HCFA surveys the surveyors

Crosswalk issues blur disparity stats

Feeling comfortable because you've just completed your survey by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations? Don't rest on your laurels just yet. You probably know that about 200 hospitals are surprised each year by Medicare teams that come in after the Joint Commission. What you may not know is that in 1996, that validation process found that 13% of surveyed hospitals were violating Medicare requirements. And there were 17% the year before. Does that statistic cast a shadow on those facilities and their accrediting agencies? Or does the Health Care Financing Administration (HCFA) have some catching up to do?

Summit Medical Center in Nashville, TN, underwent a validation survey last October. Patsy Wells, director of quality management there, says there was some advance notification by Summit's parent company, Columbia/HCA, that the hospital could probably expect a HCFA validation survey within 60 days of its Joint Commission survey. Summit's August accreditation survey was "uneventful," says Wells.

"We did well and finished with one Type 1 recommendation. We'd had three, but we appealed two that were subsequently removed. My understanding is that our facility was randomly chosen for the Medicare survey." Summit was recently named to the "100 Top Hospitals: Benchmarks for Success" list compiled jointly by William M. Mercer consulting company in San Francisco and HCIA in Baltimore.

Summit's validation survey involved four surveyors from the state - two nurses, one surveyor who concentrated on plant and safety, and one trainee. The facility fared very well with no recommendations.

Surveys becoming less punitive

"The survey had an inspection-oriented approach," Wells says. The Joint Commission is trying to get away from the white-glove inspector approach; JCAHO wants its surveyors to be more consultative and less punitive in the way they go about determining compliance with standards.

The HCFA team reviewed incident reports, and "that's something I've never had a surveyor do," says Wells. They asked questions related to a particular incident and how the facility managed it. The surveyors spent a short time in medical records and looked at how the staff stores meds and does unit dosing in the care unit. They spoke briefly with the staff, but "didn't conduct the extensive interviews that the Joint Commission does," she explains. The team never alluded to the Joint Commission survey.

Another hospital in Georgia underwent a HCFA survey recently, and the quality manager there reported a similar experience. The HCFA survey was "less painful" that that of the Joint Commission, she reported, and was "rather a cursory walk-through."

"I was never asked by the state or by HCFA how well the surveyors did," says Wells. Joint Commission surveyors routinely ask for and get feedback on how they're doing.

A downward trend of noncompliance

Generally, accredited hospitals have few problems meeting the Medicare conditions of participation (COPs). Validation of accredited hospitals indicates an overall downward trend of noncompliance. The Joint Commission survey evaluates a hospital's compliance with requirements at least as stringent as the Medicare COPs. Validation surveys show that the physical environment COP continues to be the most frequently cited condition based on noncompliance with life safety code requirements. (See chart on COPs cited during surveys, above.)

The 1997 disparity rate has not yet been determined. The 17% rate means that out of 89 validation surveys performed in 1995, 21 showed condition-level noncompliance. When HCFA compared the survey reports of those hospitals with the corresponding accreditation reports, six showed comparable condition-level deficiencies, leaving a disparity rate of 17%. Similarly, out of 92 validation surveys performed in 1996, 20 showed condition-level noncompliance. When HCFA compared those reports, eight showed comparable condition-level deficiencies, leaving a disparity rate of 13%. The disparity rates for both 1995 and 1996 fell below HCFA's 20% threshold for further action.

Some COPs conflict with JCAHO standards

"That 13% to 17% disparity rate is not surprising because HCFA and the Joint Commission are working with two sets of standards that aren't in agreement," comments Wells. "HCFA works off Medicare COPs that were last revised in the `80s, and that was clear as they were going through our facility. Some of what they were looking for was actually in conflict with Joint Commission standards." After making sure everything was in order for the Joint Commission survey, it was "disheartening" when Wells' team saw what the validation survey was going to be about. "If HCFA's aim is to validate the Joint Commission survey, they should be using the same tools," she argues.

