If you ended up with a full plate of "Type I" recommendations after your last Joint Commission survey, you aren't alone. Some of the industry's more prominent hospitals have joined a growing list of those getting a half-dozen or more unsatisfactory marks on their latest surveys.
In the past two years, the Joint Commission on Accreditation of Healthcare Organizations has saddled an increasingly larger percentage of the hospitals it surveys with generous portions of Type I's, judging the hospitals to be out of compliance with specific accreditation compliance standards, Modern Healthcare has learned. Also, a dwindling percentage of hospitals have skated through surveys without receiving any Type I's.
The JCAHO said a "number of variables" are behind its finding more problems during on-site surveys of hospitals, including new standards, improved surveyors and changes in the survey format since 1997. But some in the hospital industry say the numbers are proof of a heightened vigilance on the part of the Oakbrook Terrace, Ill.-based accrediting body that has been kept quiet until now.
Interestingly, the sharpest increase in Type I's was seen in 1999-the same year that HHS' inspector general's office charged that the JCAHO was failing to protect the public from the potential for inadequate or incompetent care. The government's criticism could be perceived as a threat to the accrediting body. The JCAHO's special status to deem that hospitals meet Medicare's conditions of participation by passing its accreditation survey, at an average cost of $20,000 per hospital, can be stripped away by a disapproving Congress.
The JCAHO denied the public accusations had any bearing on its accreditation process. "The OIG report in no way drove any change in approach or intensity in surveying," said Russell Massaro, the JCAHO's executive vice president of accreditation operations.
Instead, the JCAHO said better-trained surveyors contributed to changes in grading. "Our surveyors get better over time in terms of their techniques and in terms of finding accurate information," Massaro said. Surveyors recently have been allowed more time during surveys to independently investigate areas of noncompliance, according to Massaro.
"These data are evidence of a much more vigorous approach by the Joint Commission that has been kept pretty much discreet," said Kenneth Raske, president of the Greater New York Hospital Association.
Ironically, the crackdown on hospital adherence to the JCAHO's accreditation compliance standards comes at the same time that the JCAHO is going easy on hospital reporting of actual clinical outcome data (See story, p. 7).
The percentage of hospitals receiving six or more Type I recommendations climbed to 25% in 2000 from 21.4% in 1997. In 1999, 28.5% of hospitals surveyed received six or more Type I's, compared with 19.1% in 1998.
This pattern of increase holds true for hospitals receiving more than seven Type I's, more than eight Type I's and so on. The bottom line is that more hospitals received a heavy dose of Type I's in 2000 (the most recent full year for which the JCAHO provided data) than in 1997.
During the same period, fewer hospitals escaped surveys without receiving any Type I's. In 1997, 18.1% of hospitals surveyed had no Type I's, but in 2000 only 8.9% of hospitals managed to get through unscathed.
The average overall evaluation score fell to 90.86 last year from 92.29 in 1997. The JCAHO maintains that the scores have not varied significantly.
"The average scores have remained relatively unchanged, and therefore the average performance of hospitals has remained consistent," Massaro said.
Several hospital representatives from around the country contacted by Modern Healthcare confirmed that the perception in the industry is that JCAHO surveyors have become tougher graders in recent years. One hospital source reported hearing that surveyors had been encouraged to increase the number of Type I recommendations given by 10%.
Massaro said the JCAHO has no quota on the number of Type I's its surveyors are expected to come up with. He called the rumor of a forced 10% increase "absolutely false" and added, "There has never been a conversation like that with surveyors in any venue."
"I think there is a clear message we have sent to our staff to be fair and be clear and be vigilant with our standards," said Joe Cappiello, the JCAHO's vice president of accreditation field operations. "There is a difference between that message and the message that says, `Go out and find more Type I's.' "
For most standards, hospitals receive a Type I recommendation on their triannual survey when they score a "3" or higher on a five-point scale for a standard. A "1" is the best possible score and represents full compliance and a "5" is the worst possible score on a standard. Hospitals must resolve Type I recommendations within six months to be accredited. During the past four years, the JCAHO has denied accreditation to less than 1% of hospitals.
The American Hospital Association said it hasn't detected a rise in the JCAHO survey scrutiny as an issue for its members. "I have not heard anything from the field about more Type I's being given to organizations," said Don Nielsen, M.D., the AHA's senior vice president for quality leadership.
But there are some noteworthy examples of hospitals that have reportedly taken a recent tumble. According to sources, Chicago's prestigious 642-bed Northwestern Memorial Hospital, which opened a $580 million new building in 1999, received an overall score of 88 and was marked for six Type I recommendations by the JCAHO in the preliminary report of its hospital survey completed in April. In its prior survey in 1998, which is publicly available on the JCAHO Web site, Northwestern earned a score of 97 and had no Type I recommendations.
Northwestern President Dean Harrison declined to confirm or deny the hospital's 2001 survey score. "Until we get the final report, it wouldn't be appropriate for me to comment on that," Harrison said.
The hospital has about 90 days to appeal the JCAHO's preliminary findings.
"(For) a couple of items that they have identified, we are providing additional information," Harrison said. Gary Mecklenburg, president and chief executive officer of Northwestern's parent corporation, Northwestern Memorial HealthCare, is chairman of the AHA's board of trustees. The AHA controls seven seats on the JCAHO's 28-member board of commissioners.
Chicago's 713-bed Rush-Presbyterian-St. Luke's Medical Center fell from a score of 94 with two Type I recommendations in 1997 to a score of 87 with six Type I's in November 2000, according to a hospital spokesman.
"That trend holds true for our hospital as well," said Michael Sheffield, assistant administrator at 383-bed Carraway Methodist Medical Center in Birmingham, Ala. Carraway's staff watched the number of Type I's swell to five during the JCAHO's visit in April from two in the previous survey.
Sheffield said he felt the JCAHO surveyors assigned to his hospital were fair. But, he added, in areas such as medication use, which accounted for one Type I his facility received, they were especially vigilant. "In my opinion it would have been almost impossible for us not to get a Type I in that area because they are just looking for that," Sheffield said.
The JCAHO uses 487 surveyors, the majority of whom have experience as hospital administrators or are physicians or nurses. Only 39 surveyors are full-time employees of the Joint Commission. More than half of the staff works on an intermittent basis.
"(The surveyors) were saying that overall they are seeing the scores go down, and a lot of that has to do with things that were not scored two or three years ago," said Steven Smith, administrator of 455-bed Eliza Coffee Memorial Hospital in Florence, Ala.
Earlier this month, the JCAHO announced it was conducting a comprehensive review of and streamlining its nearly 500 hospital-accreditation compliance standards (May 7, p. 5). The JCAHO said the relatively sudden decision to revamp the standards for the first time since 1994 came, at least in part, because of "mounting concern about the questionable relevancy of some of our standards."
With the climb in Type I's for many hospitals, Raske said news of the standards' overhaul is especially timely. "The standards review task force is needed more than ever to come up with a fresh and less burdensome approach to maintaining the quality of care within our institutions."