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Office of Inspector General Public Affairs 330 Independence Ave., SW Room 5541, Cohen Bldg. Washington, DC 20201 (202) 619-1343 NEWS RELEASE FOR IMMEDIATE RELEASE Tuesday, July 20, 1999 Contact: Judy Holtz (202) 619-0893 Alwyn Cassil (202) 205-0333 Ben St. John (202) 619-1028 Inspector General Calls for Improved Oversight of Hospitals A two-year study by the Department of Health and Human Services' Office of Inspector General released today cites major deficiencies in the external oversight system intended to make sure the nation's hospitals are safe and recommends how the federal agency responsible for hospital oversight can provide leadership in improving quality and accountability. "Our study shows the current system of hospital oversight has important strengths that help protect patients, but the system -- a combination of private accreditation and state certification -- also has significant weaknesses that must be addressed," Inspector General June Gibbs Brown said. The Health Care Financing Administration (HCFA), which administers Medicare, relies primarily on two types of external review to ensure hospitals meet the minimum requirements for participating in Medicare: accreditation by private entities, mainly the Joint Commission on the Accreditation of Healthcare Organizations, and Medicare certification by state government agencies. By law, hospitals accredited by the Joint Commission are "deemed" to meet the Medicare hospital conditions of participation. About 80 percent of the 6,200 hospitals participating in Medicare are accredited by the Joint Commission, while about 20 percent of hospitals nationwide are certified by state agencies. Hospitals are vital to the nation's health care system and routinely provide valuable services. But many scientific studies and media reports have highlighted concerns about the quality of care in some hospitals, making it clear that hospitals are places where inappropriate care can lead to unnecessary patient harm. External reviews of hospitals can help minimize this danger. In a series of four reports, the Office of Inspector General identified deficiencies in current accreditation and certification practices. Key findings of the study include: Joint Commission surveys help reduce risk and foster improvement in hospital care but are unlikely to detect substandard patterns of care or individual practitioners with questionable skills. Quick-paced, tightly structured, educationally oriented surveys provide little opportunity for in-depth probing of hospital conditions or practices. State agency investigations offer a timely, publicly accountable way to respond to complaints and adverse events, but the state agencies rarely conduct routine, not-for-cause surveys of nonaccredited hospitals. About 50 percent of nonaccredited hospitals in 1997 had not been surveyed within the three-year industry standard. In some cases, nonaccredited hospitals, usually in rural areas, have gone as long as eight years without a survey. Overall, the hospital review system has been shifting toward a collegial mode of oversight, focusing on education and improved performance, and away from a regulatory mode of oversight, focusing on investigation and enforcement of minimum requirements. The Joint Commission, the dominant force in external hospital review, is leading this shift. Both the collegial and regulatory approaches have value, but as the system increasingly tilts toward the collegial mode, it could result in insufficient attention to regulatory approaches intended to protect patients from poor care. HCFA does little to hold either the Joint Commission or the state agencies accountable, obtaining limited information about their hospital oversight activities and providing little feedback about their overall performance. In dealing with the Joint Commission, HCFA is "more deferential than directive." Public disclosure plays a minimal role in holding the Joint Commission and state agencies accountable because little information is available to the public on the performance of either hospitals or the external reviewers. Based on the reports' findings, the Office of Inspector General has recommended the following: HCFA, as a guiding principle, should steer external reviews of hospital quality to ensure a balance between the collegial and regulatory modes of oversight. HCFA should negotiate with the Joint Commission to: Conduct more unannounced surveys. Make the "accreditation with commendation" category more meaningful or abolish it. Introduce more random selection of records into the survey process. Provide surveyors with more context about hospitals they are surveying. Determine year-to-year survey priorities. Conduct more rigorous review of hospitals' continuous quality improvement efforts. Enhance surveyors' ability to respond to complaints during surveys. HCFA should: Hold the Joint Commission and state agencies more fully accountable by gathering more timely and useful performance data and strengthening mechanisms to provide performance feedback and policy guidance to the Joint Commission and state agencies. Increase public disclosure of the performance of hospitals, the Joint Commission and state agencies, at a minimum, by posting more detailed information on the Internet. HCFA should determine an appropriate minimum cycle for conducting certification surveys on nonaccredited hospitals. Other than reviews triggered by complaints or adverse events, nonaccredited hospitals receive limited external review. Unlike nursing homes and home health agencies, there is no statutory requirement for a mandated minimum survey cycle for hospitals. In response to the reports, HCFA Administrator Nancy-Ann DeParle offered a detailed hospital quality oversight plan incorporating many of the Inspector General's recommendations. "HCFA is responsible for making sure that Americans are confident they receive high quality hospital care, and we continually strive for the proper balance between educational and regulatory activities. HCFA is also committed to implementing a number of initiatives to improve the quality of hospital services, including those suggested by the Inspector General, and our revised Conditions of Participation regulations will clarify our expectations for JCAHO," said Nancy-Ann DeParle, HCFA Administrator. "Our new action, for example, is designed to improve the oversight and quality of care in hospitals participating in Medicare and Medicaid and will enable us to meet our larger goals of performance measurement in hospitals." "We are pleased that the Health Care Financing Administration is taking steps to improve its oversight of the Joint Commission and the state agencies," Brown said. "We believe that our recommendations and HCFA's announced action plan can significantly improve the external review of hospital quality in the years ahead." The Office of Inspector General inquiry into external hospital oversight drew on a variety of sources, including data from HCFA's online survey certification and reporting system; aggregate data from the Joint Commission concerning hospital survey activity; information from the state agencies in the 50 states and the District of Columbia; observations of hospital surveys conducted by the Joint Commission and state agencies; reviews of accreditation manuals, policies and hospital survey files from the Joint Commission; the systematic gathering of information from representatives of HCFA central and regional offices, state agencies, the Joint Commission, American Hospital Association, consumer groups, professional associations and other stakeholders; and reviews of laws, regulation and articles from newspapers, journals, newsletters and magazines. Note: The four reports are available on the Office of Inspector General's web site at http://www.os.dhhs.gov/oig. Click on the "What's New" link to access the reports. The External Review of Hospital Quality: A Call for Greater Accountability, OEI-01-97-00050 The External Review of Hospital Quality: The Role of Accreditation, OEI-01-97-00051 The External Review of Hospital Quality: The Role of Medicare Certification, OEI-01-97-00052 The External Review of Hospital Quality: Holding the Reviewers Accountable, OEI-01-97-00053 Root Cause Analyst TM Software | FAQs on the Issues | Root Cause Analysis Training Cost-Effective Root Cause Analysis | Root Cause Analysis Software - Article Resource Links | Guestbook | About MRMA | Email MRMA  Root Cause AnalystTM is developed in partnership with Accurate Assessments. Call 1-800-324-7966 to find out how to purchase Root Cause AnalystTM or visit the Accurate Assessments Web site at www.accurateassessments.com Copyright© 1998,1999,2000 MRMA, LLC. All rights reserved. All other trademarks are the sole property of their respective owners. Page last modified 21 March 2000.