"The Medicare conditions of participation now are obsolete in so many areas," says Wells, "that it was hard to know how it would go. The old requirements for UR and QA committees and reports - these were all things we had passed years ago. That was a little disconcerting, because we weren't sure how literally we'd be held to those older standards."

"The validation survey is part of our oversight of accrediting bodies," says Rachael Weinstein, RN, senior health insurance specialist at HCFA in Washington, DC. "We compare our results with those of the Joint Commission to see how they're doing." Congress mandated in 1972 that HCFA perform annual validations of a random sample of approximately 5% or 200 hospitals subject to accreditation surveys to ensure that they meet Medicare and Medicaid requirements. The hospitals being reviewed are accredited and not subject to the jurisdiction of either HCFA or the state unless a problem is found.

Validation surveys fall into four categories:

· Random sample.

Accredited hospitals are randomly selected for survey within 60 days after their Joint Commission survey.

· 18-month sample.

Accredited hospitals are randomly selected for survey at the midpoint of their three-year Joint Commission accreditation cycle.

· Conditional sample.

Specific accredited hospitals are surveyed for selected Medicare requirements based on Joint Commission requirements not met during accreditation surveys. Those hospitals were given conditional accreditation based on numerous Type 1 recommendations. (See chart on noncompliance in the first three categories of validation surveys, above.)

· Substantial allegation surveys.

Complaint surveys are performed in response to incoming serious complaints involving potential threats to the health and safety of patients in accredited hospitals. (See chart on noncompliance in allegation surveys, p. 64.)

When, in the course of a validation survey, HCFA finds some items out of compliance at a facility, these questions are asked: "Did the Joint Commission find the same noncompliance?" and "Are they taking action to see if it's being cleared up?"

"At the first threshold," says Anthony Tirone, JD, director of federal relations at the Joint Commission's Washington, DC, office and former director of HCFA's Office of Survey and Certification, "the fact that a facility is not complying 100% with all the standards and conditions of Medicare does not say anything about whether the Joint Commission is doing its job. The next level, however, involves the `crosswalk,' where HCFA has to determine whether the Joint Commission identified the same problems it did and whether the Joint Commission addressed those problems."

Turning prunes into lemons

"We've been working very hard with HCFA for a couple of years to revise the validation process," says Tirone. (See related article on reinventing the validation process, below right.) "The problem is with the crosswalk - it's now become huge and unmanageable. It's very difficult to make any meaningful comparisons. The crosswalk has the task of turning prunes into lemons," he says.

That's because the standards of the Joint Commission don't dovetail with those of Medicare. Medicare hasn't changed its standards since 1986. Once the revised COPs are out, the crosswalk will be easier. (See cover story in Hospital Peer Review, March 1998, for an article on the revised Medicare COPs.) "But if history is any guide, the final COPs won't be out for a year or two at best," says Tirone, "and by then the Joint Commission will probably have gone beyond those, and the COPs will still be somewhat outdated."

With crosswalk problems behind, a new realistic validation process will take into account more than just the outcome. "The question that will have to be answered when we're through is, Does Joint Commission accreditation give the same level of assurance that hospitals meet health and safety requirements as the Medicare survey? We're dealing with 98% of hospital beds, and that information is crucial," explains Tirone.

"There have always been discrepancies in areas where the Joint Commission's and HCFA's standards are different," says Janet McIntyre, Joint Commission spokeswoman. The life safety code, for example, was an area where HCFA was finding a higher-than-acceptable disparity rate three or four years ago. The Joint Commission surveys against the 1997 life safety code, and HCFA at that time used a life safety code from the late `80s. HCFA sat down with the Joint Commission to review those findings, and HCFA instituted a whole new training program for their surveyors. The disparity rate came down dramatically.

The three general health and safety COPs found out of compliance most frequently in 1995 and 1996 were physical environment, quality assurance, and medical staff. Compliance with the life safety code was part of those statistics also due to its being part of the physical environment COP.