Ding-dong! JCAHO calling: No advance notice on unannounced surveys

OIG report finds major deficiencies’ in oversight

Hospital compliance officers and health information professionals who depend on advance notice when preparing for an accreditation survey had better be getting their Ps and Qs in order.

Not only has the Joint Commission on Accreditation of Healthcare Organizations increased the time period surveyors can appear unannounced at a health care facility, but surveyors also are expected to switch to a more regulatory mode of oversight.

In early August, the Oakbrook Terrace, IL-based Joint Commission announced that effective Jan. 1, 2000, health care organizations will no longer receive advance notice for random unannounced surveys. This policy does not apply to laboratories. In addition, the surveys will be conducted nine to 30 months following the triennial full survey.

Previously, the Joint Commission conducted unannounced surveys at randomly selected accredited organizations at the midpoint of their accreditation cycles. It also provided 24 hours advance notice of these surveys and communicated the standards to be reviewed prior to the survey.

Now the scope and focus of the review 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.

The Joint Commission also will be pilot testing the extension of the on-site survey to evening, night, and weekend periods. The pilot testing will begin during the last quarter of 1999 and extend through the first quarter of 2000 and will involve a 10% sample of the triennial accreditation surveys during this period.

Joint Commission president Dennis S. O’Leary, MD, says the change in policy stems from research conducted with accredited organizations, various groups who rely on Joint Commission accreditation decisions, and Joint Commission surveyors. "We believe they will make our overall accreditation process more meaningful and credible."

OIG finds oversight deficiencies

The Joint Commission announcement, however, came shortly after the publication of a series of four reports that cited major deficiencies in the external oversight system of hospitals.1-4 The two-year study was conducted by the Health and Human Services’ Office of the Inspector General (OIG) in Washington, DC.

According to the report, the nation’s 6,200 hospitals rely on two types of reviews to meet the requirements for participating in Medicare. Eighty percent of the hospitals are accredited by the Joint Commission; the remainder are certified by state government agencies.

In the reports, the OIG identified these deficiencies in current accreditation and certification practices:

- Although Joint Commission surveys help reduce risk and foster improvement in hospital care, they are unlikely to detect substandard patterns of care or individual practitioners with questionable skills, the reports say. "Quick-paced, tightly structured, educationally oriented surveys provide little opportunity for in-depth probing of hospital conditions or practices."

- State agencies rarely conduct routine, not-for-cause surveys of nonaccredited hospitals. About 50% of nonaccredited hospitals in 1997 had not been surveyed within the three-year industry standard. In some cases, nonaccredited hospitals, most in rural areas, have gone as long as eight years without a survey.

- The hospital review system has been shifting toward a "collegial mode of oversight," which focuses on education and improved performance, and away from a "regulatory mode of oversight," which focuses on investigation and enforcement of minimum requirements. This shift could result in "insufficient attention to regulatory approaches intended to protect patients from poor care," the reports state.

The OIG also criticized the Health Care Finan-cing Administration (HCFA) in Baltimore, saying it did little to hold either the Joint Commission or the state agencies accountable. In dealing with the Joint Commission, HCFA is "more deferential than directive," the report added.

As part of its recommendations, the OIG advised HCFA to "steer external reviews of hospital quality to ensure a balance between the collegial and regulatory modes of oversight."

The American Hospital Association (AHA) in Chicago, however, is concerned about the shift to the regulatory mode of oversight. "I think the question is — What is the value of the collegial approach vs. the gotcha’ policeman approach?" asks Mary Grealy, JD, senior Washington, DC, counsel for the AHA. "It’s a fine balance, and we need to collaborate on improving things."

In its reports, the OIG says HCFA should negotiate with the Joint Commission to accomplish the following:

- Conduct more unannounced surveys.

- Make the "accreditation with commendation" category more meaningful or abolish it.

- Introduce more random selection of records into the survey process.

- Provide surveyors with more context (information?) about hospitals they are surveying.

- Determine year-to-year survey priorities.

- Conduct more rigorous review of hospitals’ continuous quality improvement efforts.

- Enhance surveyors’ ability to respond to complaints during surveys.

The Joint Commission has since announced that the accreditation with commendation policy is under review by the accreditation committee of its board of commissioners. The committee is considering alternatives for recognizing outstanding organizations; the board is expected to review and act on the committee’s final recommendations in November.

The OIG also encouraged HCFA to take the following measures:

- Provide performance feedback and policy guidance to the Joint Commission and state agencies.

In response, HCFA says it is in the process of developing new, evidence-based quality measures. This initiative is part of HCFA’s "Hospital Quality Oversight Plan." HCFA has directed peer review organizations to establish and develop measures that will provide benchmarks of quality hospital care.

Three of the performance measures under development include the rate of beta-blocker drugs prescribed for patients hospitalized after a heart attack, mortality rates following surgery, and infection rates following surgery.

- Increase public disclosure of the performance of hospitals, the Joint Commission, and state agencies.

HCFA says it is currently exploring several approaches to provide more information to Medicare beneficiaries and other consumers. One pilot project will examine how to develop and distribute hospital performance data so that consumers can compare the quality of care among hospitals.

- Determine an appropriate minimum cycle for conducting certification surveys on nonaccredited hospitals.

HCFA says it plans to determine this cycle.

HCFA also plans to revise its condition of participation regulations "to reflect advances in quality improvement that are occurring in both the public and private sectors," says Nancy-Ann DeParle, HCFA administrator. The final regulations are expected to be completed by fall 2000.

(Editor’s note: The OIG’s four reports are available on the OIG Web site at www.os.dhhs.gov/oig.)


1. Office of the Inspector General. The External Review of Hospital Quality: A Call for Greater Accountability. OEI-01-97-00050. Washington, DC; July 1999.

2. Office of the Inspector General. The External Review of Hospital Quality: The Role of Accreditation. OEI-01-97-00051. Washington, DC; July 1999.

3. Office of the Inspector General. The External Review of Hospital Quality: The Role of Medicare Certification. OEI-01-97-00052. Washington, DC; July 1999.

4. Office of the Inspector General. The External Review of Hospital Quality: Holding the Reviewers Accountable. OEI-01-97-00053. Washington, DC; July 1999.