The Federation of American Health Systems wants its system surveys back-now!
In mid-January Thomas Scully, chief executive officer of the for-profit hospital lobbying group, led a delegation of members to Oakbrook Terrace, Ill., home of the Joint Commission on Accreditation of Healthcare Organizations, to demand relief.
Federation companies want the same team of JCAHO accreditation surveyors to tour all their hospitals at roughly the same time for their triennial survey. That's how the Joint Commission did system surveys until it changed its policy last year.
After the Service Employees International Union and other watchdog groups complained that the system surveyors were too cozy with big hospital companies, the accrediting agency changed tack.
Now the same team of surveyors does not go to each of a company's facilities; instead, the team leader remains the same, but the other surveyors change.
The process was changed to improve it, "not in response to the SEIU or any other specific groups that may have expressed concern," explained Janet McIntyre, JCAHO spokeswoman. She conceded, however, that "the SEIU did express some of the very concerns that we were considering."
System surveys consist of three elements:
A visit by the survey team to the system's central office to learn about procedures and mission.
A sequential survey of the organizations that are part of the system.
An aggregate report for the system's central office identifying how individual components performed. The report also might identify across-the-board strengths and weaknesses.
The recent change affected only the second element. Scully's group believes the change puts big systems at a disadvantage. "People are coming in and out; they know nothing about your system. This doesn't affect just us;" it also affects not-for-profit systems, he said. "There are 20 different groups that have multihospital survey teams."
Scully said he wants the JCAHO to set up a pool of 40 to 50 surveyors who are familiar with a specific hospital group and its structure and finances.
Why did the Joint Commission change its policy? "We were hearing a number of things," McIntyre answered. "From some people, there were concerns that those who had a system survey with the same team were beginning to identify what they thought were hot buttons for the team. They would move ahead to the next facility and make sure things were shipshape. Some thought that nonsystem facilities were at a disadvantage."
On the other side, some systems thought surveyors scrutinized their hospitals for weaknesses that had been noticed at earlier surveys.
A third view was that the systems were well-served because they received an integrated report from the same team of surveyors.
On reflection, the JCAHO tried to strike a better balance by giving some continuity but not too much, McIntyre said. To those hospitals that resent what they perceive as an inherent bias in favor of system surveys, the Joint Commission offers an alternative: "If you're not part of a system, but you'd like to band together with other hospitals based on geography, we certainly would be willing to do the surveys at the same time," McIntyre said.
That might be worth a try for small independent hospitals, because these system surveys work like a charm for big organizations like Tenet Healthcare Corp. Last year, for instance, Tenet had three dedicated survey teams: one for the East, one for the West, and one for the former OrNda HealthCorp hospitals that Tenet had just absorbed in a merger.
"The team stayed intact for the majority of the facilities," said Leonard Rosenfeld, Tenet's vice president for quality management. "There were three to five members, depending on whether (the facility) had a distinct unit, drug and alcohol, home health and so forth. They moved consecutively from Tenet hospital to Tenet hospital."
That resulted in a consistent application of standards at each hospital-the most important aspect of any accreditation process, Rosenfeld said.
When specific issues arose, Tenet tried to pass the information from facility to facility. "If a surveyor says, `I've looked at this system for continuous quality improvement; I really like it,' we will call other facilities down the road, so they know something has gone through the Joint Commission and has been accepted. The same way, if you get something negative, you share what doesn't work well."
Vicki Searcy, an accreditation consultant with BDO Seidman in Costa Mesa, Calif., said: "Part of how you get ready for a survey is how you package yourself. When you go through a system survey, you have a better chance to showcase yourself. You develop a relationship with the surveyors.
"Obviously," she added, "there has to be some reason why the Columbia hospitals are getting more accreditations with commendation than the rest of us. Either they are running better hospitals or they have a favorable relationship with the Joint Commission."
Columbia/HCA Healthcare Corp. also participates in the JCAHO's system surveys. In fall 1996 Columbia boasted that 128 of its 342 hospitals had earned accreditation with commendation. That aroused suspicion throughout the industry, especially at the SEIU, which tried to verify all 128 but couldn't.
It looked funny even to the people at Tenet. "We were scratching our heads trying to figure that out," said Lance Ignon, a Tenet spokesman. For its part, Tenet doesn't think the system surveys yield a higher rate of accreditations with commendation. As of January five of its 124 hospitals had commendation.
For-profits aren't the only companies availing themselves of the system survey. Cynthia Hartman, Kaiser Permanente's practice leader for accreditation, regulation and licensing in Northern California, said Kaiser's system surveys "had a much better, consistent interpretation of the standards."
The real benefit, she said, is "to have this corporate orientation, which acquaints the team with the system. It enables the surveyors to move more quickly."
Given her druthers, Hartman said she would prefer to go back to the same-team surveys. The modified system survey will require redundant orientation and explanation, she said.
Apart from Joint Commission survey methods, systems might have certain built-in advantages in meeting accreditation standards. Tenet, for example, held a mass meeting of 550 quality managers and executives in January to update them on changing Joint Commission requirements for 1998.
The SEIU did a lot of research into the JCAHO and its policies during organizing campaigns at 643-bed Columbia Sunrise Hospital and Medical Center in Las Vegas and other sites. The SEIU thinks the JCAHO is in bed with the hospital industry, and accreditation should be carried out by a government agency, which would be more accountable to the public than the JCAHO is.
The compromise of keeping a team leader for system surveys but changing subordinate surveyors is "a nonreform reform," said SEIU researcher Steve Askin. "(The hospitals) lead the guy in charge around by the nose."
Scully, ironically, might be coming around to the SEIU's viewpoint on the Joint Commission. "On some of their recent issues, they've got a lot of justifiably enraged hospitals," he said. "I've been a big advocate of more deeming authority for JCAHO, but I'm beginning to think HCFA may be a better option most of the time."