North Houston Medical Center, owned by Columbia/HCA Healthcare Corp., almost certainly will regain its accreditation despite admitting to falsifying hospital records later reviewed by surveyors from the Joint Commission.
Such infractions are normally considered serious enough to warrant an immediate one-year loss of accreditation. But the 180-bed Houston hospital will benefit from a little-known rule that allows the president of the Joint Commission on Accreditation of Healthcare Organizations to waive the penalty.
The Oakbrook Terrace, Ill.-based accrediting agency has not announced North Houston's status, but the disclosure of the hospital's apparent short stay in the penalty box may prompt other troubled hospitals to lobby JCAHO President Dennis O'Leary, M.D., for special dispensation.
On Sept. 9, the commission stripped the hospital of its accreditation after it verified that documents had been falsified in the hospital's last regular survey in July 1997 (Sept. 14, p. 4). The JCAHO's rules provide for a one-year loss of accreditation if there has been an attempt to deceive surveyors.
The hospital agreed not to contest its loss of accreditation, but it requested an immediate resurvey, which was conducted five days later, from Sept. 14 to 16.
At the exit conference after their visit, Joint Commission surveyors told North Houston Chief Executive Officer Joe Baldwin that "we scored a 99 with no Type I's," Baldwin said. "Ninety-nine is the best you can score, and no Type I (findings) means we are meeting all the standards."
The hospital's re-accreditation will not be official until the survey results are ratified by the JCAHO's accreditation committee. That could take 30 to 45 days, said Janet McIntyre, a Joint Commission spokeswoman.
McIntyre said it is commission policy not to talk about why the hospital lost its accreditation, and she couldn't give specifics on why such a quick resurvey occurred.
However, she said, "The president of the Joint Commission for good cause may waive all or a portion of the waiting period. Those issues are addressed on a case-by-case basis."
McIntyre said several actions can prompt a resurvey, such as if the organization comes forward to report problems, if leadership changes are made or if the organization has responded quickly to address its problems.
All three of those examples apply to the North Houston case.
The falsification came to light after an anonymous employee called the Columbia ethics hotline to complain that medical records had been updated to look more complete (March 2, p. 8). The ethics hotline was established last fall after the federal government launched a billing fraud investigation of the company.
Columbia conducted an internal investigation, verified the allegation and notified the JCAHO of the problem.
The hospital's former CEO, Mel Bishop, and two other managers were let go as a consequence. And the medical records department was overhauled. Baldwin said 20,000 man-hours had been invested to get those records in order.
The hospital was unaccredited for three days, Baldwin said, Sept. 14 to 16. Assuming the hospital is reaccredited, that full accreditation status will be retroactive to Sept. 17.
Baldwin does not expect any interruption in reimbursements from federal programs.
Hospitals accredited by the JCAHO automatically qualify for Medicare under the Joint Commission's "deemed status" relationship with HCFA. A spokesman for North Houston Medical Center said the facility did not notify HCFA directly of its accreditation loss but relied on the Joint Commission to tell the federal agency. The spokesman said that notification is the Joint Commission's responsibility.
McIntyre said a letter was sent to North Houston Sept. 10 stating the decision to deny accreditation. A copy of that letter was sent to HCFA, she said.
"We should get the final notice from the Joint Commission in three or four weeks. They've agreed to (speed up) the results," Baldwin said.
The hospital appealed the accreditation committee's findings but was rejected. "We decided not to go with second level of appeal," he said. "At the hospital's request, the Joint Commission agreed to do an immediate resurvey. We applied last week. We decided that it was best just to do the survey, get back in the program and get the issue behind us."
Earlier this year, Mike Snow, division president for Columbia in Houston, told MODERN HEALTHCARE that the hospital would plead for leniency.
"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."
He said if North Houston was reprimanded too severely, it would discourage other hospitals from coming forward.
Neither the hospital nor the Joint Commission released any public notices about the loss of accreditation.
"We don't make public announcements about this type of situation, period," McIntyre said. "We don't put out public announcements about the actions of the accreditation committee. We will put out a statement if someone calls, and we make the accreditation history available to the public."
As part of the normal process, the hospital was required to post a notice that Joint Commission surveyors were coming, Baldwin noted.
"We posted an announcement in our lobby that they were going to resurvey. We didn't know for sure until (Sept. 11). It was a very sudden survey," he said.
A survey score of 99 with no Type I recommendations would put the hospital in the top 4% of accredited facilities and would qualify it for "accreditation with commendation" under usual circumstances, McIntyre said. Baldwin said he didn't know whether the Joint Commission would allow his hospital to win commendation, given the circumstances.