Accreditation Firms Like Joint Commission Receive Further Scrutiny From Congress
Following the publication of a Wall Street Journal article last year, hospital accreditation organizations have received unwanted attention from the US Government. Members of the House Energy and Commerce Committee have requested additional information from the Centers for Medicare & Medicaid Services (CMS) and 4 major hospital accreditation organizations regarding their processes.
Concerned with CMS’ oversight of the accreditation organizations, the members of the committee and have asked the various organizations to provide documentation surrounding the accreditation process for hospitals by March 23. As this article by Maria Castellucci at Modern Healthcare notes:
“The committee wrote in the letters that it is “concerned about the adequacy of CMS’ oversight” of accreditation organizations and the rigor of their survey processes. In addition to the WSJ article, the committee pointed to a 2015 congressional report that found accreditation organizations missed 39% of condition level deficiencies at hospitals that were subsequently reported by state survey agencies in validation surveys.
About 90% of U.S. hospitals—or 3,500—are accredited by private organizations. The WSJ investigation found that the Joint Commission, which accredits about 80% of U.S. hospitals, rarely pulls its accreditation. In 2014, the Joint Commission revoked accreditation for just 1% of facilities in 2014.
The committee has asked the organizations to provide copies of hospital applications for Medicare accreditation; copies of performance reviews, survey feedback, corrective action plans and responses to those plans; and any correspondence with the CMS.
In addition to the CMS and the Joint Commission, the letters were sent to the Bureau of Healthcare Facilities Accreditation, the Center for Improvement in Healthcare Quality and DNV GL Healthcare.
The Joint Commission plans to respond to the committee’s request, said Kim McCullough, the commission’s associate director of communications, in an email. The probe “is an opportunity to share more on the work we do to improve healthcare quality and patient safety by facilitating high reliability,” she added.
In an interview with Modern Healthcare in December, Joint Commission CEO Dr. Mark Chassin said the organization views denial of accreditation as a “failure.” The commission prefers to work with hospitals to help them improve on deficiencies.
The CMS, which is charged with overseeing the accreditation organizations and the state survey agencies, has been asked to provide copies of the most recent contracts with state survey agencies that detail responsibilities for the healthcare providers to comply with certification; any correspondence between state surveyor agencies and accreditation organizations; and copies of any complaints the CMS has received since fiscal 2012 that allege patient harm or misconduct in acute-care hospitals as well as actions the CMS took in response.
A CMS spokesman said in an email Tuesday afternoon that the agency will review and respond to the committee’s requests.
The letters were sent by Reps. Greg Walden (R-Ore.), Gregg Harper (R-Miss.) and Michael Burgess (R-Texas). The organizations and the CMS have until March 23 to respond.”
Read the entire article here: House committee probes CMS, Joint Commission over accreditation process
One possible result of this congressional probe may be that hospital inspection reports will be made public in order to give additional information to consumers regarding their choice of healthcare providers. Is your hospital ready for your inspection reports to be made public? To prepare, hospitals have to make sure that they are following all of their detailed processes all of the time. Any breakdown in your processes would be made public via an inspection report, putting your hospital’s reputation and finances at risk. Consider automation tools that help track the processes that The Joint Commission and other accreditation agencies focus on during their inspections. Systems such as iRIScope have been developed to ensure that processes and protocols are being followed since your managers can’t watch over every step of the way.