA Healthcare Corp. are taking at face value their company's new ethics self-reporting policy. One of the company's hospitals is on the verge of losing its accreditation as a result.
Columbia North Houston Medical Center in Houston was downgraded to preliminary nonaccreditation by the Joint Commission on Accreditation of Healthcare Organizations. That is the last step before losing accreditation entirely, which could happen if the JCAHO turns down the hospital's appeal.
The JCAHO's accreditation committee took the drastic action Jan. 22 after a special on-site evaluation Dec. 9 confirmed that records had been falsified in preparation for the hospital's regularly scheduled accreditation survey in July 1997. After that survey, Columbia North Houston received accreditation with commendation.
The ensuing scandal cost the jobs of hospital Chief Executive Officer Mel Bishop, its medical records director and another midlevel manager.
The initial report came in November from an anonymous Columbia North Houston employee, who called the company's ethics hotline, which was set up last year after federal authorities started raiding Columbia facilities for documents and indicting company officials.
The tipster alleged that the dates of medical record transcription were being changed to fall within the Joint Commission's accepted guidelines. For example, for a surgical procedure that took place in July, the record actually might have been dictated in October, but the date was changed back to July. This made the delinquent record count look better than it actually was.
Computer tapes in Columbia's Nashville headquarters suggested that there might be truth to the allegation. Columbia assembled an investigative team and went into the hospital.
"The investigative team was able to substantiate the allegations," said Mike Snow, president of Columbia's Gulf Coast division. "We found that we had a significant records problem. We had misrepresented to the Joint Commission the number of delinquent records."
Once the allegations were confirmed, Snow, Columbia Chairman and CEO Thomas Frist Jr. and the company's ethics officer contacted Dennis O'Leary, M.D., the JCAHO's CEO, "to let him know of the misrepresentation and to let the Joint Commission know there had been a falsification of information," Snow said.
Under Joint Commission rules, any hospital that has been preliminarily denied accreditation may appeal to a review hearing panel, which then forwards a recommendation to the accreditation committee for a second consideration.
Columbia North Houston is appealing the decision, but no date has been set for a hearing. The hospital has a corrective action plan in place and has cooperated with the Joint Commission, Snow said.
The hospital hopes not to lose its accreditation. "If they lump us into the same bucket with people who had no intention of self-reporting, that's a problem," Snow said. "We don't want to be punished for doing the right thing."
If the appeal is denied and if the Joint Commission believes documents were falsified, Columbia North Houston will lose its accreditation for a full year. Falsification of documents is one of the most serious infractions against the Joint Commission's expectation of good faith participation in the accreditation process.
Cases of falsification don't come to the Joint Commission's attention very often. Janet McIntyre, JCAHO spokeswoman, couldn't cite the last such incident.
If the hospital does lose its accreditation, it can still accept Medicare patients if it obtains direct certification from HCFA.
Ironically, Snow said, if Columbia North Houston had simply reported its true delinquent records count the first time "and had the folks not tried to pull one over on the Joint Commission, we would still have gotten full accreditation with Type I recommendations. This would never have been known."