The Joint Commission on Accreditation of Healthcare Organizations is so busy teaching hospitals about quality improvement that its survey process fails to protect the public from potentially inadequate or incompetent care, HHS' inspector general's office said in a report issued last week. The accreditation survey needs to be fundamentally rethought if it is to have value, the agency said.
The four-part report, called "The External Review of Hospital Quality," is the culmination of the inspector general's two-year investigation into allegations that hospital oversight-especially that provided by the JCAHO-is not up to snuff.
The inspector general's office undertook the investigation after media accounts of patient injuries and deaths in the mid-1990s aroused public concern and outside interest groups published critical reports of the JCAHO.
A main thrust of the reports is government's role in overseeing hospital quality. The inspector general said HCFA and the states are not fulfilling their responsibilities to ensure minimum standards at the 1,442 hospitals not accredited by the JCAHO. Those hospitals are not being surveyed often enough or critically enough, the reports say.
"I think (the reports) are thoughtful and generally well done," said Dennis O'Leary, M.D., president and chief executive officer of the JCAHO. "We don't agree with everything."
He most objected to the study's contention that the JCAHO process is over-solicitous toward hospitals. As a result, "Joint Commission surveys are unlikely to detect substandard patterns of care or individual practitioners with questionable skills," the reports say.
The American Hospital Association appoints seven members to the JCAHO's 28-member board of commissioners.
The JCAHO's critics, however, said the reports stop well short of rectifying accreditation problems.
The Service Employees International Union, one of the JCAHO's leading detractors, blasted the report for failing to offer far-reaching solutions.
"Without fundamental reforms, the current system of letting the hospital industry monitor itself is a joke," said SEIU President Andrew Stern.
The SEIU wants employees and patient advocates to have a stronger role in monitoring hospital quality. Employees should be allowed to talk frankly and confidentially with JCAHO surveyors, without the threat of reprisals from management. The SEIU also wants surveys to be completely unannounced. Presently even so-called random, unannounced surveys offer at least a day's warning.
The reports note that under the commission's lead, current thinking about oversight leans more toward a collegial approach than a regulatory one. The inspector general's office sees a danger in that and says HCFA should steer a middle course. The reports also favor more accountability in hospital oversight and wider public access to information.
"I don't believe that an evaluation process has to be adversarial," O'Leary said. "Everyone needs to remember that at the end of the day, the objective is to help organizations improve their performance. The objective is not to close down a bunch of hospitals."
Some of the most interesting material in the reports was gleaned by investigators who went on seven triennial JCAHO surveys. They describe a frantic three-day schedule that permits surveyors no spare moments to probe very deeply into a hospital's potential problems.
It's so hard for hospitals to flunk accreditation, said the reports, that the JCAHO had to write up a special survey to make one clearly inadequate hospital lose its accreditation.
In a three-year period, 99% of accreditation decisions are clustered into just two of five possible accreditation levels. Only 1% of facilities fail to get accredited.
The JCAHO has been working for six months to revamp its survey process to better prepare surveyors to detect improper care (June 21, p. 8).
Public Citizen's Health Research Group, a Washington-based consumer lobby, said the report's recommendations are "a step in the right direction but not strong enough." It wants the federal government to remove the JCAHO's power to judge hospitals to be in compliance with Medicare "conditions of participation," a power known as the "deeming authority." The external review of hospitals, it said, "should be conducted by a publicly accountable body."
If the JCAHO doesn't shape up within five years, said the group, HHS should remove the Joint Commissions's deeming authority.