CMS' RFI will shine a light on fundamental issues with hospital accreditation

Hospitals keep making preventable mistakes, and patients continue to pay the ultimate price for them. Just before the new year, an update of the investigation by The Wall Street Journal found that more than 100 psychiatric hospitals hold their accreditation despite safety violations, 16 percent of them severe.

Why is this still happening, especially when we have accrediting organizations – like the Joint Commission – whose mission is to ensure hospitals are a safe place for patients to receive care? The answer is a complicated, multifaceted issue that the Centers for Medicare & Medicaid Services has made efforts to address, most recently through their December request for information. CMS’ decision to do so has not come lightly – the government is pushing for more regulation and oversight, and organizations like the American Hospital Association and the American Medical Association want less so hospitals can keep their doors open.

But when you take politics out of the equation, there is no denying that the current accreditation process has two serious problems. The first, which CMS is hoping to learn more about via their December request for information, is that some private accreditors like the JC – responsible for accrediting 80 percent of America’s hospitals – also offer consulting services to help hospitals “pass the test” and get accredited. This is a glaring conflict of interest. The second involves what accreditors are measuring against. CMS’ conditions of participation are a baseline which accreditors rightfully build upon, but those additional requirements are focused on minute details which have very little impact on improving patient outcomes. If CMS is serious about oversight and increasing value delivery, more attention must be paid to raising the standards being used and increasing transparency between accrediting organizations and the consulting services they offer.

Concerning the first flaw in the accreditation process, the JC insists there is a “firewall” between their consulting and accrediting arms and that a conflict of interest is nonexistent. CMS will find out whether this is true through the RFI, which asks them to disclose the financial repercussions they’d face if accreditors’ consultancy services were banned. But that’s not the only issue here.

The JC and other accreditors have taken an “improvement” orientation, as in they have made it their mission to show hospitals what they need to do to be better, and then award them accreditation for doing so. Failing to be accredited is a black mark that prevents a hospital from receiving Medicare reimbursements, largely why the AHA and AMA wants CMS to let accreditor organizations keep their consultancy services – they want hospitals to have the tools they need to succeed, and accreditation is a measure of success.

Currently, the JC allows hospitals to purchase consulting services ahead of their accreditation test, and also lets the hospitals know when an accreditor is coming. This allows the hospital to “study up,” aka memorize the answers they’ve paid for. And because JC surveyors are only required to visit once every 39 months, hospitals who take advantage of their consultancy services first can do what they need to do to pass, get accredited, breathe a sigh of relief and return to business as usual – going unchecked for over three years. Instead, accreditors should make surprise visits, strip noncompliant hospitals of their accreditation and then direct them to other consultancies. While accreditors want to be hospitals’ friends by helping them prevent failure, it’s their job to protect patients, not hospitals. By testing first, then showing hospitals how to be better, there will be a greater focus on building a culture of quality that has lasting effects.

What hospitals are being tested on is another critical issue. Many clients I’ve worked with have expressed anxiety about accreditation because there are so many minor details they cannot afford to overlook. For example, the way in which a syringe must be labeled has evolved to include the drug name, date, time, expiration date, concentration, tech initials, etc. This minutia matters little to the patient and neglects to ask important questions that would improve outcomes. For example, accreditors should really be asking if the drug, dosage, and concentration are correct, and how the patient responded. Accreditors need to reassess whether their requirements truly add value, or only make matters more – and pointlessly – complicated.

JC is the flagship accreditor, hence my focus. However, there’s also room for improvement here as decreased competition puts power in the hands of only a few. As a result, patients often pay the price. With more accreditors in the market, competition will drive innovation and improve outcomes. As an example, a much smaller accreditor, with whom I have no special relationship or conflict of interest, is DNV Healthcare. They lack a consultancy arm – banning consulting services would help DNV keep up with larger organizations like the JC – and use an ISO 9001 framework to make processes more efficient. Many more hospitals could stand to benefit from this approach.

CMS has taken necessary first steps to increase accreditation oversight and regulation, but their efforts have so far only scratched the surface. To truly improve patient outcomes, CMS must use the results of this RFI as an opportunity to enact fundamental change in how accreditors conduct business, and raise standards so that hospitals make fewer care delivery mistakes. Only then will we see safer hospitals.

Rita E. Numerof, Ph.D., is president of Numerof & Associates, a firm that helps businesses across the health care sector define and implement strategies for winning in dynamic markets.


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