Joint Commission's hospital program OK'd for continued deeming authority from CMS

Big changes still to come

"We're all glad it's pretty much over," Margaret VanAmringe, MHS, The Joint Commission's vice president for public policy and government relations, says with a laugh. In what was not much of a surprise for people in the industry, on Nov. 27, the Centers for Medicare & Medicaid Services (CMS) gave the nod for continued deeming authority to The Joint Commission's hospital accreditation program, following Congress' 2008 revocation of the organization's unique deeming status, awarded by Congress in 1965.

It was a long and arduous process VanAmringe says, mostly for the good, but she says the awarding of deeming authority does not mean there is not more work for The Joint Commission, and thus its accredited hospitals.

"We did expect that it would go through," she says, "but it was a very complicated process." In part, she says, that was because The Joint Commission wanted to phase in some of the changes to give their hospitals time to implement them. Going forward, if any "substantial" changes are made to its survey processes, standards, or policies, The Joint Commission will have to notify CMS and seek its review and approval.

She says some of the phased-in changes, part of the revised standards posted March 26, are not effective until July 2010, at which point CMS will return to review and ensure those changes have been made. She also adds: "We have a separate effort where we are hoping to work with CMS to see them update some of their standards, to modernize some of them. So we're hoping they also will be continuingly looking at their standards, making them more state of the art."

More changes on the way?

VanAmringe admits there is more work with CMS in the near term. In working with CMS to ensure Joint Commission standards were in line with the governmental agency's Conditions of Participation, there were a few things she says that were too complex to come to terms on — items The Joint Commission will continue to work with CMS on to deliver "acceptable" changes.

One of those areas relates to The Joint Commission's telehealth standards. "We have a very different approach to credentialing and privileging of telehealth services than CMS," she says. "We had left that to the end because we had been trying to convince CMS to not change the standard, or not make us change our standard. And that was not successful. So we always knew that if that wasn't successful, we would have to make that change in January." She says it was too large a change to make, so The Joint Commission has held off on finalizing that.

Some other changes, she says, involve the survey process — "the way we weight things and decide when Conditions of Participation are out of compliance or the follow-up requirements," she says. The Joint Commission is still negotiating with CMS on determining "new policies in terms of corrections." Changes likely will affect The Joint Commission's condition-level follow-up survey. She says there will be further guidance likely this month.

Another change that could have a big impact on hospitals is that CMS wants the accreditation number The Joint Commission gives a hospital to match CMS' certification number, or CCN number. "That's not as simple as it sounds because of the many requirements [CMS] has," VanAmringe says. "We have hospitals that may have to do some reevaluation of the way they are configured in order to do this." For some hospitals, it will be simple. For others, she says, it will be difficult.

For instance, she says, if a hospital has two locations but one CCN number and the hospitals run as separate hospitals with common ownership but each has its own medical staff ownership, CMS would not deem that acceptable. Each hospital would have to have its own CCN number. Or if it's the same scenario but there's one medical staff, CMS may require each organization to have its own medical staff, which could require "a whole new set of organizational policies and privileging and all sorts of things," she says.

Or if there is one governing body over the two hospitals but each has its own medical staff organization, VanAmringe says CMS would require that each have its own governing body.

"So that means some changes. The hospital has to either now create a second governing body for the second hospital or it has to find a way to have the governing body do business for the first hospital and then sort of close its agenda and start up on the second one. That's a possibility that we've been looking at. It's not definite yet," she says.

Getting a CCN number, she says, is no easy matter. "It doesn't happen overnight. There is a lot of paperwork and hoops and requirements that have to be met, understandably so," she says, adding that The Joint Commission is still working with CMS on this and trying to ease the burden as much as possible for its hospitals.

What does VanAmringe say to critics of The Joint Commission, often politicians or consumer advocates, who say The Joint Commission is "too cozy" with its clients, i.e. hospitals?

"I know people have that perception. But I can tell you, having worked at The Joint Commission for 15 years and having worked at CMS on the other side in the survey area, that it is not the case. We try to advocate for hospitals... [o]ur mission is to improve the quality and safety of care to the public and to help health care organizations do that. And we believe we have to continuously increase the relevancy and rigor of our standards, which we do. If we were that close to our accredited organizations, we would sit back and never change our standards," she says.

She says The Joint Commission welcomes competitors to the accreditation field and says competition has helped the organization home in on who it is and what it brings to the table. The only concern the organization has, she says, is it "wants to be judged fairly by the government. We are always subject to validation surveys, and we welcome those. But in the past, the other hospital accreditation bodies, and in the past there was only one, now there's two, have not had the same validation oversight."

In response, a CMS spokesman says: "We conduct validation surveys for all accreditation organizations and their approved programs. Validation surveys are conducted in AOA- [American Osteopathic Association] and DNV-accredited hospitals. However, AOA and DNV have smaller hospital programs than The Joint Commission. As a result, more validation surveys are conducted on Joint Commission hospitals."

VanAmringe says if there is an issue with accrediting bodies, it isn't competition. It's the economy. Her concern is that as Congress continues to look at cuts for providers and the economic situation being what it is, hospitals may find themselves unable to afford accreditation. "[I] think that is a public policy issue that we as a country need to confront, because one of the things that accreditation has always brought to the table is the ability to be flexible and nimble, to always continuously [improve standards] in accordance with health and medical practice, where the government takes three years to finalize a regulation because of the way the government has to go out and do all of its mechanizations," she says.

"I worry about that more than I would ever worry about competition among accrediting bodies."

On the topic of competition, Yehuda Dror, president and CEO of DNV Healthcare, which last year was granted deeming authority, says, "now that all hospital accreditation organizations are subjected to the same governance, I wholeheartedly agree with Dr. Chassin's [Joint Commission president] recent comment that 'competition makes us better.' Competition makes everyone better. Whenever customers have a choice, providers must perform at a higher level."