Stark, along with Sens. Max Baucus
(D-Mont.) and Chuck Grassley (R-Iowa), the chairman and ranking member of the Senate Finance Committee, respectively, sent letters to Acting CMS Administrator Leslie Norwalk and Joint Commission President Dennis OLeary (who is retiring at the end of this year) seeking an explanation for how a hospital can be found out of compliance with CMS standards two years after receiving Joint Commission accreditation.
The events at Walter Reed and West Texas Hospital highlight the Joint Commissions ongoing failure to protect Americans from hospitals that provide inadequate or incomplete care, Stark said in his e-mail. My concerns about the Joint Commission, however, extend beyond these tragic cases. I will continue to work with Senators Grassley and Baucus to improve the hospital accreditation process.
The spotlight shines on the commission just as its board was poised to potentially anoint a new president to replace OLeary and begin the search for a new executive vice president for accreditation and certification operations.
Last year, the same three legislators were investigating another Joint Commission-accredited, physician-owned general hospital, Physicians Hospital in Portland, Ore., in similar circumstances. In a March 6 news release, Stark referenced the Redding (Calif.) Medical Center, which was accredited in July 2002, but raided by federal agents in October 2002 after being accused of performing unnecessary heart surgeries. The hospital settled about 750 lawsuits in 2005 when parent Tenet Healthcare Corp. agreed to pay $395 million. Perhaps it should come as no surprise that the Joint Commissionwhich accredited Californias Redding Medical Center despite years of deadly heart surgeriesis partly responsible for this breakdown and for the death of a patient at a physician-owned facility in West Texas, Stark said in a news release. I expect more from CMS and its fiscal intermediaries.
CMS spokesman Don McLeod said the CMS must play the cards it is dealt and that includes federal law mandating that it accept the Joint Commissions decision to accredit. Congress can ask Why did they certify a hospital if theyre not up to standards? but thats not up to us, McLeod said. If the Joint Commission approves them, the law says we have to accept that. We can only go back if theres a problem.
OLeary defended the value of his organizations accreditation, but acknowledged that the process has its limits. Accreditation is not a warranty that any organization is perfect, he said.
Other factors at play, OLeary said, are that healthcare can be delivered in a volatile setting that can go into a slide very fast, and that Walter Reed and West Texas were accredited before the Joint Commission changed to unannounced surveys that use tracer methodology, which tracks care given to individual patients. The previous survey methods were described as a snapshot in time, while the new methods aim at continuous standard compliance and require the submission of data for periodic performance reviews between surveys.
Their last survey was announced, so maybe they dressed up for the party, OLeary said. He added that, while unlikely, its possible that problems were missed, and its also possible that the environment deteriorated rapidly.
OLeary also called media coverage of Walter Reeds problems a little hyperbolic and said that he didnt think this hospital is going to be in trouble with us.
He said any deficiencies Walter Reed has with diagnosing and treating mental disorders are shared with the nations healthcare system as a whole. Youve got injured soldierssome terribly injured and some not as badlybut all of them bear significant psychological scars, OLeary said. We dont pay enough attention to those issues in our society.
Joint Commission surveyors did a special unannounced inspection of Walter Reed for cause Feb. 28-March 2, and had done the same for West Texas on Feb. 6. OLeary said there may be a special conference call set up in early April for the accreditation committee to discuss the survey findings in Abilene. In 2006, about 3% of the hospitals surveyed received an adverse decisioneither conditional or preliminary denial of accreditation. Of these, one preliminary denial and seven conditional decisions were based on complaint surveys like those done at Walter Reed and West Texas, according to Joint Commission spokeswoman Charlene Hill.
Texas Hospital Association spokeswoman Amanda Engler defended the Joint Commissions survey at West Texas. They make sure that processes are in place to prevent these sort of things from happening, but theyre not going to stand over everyones shoulder and watch, Engler said.
At Walter Reed, the problems may be linked to the accreditation process focus on clinical areas. Dean Samet, director of regulatory compliance services at consultancy Smith Seckman Reid and a former Joint Commission associate director, said it wouldnt be uncommon for a building like the one affiliated with Walter Reed to not be included on the survey list. Whether any of the Army hospitals staff mentioned the buildings condition during the overall accreditation survey is unclearbut also unlikely. To be quite honest, the staff normally wouldnt be airing their problem areas to surveyors, Samet said.
Typically, Joint Commission surveyors focus first on the main clinical areas, such as inpatient and ambulatory-care settings, Samet said. Time permitting, they may try to do a random sampling of some of the other areas, he added. But thats only time permitting.
Ticking off the checklist, Samet said that surveyors need to focus on emergency management, sentinel event alerts, compliance with the National Patient Safety Goals and, at the base level, the ever-changing Joint Commission standards. That typically keeps surveyors pretty busy, he said.
OLeary, however, disagreed and noted that the new survey method is flexible so surveyors can go where the issues take them.
But the very nature of military and Veterans Affairs Department hospitals often complicates the survey process, said consultant Ruth Elzer, director of accreditation and compliance services at Compass Group in Cincinnati. VA hospitals in particular often have separate housing facilities where patients are boarded but dont receive direct care. Such buildings are often not subject to survey by the Joint Commission and CMS, she said.
The latest string of attention probably wont prompt the Joint Commission to dramatically alter its survey process because of the intricacies of Walter Reed and other similar facilities. If the Joint Commission were to start surveying nonclinical areas, she said, the result could potentially open a Pandoras box of medical center problems, where inspectors could survey inside individual offices or dormssomething few people would like to see happen. When it comes to CMS regs and (Joint Commission) regs, theyre all about patient care, she said. This is not about business settings.
Paul Keckley, executive director of the Deloitte Center for Health Solutions, Washington, noted that its generally accepted that Walter Reeds problems are on its ambulatory side while the Joint Commission is more geared toward assessing acute care, but that the Joint Commission is probably getting a spotlight it deserves and thatat timesit has been its own worst enemy.
What these scandals illustrate is that you can do all the right things to get accredited, yet there can be systemic problems in your organization, Keckley said. I think (the Joint Commission) made a couple changes that are significant in the past 18 months. That said, I still dont think the Joint Commission is as significant a force in quality and safety as it should be.