House committee probes CMS, Joint Commission over accreditation process
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When Hospital Inspectors Are Watching, Fewer Patients Die
By Nicholas Bakalar, The New York Times. March 20, 2017.
Hospitals in the United States are accredited by the Joint Commission, which periodically makes unannounced inspections, spending several weeks assessing whether the staff is following best practices.
Now a new study suggests that when the inspectors are watching, fewer people die.
The study, in JAMA Internal Medicine, used records of Medicare admissions from 2008 to 2012 at 1,984 hospitals. During that time, there were 244,787 admissions during Joint Commission inspections, and 1,462,339 in the three weeks before and after.
They found that in the non-inspection weeks, the average 30-day death rate was 7.21 percent. But during inspections, the rate fell to 7.03 percent. The difference was greater in teaching hospitals — 6.41 percent when the inspectors were absent, and 5.93 percent during survey weeks.
The effects were modest, ranging from a relative decrease of 1.5 percent over all to 5.9 percent in large teaching hospitals. Still, with 900,000 annual Medicare admissions, an absolute reduction of only 0.39 percent in the death rate would mean more than 3,500 fewer deaths per year.
Although the reasons for the effect are unclear, the lead author, Dr. Anupam B. Jena, an associate professor at Harvard, suggested that “when docs are being monitored, the focus and attention placed on clinical care goes up. I’d say it was figuring out the diagnosis and matching the treatment correctly because you’ve been a little more thoughtful.”
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Patients suffer as agency shields troubled hospitals. Clean bills of health are awarded despite deaths, infection outbreaks.
By Michael J. Berens and Bruce Japsen, the Chicago Tribune.
The nation’s most influential healthcare regulator frequently serves the interests of the hospital industry over those of the public, giving its seal of approval to medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.
The Joint Commission on Accreditation of Healthcare Organizations, based in Oakbrook Terrace, has been empowered by Congress to ensure the quality and safety of hospitals. Operating as a virtual monopoly for monitoring public health care, the commission touts its surveys as an assurance that hospitals are clean, adequately staffed and provide superior care.
But the Tribune found that the Joint Commission often fails in its role as public guardian. Among the findings:
– Less than 1 percent of hospitals failed to receive accreditation from the commission in the last 17 years, and some hospitals received high accreditation scores even in the midst of a public health crisis. In Florida this month, Palm Beach Gardens Medical Center retained its high accreditation ranking from the Joint Commission even after federal public health investigators swooped into the hospital and found that patients were in “immediate jeopardy” of harm because of infection-control deficiencies.
– Hospital inspection dates are announced up to three months in advance, allowing medical centers to quickly upgrade conditions and obtain accreditation. In some instances, medical centers have temporarily hired more nurses and transferred patients to ease overcrowded and unsafe conditions. Additionally, the Joint Commission allows hospitals to choose the patient files that will be reviewed by inspectors.
– Using a voluntary system of reporting, the Joint Commission vastly underestimates the number of avoidable patient deaths. The organization, for instance, documents just 12 cases of preventable hospital-borne infections since 1995. The Tribune found about 75,000 such deaths in just one year, a figure supported by state and government files. Joint Commission officials acknowledge substantial inaccuracies in their records.
Accreditation by the Joint Commission is crucial to the financial health of a hospital because it allows facilities to treat federally subsidized Medicare patients. But because of the way the surveys are conducted–with attention often focused on paperwork and administrative issues–accreditation doesn’t always translate into quality care.
For instance, under commission standards, hospitals are required to properly install exit signs for all doors, but the Joint Commission does not check to see if surgeons are properly licensed. Kick plates must be glued, not screwed, to doors, yet no audit is conducted to track patient safety through infection and mortality rates.
“Their standards are a moving target” and often bear no relationship to patient care, said Gary Mecklenburg, chief executive of Northwestern Memorial HealthCare, parent of Northwestern Memorial Hospital in Chicago.
