OIG’s blast of JCAHO/HCFA hospital surveys raises the bar for QI directors

Get ready for drop-in surveys and random file checks

Many hospital quality improvement directors and other hospital executives will be and are scrambling to fast-track their QI initiatives and upgrade their files due to the shot heard round the industry fired by the Office of the Inspector General (OIG) on July 20. The upshot of the OIG blast for QI managers is that inspections will be more frequent and unannounced, and files will be pulled for audit purposes on a random basis.

In the long-awaited report, the OIG takes aim at the hospital oversight process conducted by the Joint Commission for the Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, and by the Health Care Financing Administration (HCFA) in Washington, DC. It charges that JCAHO is soft in its inspections and says that HCFA goes along with the survey practices.

In response, HCFA Administrator Nancy-Ann DeParle can point to the Hospital Quality Oversight Plan already offered by her agency that incorporates many of the OIG recommendations, especially the call for more frequent and unscheduled surveys by the Joint Commission. HCFA says the agency will:

• require state agencies to conduct more surveys of nonaccredited hospitals;

• strengthen oversight of both the state agencies and JCAHO;

• make a better effort to balance the collegial and regulatory approaches to oversight.

The OIG report takes issue with the tone of "collegiality" that characterizes surveys in recent years. Further, it attacks the lack of public disclosure of survey findings, especially adverse events and lapses in patient safety measures. "The clear and disturbing conclusion of this report," concludes the OIG, is that both the Joint Commission and state agencies are only minimally accountable to HCFA for their performance in reviewing hospitals." In its response to the findings, HCFA promises more unannounced surveys and JCAHO vows to regulate as well as educate. Surveyors will be asked to pull and review files on a random basis.

HCFA also says that in an upcoming revision of its Conditions of Participation regulations (COPs) the agency will more clearly define its priorities for hospital surveys of basic health and safety issues, such as medication errors and surgery mix-ups. The final COPs are expected to be completed by fall 2000 and will include Inspector General June Gibbs Brown’s recommendations and HCFA’s Hospital Quality Oversight Plan.

As the product of an exhaustive two-year study by the Department of Health and Human Services’ OIG, key findings from the series of four reports describe flaws throughout the hospital oversight system:

• The hospital review system’s shift to a more collegial than regulatory style of oversight could result in less emphasis on practices that reduce the risk of poor patient care.

• HCFA fails to obtain meaningful or complete survey feedback from either JCAHO or the state agencies. The report describes HCFA’s posture toward JCAHO as "more deferential than directive."

• Minimal public disclosure of either of the state agencies’ findings or of JCAHO survey reports on hospitals hampers consumer evaluation of a hospital’s performance.

• While JCAHO surveys lead to reduced risk and improvement of hospital care, they are not likely to find substandard patterns of care or to identify individual practitioners with "questionable skills."

• State agencies drop the ball in surveys of nonaccredited hospitals. About 50% of the nonaccredited hospitals, in 1997, fell below the industry standard of three-year survey cycles. Rarely do state agencies conduct routine surveys. Some nonaccredited hospitals in rural areas have gone for eight years without a survey.

HCFA should, according to the report, "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."

In a set of recommendations for HCFA, the report directs the agency to negotiate with JCAHO to conduct more unannounced surveys and introduce more random selection of records into the survey process and conduct more rigorous review of hospitals’ continuous quality improvement efforts.

Tell about reviewers and performance’

The report states that public disclosure "conveys not only something about the hospitals’ performance" but it also fosters public trust. In a response to the report, HCFA created a Hospital Quality Oversight Plan. By publicizing information about the reviewers, "HCFA conveys that it is monitoring the work they do on [the public’s] behalf."

The Medicare supervisory agency announced that it is currently coordinating a pilot project to examine how to develop and distribute hospital performance data that will enable consumers to compare the quality of care among hospitals. No doubt, it’s a worthwhile goal, "but we can’t say we’re good to go on that recommendation today," asserts Mary Grealy, chief counsel for the American Hospital Association (AHA) in Washington, DC. Health care has a way to go before meaningful performance data will be ready to present to the public, she adds. Already there is a plethora of hospital comparison data out there on the Internet, but reliable public disclosure "needs to offer apples to apples comparisons," not information for information’s sake. She reiterated the longstanding desire of hospitals for coordinated data reporting for HCFA and JCAHO.

Ruth Loncar, MBA, CPHQ, corporate director for Quality and Outcomes Management at Adven-tist Health in Roseville, CA, shares concerns about how the disclosure will happen. "If we use ORYX data, it is somewhat standard, but it’s not risk-adjusted yet, so anyone looking at it would not be comparing apples to apples." Loncar also wonders how much explanation would be offered about the statistical significance of data changes on a quarterly basis. For example, the public might draw incorrect conclusions from a one-time increase in infection rates, unless the difference between trends and isolated events was explained.

In a response to the report, HCFA discloses that it is developing evidence-based quality measures. In progress are performance measures of the rate of beta-blockers prescribed for patients hospitalized following heart attacks, mortality rates following surgery, and infection rates following surgery.

As for an added reporting burden for QI managers, Loncar does not foresee much change if JCAHO uses the ORYX data that are already available. Anything beyond that could require added resources.

Unannounced surveys, random file audits

HCFA also will clarify JCAHO’s responsibility for, and will cooperate with, the private organization to conduct more unannounced surveys. The Joint Commission is to "perform more rigorous assessments of each hospital’s internal quality assurance process."

Larry Wall, president of the Colorado Health and Hospital Association in Denver, observes, "A difficulty with unannounced surveys is that often you’re missing key folks that the surveyors need to talk to, so the surveyors are left without appropriate feedback for a good survey."

Loncar notes, "I would hope that unannounced surveys would not send QI managers scrambling to get their records in order." To keep its own house in order, the 20-hospital Adventist system conducts midcycle internal audits every 18 months to complement JCAHO’s three-year survey process. Accustomed to unannounced state surveys, Loncar says a similar change by JCAHO "would not make any difference in how we do our operations."

The OIG is troubled by the collegial tone of survey visits. "As a guiding principle, [it instructs HCFA to] steer external reviews of hospital quality so that they ensure a balance between collegial and regulatory modes of oversight." The report concedes, however, that "Although a mix of cooperation and punishment is likely to be an optimal enforcement policy, the literature provides no clear guidance concerning what policy is optimal."

Grealy counters, "One of [AHA’s] concerns is that you need a balance of the regulatory approach with the collegial or educational. It’s important that we don’t have a policing approach to surveys." In a letter to Inspector General June Gibbs Brown, Grealy wrote, "We find no evidence or discussion of whether the problems identified in the report, for example, the lack of ability to detect substandard patterns of care or individual practitioners with questionable skills, have grown worse as oversight organizations have emphasized a non-punitive approach. Additionally, there is very little discussion of why increasing punitive efforts will be more effective."

Wall challenges the "underlying assumption that the collegial approach does not improve the process of care." He continues, "Providers are not in business to provide bad care. With the exception of a few, if you can get quality information into their hands, they will use it.

"And who is better prepared than the Joint Commission, with their position of oversight and acquaintance with hospitals around the country, to spread the learning from good patient care practices?"

(Next month, QI/TQM will bring you in-depth coverage of the report’s implications for QI managers.)