Making accreditation relevant in the compliance era

NHO proposes new program for hospice, but JCAHO continues to grow

A key component of a bold plan for reforming hospice, proposed by the National Hospice Organization (NHO) Committee on the Medicare Hospice Benefit and End of Life Care in Arlington, VA, is a recommendation that NHO create a new, hospice-specific accreditation organization or endorse one that meets NHO specifications. (Please see related story, p. 95.)

This proposal reflects the dissatisfaction expressed by many hospice providers regarding the approach taken in recent years by the Joint Commis sion on Accreditation of Healthcare Organizations (JCAHO) Oakbrook Terrace, IL, to incorporate hospice standards into its home care manual. Critics argue that these integrated standards fail to reflect the unique features or philosophy of hospice.

Yet the number of hospices accredited by JCAHO has passed 800, nearly one-third of the country's hospice providers. This is a greater number than were accredited when JCAHO offered a hospice-specific accreditation program from 1986 to 1990. That program was closed down because of lack of provider participation, and JCAHO reintroduced accreditation of hospices as part of its 1995 Home Care Accreditation Manual.

Compliance with Medicare conditions of participation and other government regulations has become a bigger concern for hospices in the wake of Operation Restore Trust and other government initiatives targeting health care fraud and abuse. In this era of accountability, some hospice professionals question whether JCAHO's largely voluntary hospice standards are still relevant to the beleaguered industry. The challenge for providers is to incorporate efforts to qualify for JCAHO accreditation into an overall agency commitment to quality and an integrated approach to compliance with the multiple standards to which hospices answer.

"The whole mission of the Joint Commission is improving the quality of health care. That's where organizations should concentrate, instead of worrying about getting dinged by surveyors," says Cindy Rider, RN, MPH, a JCAHO surveyor and health care consultant from Metairie, LA. "The performance improvement standards really pull it all together."

"Having lived with a lot of different [accreditation] manuals, I think these standards are the best by far," observes Anne Rooney, a veteran JCAHO surveyor and consultant based in Chicago whose involvement dates back to the organization's original hospice standards in the late 1980s. "The relevance of the accreditation standards is to help programs adopt an agencywide philosophy of compliance. They can be a great tool," Rooney says. "The message I would give to the field is that some of you have had your hearts in the right place, but others have just drifted."

Rooney says she finds one of the biggest areas needing improvement in hospice, surprisingly, is pain and symptom management. Sometimes staff are not given adequate orientation to the hospice approach, while others are not knowledgeable about Medicare conditions of participation. She also finds that bereavement and spiritual services in hospices have fallen off from the 1980s.

Kathy Coffee, MS, RN, CS, administrator of Samaritan Hospice Care in Babylon, NY, says her agency hired Rooney to help during its yearlong preparation for its accreditation survey. "We learned a tremendous amount from this whole process, even though we thought we ran a good ship already," Coffee says. One of the biggest lessons Samaritan learned was how to trend problem areas without placing blame, with the goal of looking at systems issues first, not at individuals, she notes.

Bonnie Kosman, MSN, RN, CS, CDE, director of patient care for Lehigh Valley Hospice in Allentown, PA, says her hospice program and its affiliated home health agency recently went through a grueling eight-day accreditation survey. Most of the attention was focused on the home health side, with one day devoted to hospice. "I wish I could say it was a positive experience, but I didn't learn much about how to make my agency better." The surveyor was more interested in contracts and charts than in the actual delivery of hospice services, Kosman relates. "Several times she said she wasn't here to give suggestions or recommendations. Even though we came through with high marks, it came with a price in terms of negative staff reactions to the experience," she notes.

"We're spending a lot of money trying to prove that we're a reputable agency. It has almost become a religion or a way of life in health care. But right now there are just so many separate entities that hospices must answer to," Kosman says. "We all should be after the same goal - to be a quality, cost-effective organization."

ORYX looms for accredited hospices

ORYX, a new outcomes initiative introduced by JCAHO in February 1997, is intended to promote affordable outcomes and performance measurement for accredited providers. By the end of this year, every participating home care or hospice organization must select one or more performance measurement systems from the list of 200 vendors approved by JCAHO.

Then the provider must select from its system two or more measures of clinical performance or client perception of care and service quality, sufficient to address 20% of its overall patient population. Agencies must begin collecting data for these measures during the third quarter of 1999 and start submitting the data to JCAHO by March 31, 2000.

Stephen Connor, PhD, co-administrator of the Alliance of Community Hospices in Elizabeth town, KY, says, "We need to have a conversation about ORYX, because a great many people in the field are unaware that the requirement is coming for all accredited hospices." Some hospice managers have complained that none of the currently approved ORYX systems directly addresses hospice issues, while others are trying to work hospice-oriented outcomes measures into the format required for inclusion in ORYX.

"ORYX is forcing our hand. It's forcing us to create a certain amount of standardization in our world about how we measure outcomes," Connor says. Some hospice leaders believe hospice is being pushed too quickly down this road. Some groups are forming to try to come to consensus on hospice outcomes." A long-term goal for the ORYX initiative is to achieve consensus on performance measures that are relevant to the quality of clinical practice, and then share comparative data with consumers, Connor says. "Wefive or more years away from that goal, but in the meantime you have to start somewhere."

Enhancing relevance

Barbara Head, CRNH, ACSW, director of performance improvement and staff development for the Alliance of Community Hospices in Louisville, KY, describes JCAHO's hospice standards as the state of the art in performance measurement. "All of these standards improve quality and organizational performance. It's not the survey that makes you better as much as preparing for the survey. It makes you address things you otherwise might not pay attention to, that still are important aspects of quality." Unfortunately, Head says, the standards relate more to good business practices generally than to hospice philosophy or clinical practice. "Overall, they are weak in the things that make hospice special."

Head hopes the dissatisfaction that engendered NHO's proposal for a new accreditation program could also be channeled into working with JCAHO so its standards better reflect high quality hospice care. She says the past relationship between the two organizations may have been somewhat confrontational around the issue of hospice philosophy. As the number of accredited hospices grows, the industry may have more clout in advancing its point of view. "It would be a business issue to them if we said we're considering starting our own accreditation program," Head says, adding that she believes JCAHO is open to working collaboratively with NHO. "But it will take constant communication and a consistent message."