Joint Commission officials said that the survey process is not flawless. “We have missed things,” acknowledged commission president, Dr. Dennis O’Leary. “These are fallible systems.”
In response to criticism from the federal government and some hospitals, the accreditation process is undergoing a dramatic overhaul, which will include tougher grading standards and heightened focus on patient care, he said. The changes are scheduled to take effect in 2004. But O’Leary also defended the Joint Commission, saying it has long been an advocate of life-saving innovations–from enhanced infection control measures to new surgical techniques.
The commission, he said, favors voluntary reporting of avoidable patient deaths and confidential survey reports because they are the most effective way to earn the trust and cooperation of hospital officials. “We encourage organizations to share information, to share their problems and drive them to improvement versus having them hide them from you and sometimes, honestly, hide it from themselves,” O’Leary said.
Founded in 1951
The Joint Commission was formed in 1951 by a small group of healthcare leaders who encouraged the adoption of uniform healthcare standards. Their lobbying efforts for improved patient care did not go unnoticed.
In 1965, Congress tapped the group to evaluate and certify hospitals to receive funds from a newly minted Medicare health insurance program earmarked for the elderly and disabled. With its unique federal powers, the Joint Commission quickly assumed a dominant role among a loose network of government public health agencies.
Increasingly, state public health departments and the U.S. Department of Health and Human Services have turned to the private resources of the Joint Commission. A dozen states, including Illinois, have a five-year backlog of hospital inspections yet to complete, furthering their reliance on the Joint Commission to detect and correct problems.
The organization now sprawls worldwide from a $30 million headquarters in Oakbrook Terrace, pulling in more than $100 million in revenue annually, primarily from the fees it charges for surveys. The top five executives all earn more than $250,000, with O’Leary’s salary now $478,000.
In addition to accrediting 4,800 hospitals –which provide care to 90 percent of the nation’s patients– the organization has expanded its reach to 14,000 other medical facilities, from nursing homes to psychiatric institutions.
Representatives of the major medical disciplines long have dominated the board that runs the commission. These members are handpicked by the American College of Surgeons, American Medical Association, American Hospital Association, American College of Physicians, American Society of Internal Medicine, and the American Dental Association.
Altogether, members of those organizations make up three-quarters of the current 28-member board. Six remaining seats are selected by the Joint Commission.
Many in the healthcare industry, even critics of the commission, point out that it has contributed to advances in hospital care. But in recent years, the organization has fallen under increasing criticism from consumer watchdog groups and the federal government. In 1999, the Inspector General Office of the U.S. Department of Health and Human Services published four investigative audits of the Joint Commission.
Federal investigators warned that the Joint Commission’s focus was skewed in favor of hospitals, which were the beneficiaries of “collegial” surveys that were “unlikely to detect patterns of substandard care.”
Despite its government-approved role, the Joint Commission exists as a self-regulating tool set up and run by medical professionals to grade other medical professionals.
“They are bought and paid for by the people they investigate, which is an absolute conflict of interest,” said U.S. Rep. Fortney “Pete” Stark of California, ranking Democrat on the House Ways and Means Subcommittee on Health. “It is not a role for hospitals to say we are going to have our own internal auditors. They should be more responsible to us.”
Critics raise questions
Others wonder whom the accreditation process really benefits. “When you set up the game, and game the game, that is preposterous,” said Dr. Jack Lord, a former vice president of the American Hospital Association who is an executive at one of the nation’s largest health insurers, Humana Inc. “The key question is, has accreditation really improved the quality of care?”
The Joint Commission often has failed to alter a hospital’s accreditation when faced with overwhelming evidence that patient care may have been compromised.
In early 1997, Bridgeport Medical Center in Connecticut was experiencing a crisis. Hospital-borne germs infected dozens of patients. Up to one in five patients contracted antibiotic-resistant germs after open-heart surgery. Dust and flies littered the operating room during surgeries, according to internal hospital records obtained by the Tribune. The Joint Commission learned of a potential infection outbreak after receiving complaints filed by a patient. But the organization decided not to visit the hospital or conduct interviews with patients or doctors, hospital and court records show. Instead, the Joint Commission reviewed patient files selected and mailed by hospital officials.
