The Joint Commission on Accreditation of Healthcare Organizations does not expect lasting damage from a stinging government report issued last week, but Congress' response may subject the recently made-over JCAHO to new federal oversight.
Even if the JCAHO faces potential new scrutiny from regulators, hospitals themselves would feel little if any effect from a law proposed last week by Sen. Charles Grassley (R-Iowa) and Rep. Pete Stark (D-Calif.) in response to a Government Accountability Office report finding that the JCAHO failed to discover deficiencies in some of the hospitals it certified.
In a Capitol Hill press conference, Grassley and Stark used the critical report and its ominous numbers as ammunition to attack the JCAHO for going too easy on hospitals and missing some potentially serious patient-safety violations. The two lawmakers, who are prominent in the health policy arena, also introduced legislation that would make the JCAHO more accountable for its hospital surveys, putting the CMS in charge of overseeing the overseer.
Grassley and Stark argued that the JCAHO-where 14 board members out of 29 hail from the American Hospital Association or the American Medical Association-is beholden to the facilities it is charged with overseeing. "Congress expects the Joint Commission to be a consumer watchdog," Grassley said. "It looks like the Joint Commission instead is a lapdog."
Under pressure from hospitals, the JCAHO recently backed away from several costly patient-safety goals.
The JCAHO has a long history of run-ins with both Stark and the hospitals it certifies. In 1990, Stark took aim at the JCAHO in a House Ways and Means Committee hearing that examined problems with the accreditation process. The lawmaker from northern California raised the issue again in 1999, armed with a report from HHS' inspector general's office concluding that JCAHO surveys were not likely to identify patterns of deficient care.
In 2002, it was the AHA that was upset with the JCAHO for venturing into businesses outside its core mission and acting more like a regulator than an accrediting organization. It took a 31/2-hour meeting between AHA President Richard Davidson and JCAHO President Dennis O'Leary to hash out the dispute, which left in its wake some unresolved tension (June 3, 2002, p. 6).
Last week's GAO report surfaced about seven months into the JCAHO's revamped accreditation process, under which hospitals assess their own performance and create improvement plans that JCAHO inspectors use to monitor progress. The JCAHO and some hospital officials said last week that members of Congress may not understand the new approach, which they say will improve rather than harm the survey process.
"People really like this new JCAHO system, and it's not easy," said Pat Mennonna, director of quality assessment and risk management at 264-bed Virginia Hospital Center in Arlington, Va. The self-assessments, she said, "get everybody involved in thoroughly focusing on safety issues. I think (the JCAHO) is doing a fabulous job."
Of 500 hospitals surveyed from 2000 to 2002, the JCAHO identified serious deficiencies at 74, but state surveyors found 241 of that same pool to have serious deficiencies, according to the GAO. Hospitals with serious deficiencies are those that violate at least one of Medicare's conditions of participation.
More than half of the deficiencies the JCAHO missed were fire-safety and other "physical environment" violations, but some involved more serious matters, such as failure to properly prepare and administer drugs.
Under the legislation Grassley and Stark proposed, the JCAHO would not lose or cede to the CMS its authority to deem hospitals compliant with Medicare rules. Instead, the CMS would review and approve the JCAHO's accreditation program, as it does for all other major healthcare accrediting organizations.
The JCAHO's chief said he has no problem with that plan and welcomes a new level of accountability that is long overdue. "We're flying by the seat of our pants, and nobody is in the barrel with us, particularly CMS," O'Leary told Modern Healthcare last week. "Not having that accountability is a problem for us."
As a result of language in the 1965 Medicare law, the JCAHO is the only industry accrediting body that does not answer to the CMS. "The basic principle we are supporting, and that I believe Capitol Hill and the CMS will support, is that the Joint Commission's hospital accreditation program be made like all the rest. Create a level playing field for everyone," O'Leary said.
O'Leary acknowledged that his inspectors do occasionally miss problems but argued that the GAO's report was "based on a flawed study methodology and erroneous, alarming statistics that seriously mislead the public."
State surveyors inspect a given hospital as many as 60 days after the JCAHO, O'Leary said. Things can change during that time, such as an exit-sign light bulb that worked when the JCAHO visited but had burned out by the time state surveyors arrived.
Giving the CMS authority over the JCAHO and its accreditation programs would have little if any effect on individual hospitals or the certification process, lawmakers and industry officials said last week. The JCAHO's plan to move to unannounced surveys beginning in 2006, for example, is still on track, O'Leary confirmed.
The CMS would require additional resources to carry out the GAO's recommendations, an agency official said. Congressional committee staff members have assured the CMS that if legislation requires the agency to expand its patient-safety efforts, "those needs would be addressed," the official said.
In a letter included in the GAO report, CMS Administrator Mark McClellan said the CMS could strengthen its oversight of the JCAHO's efforts with such steps as increasing the number of surveys states conduct to validate the group's findings. He did not directly address whether the agency is interested in approving an accreditation program every year.
Some critics said the legislation Grassley and Stark are promoting would not go far enough to change a flawed, outdated accreditation process.
The JCAHO's accreditation program "is dominated by providers when it ought to be dominated by buyers, and it uses an inspection technique when it ought to be using outcomes measures," said John Griffith, collegiate professor of health management and policy at the University of Michigan in Ann Arbor. In a paper he published in 2002, Griffith concluded there is no relationship between a hospital's outcomes measures and the score it receives from the JCAHO. To help correct that, he favors restructuring the JCAHO's board and forming an independent panel to determine how accreditation should be modernized to focus more on outcomes.
Stark and others maintain that the JCAHO's board should not be so heavily stacked with providers. "I don't think the Joint Commission ought to be accountable to CMS," Griffith said. "I think it ought to be accountable to the American public."
The JCAHO's board, Griffith argued, should have no more than one representative each from the AHA and the AMA, and the rest should consist of consumer and patient-safety advocates.
O'Leary said "very strict conflict-of-interest policies" are in place to keep things on the up and up. A spokeswoman for the AHA said there is already a "diverse mix" of officials on the JCAHO's board but would not say if there should be fewer hospital representatives.