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Random record-pulls expose hospitals to new liabilities
If you thought Joint Commission surveys were stressful before, just wait until you get a knock on the door for a random unannounced survey. Instead of being able to choose which records the inspectors see, they will tell you which ones to produce.
The new policy announced recently by the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, is bound to make the entire accreditation process much more difficult and dangerous for risk managers, says Grena Porto, RN, ARM, DFASHRM, director of clinical risk management and loss prevention services at VHA Inc. in Berwyn, PA, and president of the American Society for Healthcare Risk Management.
There is a greater chance that your organization will run afoul of some Joint Commission expectations under the new policy, so the entire accreditation process becomes more difficult, she says. (See "OIG: Joint Commission too easy on hospitals," September 1999 Healthcare Risk Management, pp. 107-108.)
"This is very much a significant change for risk managers," Porto says. "It used to be that if you had your triennial survey done in March, you know the next one will be March 2002. They might change it to February or April or May, but you know well in advance when you’re due for an on-site survey. You only got a surprise inspection if you had some really big blow-up at your facility."
Changing the policy so providers can be subjected to unannounced random surveys completely changes the way risk managers must participate in the accreditation process, Porto says. Some of those effects are good, eliminating what she says were inherent weaknesses in the process, but some of the effects also will make your life more difficult.
Stricter policy in response to OIG audit
The changes were made in response to a report from June Gibbs Brown, PhD, inspector general of the Department of Health and Human Services (HHS) in Washington, DC. In her report, "Exter nal Review of Hospital Quality," she said the Joint Commission has been too easy on hospitals, trying to foster a collegial atmosphere instead of ensuring that its on-site surveys would ferret out any problems. The Joint Com mission is 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 report says.
When the HHS report was released, the Joint Commission wasted little time in responding. President Dennis O’Leary, MD, indicated that he accepted most of the criticism without argument, but he noted that oversight does not have to be adversarial. Almost immediately after the critical report, the Joint Commission’s board of commissioners reported that it was modifying its policy for on-site surveys. Under the revised policy, which is expected to go into effect Jan. 1, 2000, providers will receive "no advance notice for random unannounced surveys." The random unannounced surveys may be conducted any time between nine months and 30 months after the provider’s triennial full survey.
"The scope and focus of review during an unannounced survey will vary from organization to organization and will be based on information relating to recommendations made during the organization’s previous triennial survey, known sentinel events, and other relevant information regarding the organization’s performance," according to the Joint Commission announcement. The group also is considering a change in the way it awards Accreditation with Commen dation to exemplary providers, based on the HHS criticism that the award becomes meaningless when too many providers earn it.
Porto says that the Joint Commission’s new approach is understandable to some extent because even the providers who benefited from the older policy admit that it was a bit lax. With three years to prepare for the next survey, it was too easy to put on the best face no matter what was going on at your facility the rest of the time, she says.
"I think most everyone would agree that a triennial survey really was not any indication of continual compliance. It’s an indication that you’re in compliance every three years when you’re surveyed," she says. "In the past, they would say they wanted 100 charts, and, if you had half a brain, you pulled 100 charts that looked pretty good. Now this policy will create more of a burden for hospitals, but the old system was fundamentally flawed."
Still, Porto says she is not entirely happy with what she hears of the Joint Commission’s new approach. Even if some of the measures are justified, she says she is uncomfortable that the Joint Commission reacted so quickly to the Office of the Inspector General report without consulting industry leaders or proposing new options for feedback. The Joint Commission always announces it wants to consult the industry before making big changes, she says, "yet here’s another instance of them making a huge change without consulting anybody."
It would have been more productive to sit down with those responsible for compliance and work out ways to make the process more productive without placing an unreasonable burden on hospitals, she says.
Confidentiality problems could result
Not all risk managers think the changes were needed. The previous policy was better than switching to unannounced visits, says Peggy Nakamura, RN, MBA, JD, DFASHRM, execu -tive director of risk management and associate counsel at Adventist Health in Roseville, CA. Nakamura also is an immediate past president of the American Society for Healthcare Risk Manage ment in Chicago. She tells Healthcare Risk Management the recent changes would be more appropriate for a regulatory body, not an accrediting body like the Joint Commission. The process could be counterproductive if providers see the prospect of random surveys as more of a regulatory activity, some observers say. (For more on that possibility, see story, p. 117.)
"I don’t see that there is an appreciation by the Joint Commission of what it means to be an accrediting body," she says. "The more they do this sort of thing, the more they seem like a regulatory body. It’s sort of a policeman mentality, and I don’t think that encourages quality."
