As accreditation organizations look to reopen their surveys amid the COVID-19 pandemic, the process looks very different and has sparked discussions about the feasibility of virtual surveys long term.
The Joint Commission announced this week it would resume accreditations of healthcare organizations starting in June. It comes months after CMS asked all accrediting organizations to temporarily suspend and postpone accreditation surveys as part of its package of waivers intended to ease burden on providers as they deal with the COVID-19 pandemic. Although the Joint Commission complied, leadership determined surveys could safely resume in some areas of the country beginning in June as state-at-home orders lift and COVID-19 cases decline.
"There were enough counties that looked to be in the green … (we determined) that it would be safe to send surveyors in those areas," said Mark Pelletier, the Joint Commission's chief operating officer of accreditation and certification operations. He acknowledged the organization will stop surveying if the downward case trend changes.
The Joint Commission's modified survey process relies heavily on technology, using audio or video conference calls to increase the number of individuals that can participate in group sessions, interviewing patients or staff by phone and reviewing medical records using screen sharing. Surveyors will also wear masks, avoid areas with aerosolized procedures and will only take cars to locations rather than flights for the time being.
CMS currently hasn't granted approval for accrediting organizations to do a re-accreditation survey remotely but the agency has made exceptions during the pandemic. Virtual surveys can occur for facilities that just opened, although the expectation is that in-person surveys will occur at a later date. CMS also made an exception for DNV GL Healthcare, allowing it to conduct its annual surveys virtually because the process is actually required every three years.
Even though CMS hasn't indicated it plans to change its rules on in-person surveying, accreditors say the coronavirus pandemic has opened up discussions about how some aspects of accreditation could be done virtually permanently.
"I can see a hybrid (survey) where a lot of stuff we do right now that takes a lot of time and effort could be done remotely and the on-site part could be focused on very critical areas," said Richard Curtis, CEO of the Center for Healthcare in Improvement Quality, which accredits about 110 hospitals.
Review of medical records and other documents takes a significant amount of time and if those reviews could be done beforehand, surveyors would have more time to observe care delivery and talk to staff, Pelletier added.
The Joint Commission plans to send a request to CMS next week asking for some aspects of remote technology to be part of the survey process permanently going forward considering the uncertainty around how long the pandemic is expected to go on. "I think that is in our future," Pelletier said.
The CMS didn't respond to a request for comment.
That's not to say on-the-ground surveys can ever completely go away, according to accreditors.
"Let's not kid ourselves, (virtual surveys) aren't the same as being in person," said José Domingos, CEO of Accreditation Commission for Health Care, which accredits hospices, home health agencies and other sites.
Similar to other accreditors, ACHC has been conducting remote surveys for re-accreditation, and Domingos said he sees a place for both in-person and virtual oversight. He suggests initial surveys are always done on-site because "you want to make sure an organization gets off on the right foot." If an organization has a track record of positive results for some time, a combination of both in-person and virtual surveys could work, he said.
One provider liked the virtual survey process. Emerus, which operates 30 micro-hospitals and two freestanding emergency departments in five states, underwent two virtual surveys with DNV GL since the pandemic. It went surprisingly well, said Dr. Dan Middlebrook, chief medical officer.
"It really was shocking to us how much it felt like a live in-person survey," Middlebrook said.
DNV GL staff reached out to Emerus to ensure they had the technology to conduct a survey although they didn't tell Emerus exactly when the survey would occur to maintain the element of surprise. Video interviews with staff were conducted and electronic medical records were shared. Emerus even purchased a robot with a camera to allow DNV GL to see aspects of units and structures up close such as ceiling tiles.
Patrick Horine, CEO of DNV GL, said CMS has been interested in receiving feedback about how the virtual surveys have gone.
The American Hospital Association said in a statement that it supports the approach accreditors are taking. "We are confident that the gradual resumption of surveys, including the utilization of virtual surveys when possible, will help our members assess their operations as they safely transition to resuming non-emergency care," said Nancy Foster, AHA's vice president of quality and patient safety policy.
The pause on surveys has taken a financial toll on accreditors.
While the Joint Commission didn't furlough or layoff staff, "we continue to evaluate where we are at — that is the last thing we want to do," Pelletier said.
He said once surveys begin to ramp up he's hopeful the Joint Commission will see a revenue boost.
CIHQ charges an annual flat fee for accreditation so it wasn't negatively impacted but the consultancy division has been, Curtis said. Once the pandemic hit, clients canceled services. About 66% of CIHQ's business is consulting.
Despite the tough financial times, accreditors expect to see a large need in their services as operations return to normal. The backlog of postponed surveys will need to be completed along with new initial and re-accreditation surveys that come up.
"It's going to be extraordinarily busy for us in the latter part of the year," Horine said.
The accreditors are still waiting on information from CMS regarding how long they have to complete the backlog of postponed accreditations.
Accreditors are being lenient on providers though. For instance, the Joint Commission is calling organizations to gauge how much coronavirus has impacted them and if they are ready to be surveyed soon. "If they aren't ready, we back off," Pelletier said.
CIHQ is also doing something similar and about half of the organizations they reach out to say they aren't ready right now, Curtis said.
Accreditors expect some organizations to have deficiencies present when surveyors visit given the upheaval the coronavirus pandemic has had on operations including layoffs and furloughs.
"These hospitals are going to be a mess," said Horine at DNV GL, which accredits more than 500 hospitals.
Hospitals that were well-prepared for the crisis will likely do better than those hit hard and weren't prepared, he added.
Hospitals that experienced many coronavirus patients or were financially harmed should be given additional time by CMS to return back to normal operations and get into compliance, Pelletier said.
"The hard hit organizations are going to need some time," he said.