A Joint Commission regional supervisor telephoned the Bridgeport hospital on Feb. 25, 1997, according to a hospital memo. “Based on the review, he stated that while they appreciated the information which they have received, that no follow-up was deemed by the Joint Commission to be necessary at this time,” according to the memo.
The Bridgeport hospital had been accredited in June 1996, ranked as one of the top 1 percent best medical centers nationally. It retained a high ranking even after the hospital settled four lawsuits involving patients who contracted infections. But during the same month that Joint Commission officials closed their inquiry, state public health investigators conducted a surprise inspection and found myriad patient care and infection control violations, such as failure by surgical assistants to wash hands.
The hospital initiated dozens of reforms after the state inspection and currently is in compliance with all standards, according to state public health agencies. Infection rates have been reduced to less than 1 percent from a high of 20 percent.
As the Bridgeport case illustrates, the Joint Commission’s rankings are often at odds with findings by state and federal public health agencies. The Tribune’s computerized review found 2,352 hospitals that had received state or federal citations during 2001 for life-threatening deficiencies after the Joint Commission issued its stamp of approval.
Joint Commission officials said surveys represent a “snapshot of quality,” not guarantees of patient safety. However, new monitoring programs are being adopted to send surveyors into hospitals and require hospitals to self-report problems between inspections, O’Leary said.
When faced with informing the public or shielding information about a hospital, the Joint Commission’s loyalty is clear.
Last year, Ralph O’Connell, 75, developed a chest infection that spread to his sternum after cardiac surgery at the 204-bed Palm Beach Gardens Medical Center, owned by the Tenet Healthcare Corp.
He is one of more than 100 patients who filed medical malpractice suits earlier this year against the medical center. The patients contracted infections after cardiac surgery, resulting in 18 deaths, court records show. Almost all the surviving patients, including O’Connell, complained to the Joint Commission.
Findings not released
Joint Commission officials said they sent investigators to tour the hospital in August and October 2002. But their findings are withheld from the public. “If we want any modicum of cooperation from the hospitals, they have to feel we’re not to put it [investigative findings] right out on the street,” O’Leary said.
Three weeks ago, O’Connell received a thank-you letter from the Joint Commission, but the letter also included this cautionary note: “Please be aware, our current Confidentiality and Disclosure Policy precludes us from providing you with specific results of any complaint violation.”
“It’s outrageous,” said O’Connell, who is recuperating at his home after six surgeries to remove the infection from his chest. “This infection has destroyed my life, but I’m being treated like I’m the bad guy.”
The Joint Commission referred O’Connell to its Web site to check for any changes in status to Palm Beach Gardens Medical Center. The public can search for accredited hospitals but discern little beyond the facility’s overall score–and even then it’s unclear what those numbers mean in terms of quality. Palm Beach Gardens achieved 94 out of 100 possible points.
In late October, inspectors from the federal Centers for Medicare & Medicaid Services staged a surprise inspection at Palm Beach Gardens and declared that uncorrected infection-control deficiencies represented “immediate jeopardy” to patients. The investigators said they were responding to patient complaints of inadequate care.
Hospital officials say all deficiencies now have been resolved and characterize the patient suits as unjustified.
O’Leary described the hospital’s struggle with infection control as a “serious and very significant problem.” However, because problems are corrected, he indicated that the Joint Commission will not alter the hospital’s accreditation.
“There’s been no change to the score,” O’Connell said. “You would have no idea that anything has ever happened.”
Hospitals try to prepare
Joint Commission surveys are conducted every three years, and for an average-size hospital, the fee is about $40,000. With Medicare certification on the line, the stakes are high.
To bolster chances of receiving a passing grade, hospitals sometimes hire a spinoff consulting business of the Joint Commission itself. The non-profit Joint Commission Resources, which dates back to 1986, offers to help healthcare facilities prepare for accreditation and charges about $10,000 for a three-day evaluation.
