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Responding to a scathing report from the Department of Health and Human Services, the Joint Commission on the Accreditation of Healthcare Organizations is sending word that its inspections will be more frequent and at least some will be unannounced. The new approach is meant to counter recent concerns that the Joint Commission’s on-site visits were too easy on health care providers, allowing them to prepare for the visits and choose many of the documents to be reviewed.
Joint Commission administrator Nancy-Ann DeParle, PhD, says the changes will include new evidence-based quality measures, including benchmarks developed by peer review organizations. An example of a benchmark under development is the rate of beta-blocker drugs prescribed for patients after heart attacks.
She tells Healthcare Risk Management that the Joint Commission supports the report’s call for an appropriate mix of announced and unannounced on-site hospital evaluations; timely and effective responses to complaints and identified adverse events; use of performance measures; and focused emphasis both on patient safety and quality improvement.
The Joint Commission is too easy on hospitals because it tries to foster a "collegial atmosphere" with providers, says June Gibbs Brown, PhD, inspector general of the HHS in Washington, DC. Her report, titled External Review of Hospital Quality, says the Joint Commission is generally unable to detect substandard care or identify incompetent doctors because Joint Commission inspectors announce their visits in advance and rely on hospital employees to select the records that will be reviewed. The result, Brown says in her report from the Office of the Inspector General, is that the Joint Commission is more of a yapping lap dog than an aggressive watch dog — annoying maybe, but not really threatening.
Among the criticisms, the OIG report says Joint Commission surveys are unlikely to detect substandard patterns of care or individual practitioners with questionable skills because they do not include an objective, aggressive examination of hospital conditions and practices. The report also says the Joint Commission should use public disclosure of substandard practices to force change, a tactic that currently is rarely used because so much information is protected from public disclosure.
Many risk managers would disagree, but Joint Commission president Dennis O’Leary, MD, released a statement saying he does not dispute most of the OIG report. O’Leary says he welcomes suggestions for how to make the Joint Commis sion’s oversight more effective, but he points out that the oversight does not have to be adversarial. Nevertheless, the Joint Commission responded quickly to the OIG report by offering a set of improvements that will be incorporated in an upcoming revision of the Medicare Conditions of Partici pation. The Joint Commission accredits about 80% of the nation’s hospitals.
Here are some of the upcoming efforts, some of which address recommendations cited in the OIG report:
• more unannounced surveys;
• randomized selection of medical records, credentials files, and personnel files for review during accreditation surveys to make the evaluation process more objective;
• greater focus on consistency in the accreditation process;
• new toll-free consumer complaint hotline;
• emphasis on reducing the risk of adverse events;
• increased emphasis on continuous compliance with standards;
• introduction of standardized performance measures into the accreditation process;
• establishment of a public advisory group to build closer working relationships with recipients of care and those who advocate on their behalf;
• focusing accreditation surveys on areas of current concern (examples: staffing, Y2K, adverse outcomes).
Currently, more than 85% of hospitals evaluated by the Joint Commission are cited for standards deficiencies, DeParle says. The Joint Commission requires both implementation and demonstrated effectiveness of specific corrective actions to address those deficiencies as a condition of achieving and maintaining accreditation.
In a related matter, the Joint Commission has approved five focus areas for initial development of core sets of performance measures, based on the consensus reached at its annual State Hospital Association Forum. These are the new focus areas:
• acute myocardial infarction (coronary artery disease);
• congestive heart failure;
• surgical procedures and complications;
• pregnancy and related conditions.
The Joint Commission intends to require the use of core performance measures as an integral part of the accreditation process in the future, DeParle says. Content and methodologic experts will participate in clinical advisory panels for each of the focus areas, helping establish the clinical measures within the five measurement areas. The measures selected then will be subject to a final review by the field.