Pending CMS rules put hospital reputations at risk, and that’s a good thing

Can Health Systems Handle the Truth?

"You can't handle the truth!" exclaims a frustrated Jack Nicholson, as Col. Jessup in "A Few Good Men" confronted by Tom Cruise as Lt. Kaffee in the iconic 1992 military courtroom drama. In light of pending new rules for hospital accreditation from the Centers for Medicare and Medicaid Services (CMS), health care providers might be wondering the same thing about their organizations. Can they handle the truth about accreditation and safety issues and Plan of Correction data? Savvy health systems are learning to preserve their reputation, and perhaps even enhance it, by deploying new strategies to mature an approach to risk including preventing adverse events, engaging patients, documenting and mitigating risk and developing a credible plan to survive the move to greater accreditation transparency.

CMS Drive to Transparency of Data

The CMS draft regulation, to be released for comment on the Federal Register April 281, would require private accrediting organizations (AOs), like The Joint Commission, to make their accreditation survey data public. CMS, in the preamble2 to the proposed ruling, believes that "it is important to continue to lead the effort to make information regarding a healthcare facility's compliance with health and safety requirements" publicly available. The rule language acknowledges that evidence of compliance is an important measure of quality of care, and is important for patients to understand as they select the right health system to care for them. This is an important acknowledgement that the quality of a health system's process, or continuous compliance, is just as important as quality of outcomes, and that connection is likely to be further validated moving forward.

Risk to Healthcare Systems

Continuous compliance, once defined3 as "having staff at all levels doing the right things for the right reasons because they understand those reasons," emerged as a top CMS priority after perceived lack of compliance measure reporting from accrediting organizations such as The Joint Commission. The rule acknowledges that AOs like The Joint Commission or DNV have not been complete in their view of compliance. In 2014, according to ProPublica, "...state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations."4

The new rules are intended to improve care and better equip patients to make sound decisions about care providers, but they also put health care organizations at significant reputational risk. If every adverse event, environment of care issue or inconsistency in a safety plan were suddenly made public, few would survive the additional scrutiny without consequence. In addition to reputational concerns, there is significant legal risk associated with documentation that is public and discoverable. This additional risk validates the relationship between accreditation and compliance and the need to ensure that policies are not just in place, but are being followed. This provides protection for health care providers and patients.

Combine Safety and Compliance to Protect Against Reputational Risk

Hospitals and health systems who are able to demonstrate their value to payers and patients through strong continuous compliance and patient safety efforts are best suited to adjust to the new transparency. Information technology that integrates a compliance program with events management into a single platform gives organizations what they need to quickly and efficiently correct variations in care process that could lead to compliance problems.

Accidents happen. But facilities that validate issues have been corrected and stay resolved should frame the adverse event in the context of a complete strategy that ensures it doesn't recur. This is consistent with what The Joint Commission published recently, which underscores how important the proper patient safety system, including constant surveillance, is to the continuous compliance of an organization.

The impending visibility of accreditation data also underscores the value of Governance, Risk, and Compliance (GRC) as a continuous process improvement strategy. Those with a holistic view of GRC are better able to anticipate problems before they occur and come up with a plan to address them.

The Next Move in the Drive Towards Transparency

Currently, the proposed rules are just that – a proposal. Comments on the proposal may be submitted from April 28 to June 13 through the CMS website. The American Hospital Association supports the new rules, with reservations.5 But whether these rules, or a revised version of them are ultimately implemented, the push towards transparency isn't going away.
Providers need to prepare for this new scrutiny with technology, teams and processes that manage compliance across a number of different standards leveraging best practices, preserve their Quality Management programs in a continuous way, and help remove unnecessary risks.

The fictitious Colonel Jessup from "A Few Good Men" is ultimately found to have his own problems with the truth, and is arrested. While health care organizations are certainly not facing a similar fate, they do need to find ways to "better handle the truth" that the drive toward transparency brings.

5 Ibid.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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