Because of the advance notice of inspections, hospitals also have time to temporarily clean up their facilities, which may impress inspectors but does little in the long run for patients if the hospital reverts to its former practices.
In one instance, a New York hospital hired movers with semitrailer trucks to clean out antiquated and broken-down medical equipment that cluttered hallways. The equipment was returned for use on patients after surveyors left, according to a Joint Commission surveyor and confirmed by a hospital executive.
A Minnesota hospital bought hundreds of new towels and pillows to grace every empty bed, then returned the merchandise after the survey, according to a Midwest surveyor who learned of the purchases by interviewing nurses.
And a California hospital drilled doctors on Joint Commission standards, including issuing palm cards with statements doctors should deliver if approached by a surveyor. Any doctor who used a statement from the palm card received a $1,000 bonus, according to nurses who were on duty during the survey.
From the hospitals’ perspective, a survey can be a maddening and unpredictable experience. Hospital officials complain that there is a lack of training and consistency among surveyors, who may be former hospital executives, nurses, and doctors, even retired military officers. Some feel as though they are beholden to the surveyors’ whims. “I had one surveyor fax over his menu requests in advance, from the kind of steak he wanted to the salad dressing,” said a Denver hospital executive who asked not to be identified.
Still, many in the healthcare industry praise the Joint Commission. “I think they do a good job and it’s getting better,” said Larry Boress, executive director of the Chicago Business Group on Health, a business coalition that represents some of the city’s largest employers including Sears, Roebuck & Co., Abbott Laboratories, and The Northern Trust.
As an alternative to the Joint Commission, hospitals can turn to state public health agencies, which charge no fees for accreditation. If the state route is chosen, however, hospitals must be accredited annually, instead of every three years, and full inspection reports are made public.
But a handful of hospitals are bucking accreditation from the Joint Commission in favor of free state surveys.
North Country Hospital and Health Center in Vermont allowed its accreditation to expire after deciding the Joint Commission’s process didn’t improve quality of patient care at the 36-bed facility. “When I started as CEO in 1987, the Joint Commission’s volume of standards was three-quarters of an inch thick, and we ended up more recently with three-inch notebooks that were the standards,” said Sidney Toll, former chief executive of North Country before he retired in June. “It was getting overwhelming for us.”
In one such evaluation, Joint Commission surveyors criticized how a kick doorplate was attached to the bottom of a metal door. Surveyors wanted the plate glued, rather than screwed on.
“They said the screws ruined the integrity of the door, so we had to fill in the holes with fireproofing and glue the plate back onto the door,” Toll said. “We wanted to focus on standards that had to do with patient care.”
Although the hospital has no regrets about leaving the Joint Commission, North Country officials said they were worried about how they would be perceived in the industry.
The hospital has passed every state inspection, and commercial insurance plans continue to provide the hospital with payments as they had under Joint Commission accreditation.
“It is a scary thing to leave the Joint Commission, because people think there is something wrong with you if you are not accredited by them,” North Country’s current Chief Executive Officer Karen Weller said. “But that’s just not the case.”
The Joint Commission is also losing favor with some health insurance companies and employers that don’t see the group as improving quality despite such a vaunted stature.
Alternatives sought
Instead of looking to the Joint Commission, business groups and the government are looking for their own answer to holding hospitals accountable by creating their own quality measurements to allow consumers to choose the best medical care providers.
In a potentially dramatic move, the Bush administration’s top Medicare official said he is researching ways that would open hospital accreditation to more organizations. “There is no reason why the Joint Commission should have a lifetime monopoly,” said Thomas Scully, director of the Centers for Medicare & Medicaid Services in Washington.
“I just think keeping a lot of competition keeps everybody on their toes.”
Chicago Tribune staff reporters.
Nov. 2, 2002
Editor: Although the publication date of an article may not be current the information is still valid.