The biggest problem with the new approach is the way the Joint Commission will request records for review, Nakamura says. With no advance request, it will be difficult for the hospital to just turn over all the records immediately. When medical records are involved, it is never easy to just hand them over without a thorough review of whether such a release is acceptable. The question is not so difficult when dealing with regulatory bodies, such as the state health department, because state laws usually provide clear exclusions that make it acceptable for the hospital to hand over the records, she says. But with the Joint Commission, it’s a different story.
The records could involve behavioral medicine patients whose records must be kept confidential, for instance, or they could involve potentially compensable events that the hospital wants to protect from discovery. Under the previous method, the hospital would know far ahead of time if certain records or types of records were requested, and there would be adequate time to investigate the situation and determine what to do.
"Now we’re going to just have to hash all that out in real time, after they give us a list of what they want," she says. "I think that’s asking a lot for people to be able to make these decisions on the spot. It’s hard to sort out all the multiple layers of regulations and statutes that apply when you’re on the front line and someone’s asking for the records right now."
At the very least, Nakamura says, the process will be extremely inefficient for both the Joint Commission representatives and the hospital. There won’t be any choice in some situations but to just tell them to wait while you decide whether you can release the record, she says. One tip: Nakamura suggests that when you have to delay handing over a record, ask what else you might provide in the meantime. That helps diminish the appearance that you might just be stalling or uncooperative.
Sentinel events could pop up in review
Another possible problem with the record review is that the Joint Commission might get wind of a potential sentinel event it didn’t know about already. Especially if the incident is recent and you are just beginning the review process, you may be faced with a situation in which the Joint Commission has requested records related to that event, but you don’t yet know whether you should release those records. And there always is the possibility that the records will reveal a sentinel event you chose not to report, one that the Joint Commission never would have heard of otherwise.
It is a good idea to have legal counsel involved in the review of records requested by the Joint Commission, Nakamura says. (See p. 116 for more advice on who to involve in the on-site visit.) "My greatest concern is that, with unannounced appearances and the request of medical records, it’s going to bring the hospital to a standstill," she explains. "What if your medical records director is on vacation? With staffing constraints, who knows if all the right people will be available when the Joint Commission appears?"
The "minuteman" aspect of the new policy is what seems to make risk managers uneasy. While many would agree that the previous policy was too lax to be truly effective, the new policy of random unannounced visits seems to go too far in the other direction.
Now risk managers, and the rest of the hospital, have to be on their toes every day, ready for a Joint Commission team to walk in with clipboards.
Porto says she has heard that hospitals might get 24 hours notice, but that’s not much. Still, some might say that if your facility is in compliance, as it should be at all times, then what’s the problem with having inspectors come with little or no notice? That makes sense theoretically, Porto says, but it ignores the reality of running a busy hospital.
"In reality, we know that’s not the way life works. You’re operating 365 days a year, 24 hours a day, and there are going to be natural slips, ebbs, and flows in that operation," Porto says. "If you were only open Monday through Friday, nine to five, maybe you could ensure the same high level of quality all the time. But, in a hospital, there will be times things are suboptimal and times when they are superoptimal. I think that’s what everyone is scared about."
Attention will be diverted on short notice
Even when you could expect to see Joint Commission inspectors just every three years, it took a great deal of time and effort to prepare for the survey, she notes. Now you may have to throw all that attention to the inspectors with little or no notice. Having enough time to hide your problems should not be the goal, of course, but Porto says she worries that risk managers will be diverted from other concerns by the ever-present possibility of an inspection.
"You need some amount of time to prepare, not because you’re out of compliance but because you’re running a business," she says. "If you suddenly pull all your department heads away from their jobs to meet with the Joint Commission inspectors, something is going to slip. It’s like if any company suddenly announced to the employees that they’re going away on a three-day retreat starting tomorrow. What happens to the work they should be doing?"
The constant need to be ready also changes the job description for risk managers involved in the accreditation process, Porto says. You may need to make your boss aware of how the new policy changes your daily activities so that he or she understands why you suddenly have more on your plate.
Another likely downside from the new policy is that the scores from unannounced visits are likely to be lower than those for which you’ve fastidiously prepared, Porto says. It would be nice if the Joint Commission took into consideration the surprise nature of the visits when scoring, but there has been no indication that will happen. To the contrary, the Joint Commission appears eager to shed the image that it is too easy on hospitals during on-site surveys.
"They’re looking to find things," Porto says. "They’re not interested in giving a lot of high scores. The OIG pointed out that an extraordinary number of facilities got high marks, so the implication is that the OIG would like to see more failing scores. My guess is that if they start showing up unannounced in hospitals, lots of people will start getting low marks in some areas."
It also is possible that, for a short time at least, there will be a double standard for Joint Commission scores. An Accreditation with Commendation achieved this year might not mean the same thing as an Accreditation with Commendation achieved next year, she says.