You have been sent this message as a courtesy of
washingtonpost.com
Accreditors Blamed for Overlooking Problems
By Gilbert M. Gaul
Second of three parts
The creators of Medicare faced a problem. They were about to hand out
millions -- eventually billions -- of dollars each year in tax money for
hospitals to care for the nation's elderly. But how to make sure those
hospitals were qualified?
Government bureaucrats had no experience overseeing the quality of health
care, so in 1965 lawmakers turned instead to a private group -- a
little-known organization that already was in the business of evaluating
hospitals.
The responsibility as Medicare's gatekeeper came as a shock to the Joint
Commission on the Accreditation of Healthcare Organizations, which never
lobbied for it. "In fact, we woke up one morning and found some language in
the legislation," said Dennis S. O'Leary, now president of the group. "It
was a complete surprise."
Over the next 40 years, that surprise turned out to be a boon to the joint
commission's prestige and finances. Today, the nonprofit is one of the
nation's most influential health groups, evaluating thousands of medical
facilities annually. It collects $113 million in annual revenue, mainly from
the fees it charges hospitals.
Yet at the same time, the joint commission's practices raise questions
about potential conflicts of interest and the rigor of its hospital surveys.
It operates a thriving subsidiary that charges hospitals thousands of
dollars for coaching on how to pass its reviews. About 99 percent of the
hospitals reviewed by the joint commission win accreditation, and in recent
years it has missed glaring examples of poor care in which patients have
been injured or killed:
· The joint commission accredited California's Redding Medical Center in
July 2002. A few months later, FBI agents raided the hospital amid charges
that doctors had performed hundreds of unnecessary heart surgeries and tests
from 1999 to 2002, allegedly resulting in some deaths.
· The joint commission gave Maryland General Hospital in Baltimore its seal
of approval twice in four years. Yet even as the hospital was collecting
plaudits, lab technicians complained that testing equipment didn't work and
that hundreds of HIV tests were mishandled. Some patients who tested
positive for the virus may have been told they were negative. State
regulators found last year that the lab had been "rife with equipment
failures and malfunctions" and had lost or mishandled specimens.
· Norwalk Hospital in Connecticut won accreditation from the joint
commission in May 2004. Less than a month later, state regulators reported
numerous violations at the hospital. One patient received 10 times the
prescribed dosage of a painkiller, according to state records. Another had
his left testicle mistakenly removed. Still another, experiencing suicidal
thoughts, was given a taxi token and told to find a treatment center. He
hanged himself hours later, according to a November 2004 consent agreement
between the hospital and state. Norwalk officials agreed to pay the state a
$50,000 fine without admitting wrongdoing.
· The group awarded accreditation in August 2000 to Florida's Palm Beach
Gardens Medical Center even though the hospital received a less than
satisfactory grade on infection control. It affirmed the accreditation in
2003, about the time that state and federal regulators were poring over more
than 100 complaints of life-threatening infections in the heart unit. The
hospital's owners were later fined by the state and paid $31 million to
settle plaintiffs' allegations of poor care.
O'Leary said the group's surveys "are the most rigorous in the world," with
safety and quality standards that exceed those of Medicare. He acknowledged
that joint commission reviewers "still miss" problems, "but so do state
agencies and others," he said. "I bet if we went in behind state regulators,
we would find things, too."
Some state regulators and consumer advocates take a different view, saying
that Medicare relies too heavily on the joint commission and other private
groups, which are closely aligned with the health facilities they review.
Nelson J. Sabatini, Maryland's health commissioner during the troubles at
Maryland General, said federal oversight of health care is "a fraud. A lot
of what they call regulation is really self-regulation," he said. "They're
being told to be partners. It doesn't work."
Under Medicare rules, any hospital meeting the joint commission's standards
automatically is eligible to participate in the federal health program and
receive government reimbursements. Over the years, to save money and avoid
duplicating federal efforts, all but a handful of states have abandoned
their separate procedures for licensing hospitals and now rely on the joint
commission.
The group's role, O'Leary said, is to help hospitals and other facilities
meet the standards, not to regulate or punish them.
"We can't fine you or close you," O'Leary said. "It's right in the articles
of incorporation. Our role is to evaluate and educate."
The joint commission is one of three main legs in Medicare's oversight
system. To ensure that the care it pays for meets quality standards,
Medicare also allocates more than $250 million a year to state regulators to
investigate complaints and inspect a wide range of health care facilities.
And it awards nearly $300 million annually to private groups in each state
called Quality Improvement Organizations, which work closely with hospitals
and others to improve care and review patient concerns.
In recent years, Medicare officials have stressed a more collegial approach
in which the private groups and even some state regulators work together
with the hospitals and other groups they oversee. The focus of this approach
is collaboration, not punishment.
The joint commission is a good example of the change. The idea is that
collaboration and continual monitoring can result in broader improvements
and better care than simply weeding out poor performers.
But some critics say the outsourcing and shifting focus of Medicare's
oversight system puts patients at risk.
The relationship between Medicare and the joint commission is a large part
of the problem, Sabatini said. "The fundamental structure of the joint
commission doesn't make sense," he said. "It's one big built-in conflict,
and the fact that Medicare allows it is appalling."
For their part, Medicare officials say they are required by law to accept
the joint commission's congressionally mandated accreditation system.
"Legally we have no authority" over the commission, said Frank Sokolik, who
directs hospital surveys for the Centers for Medicare and Medicaid Services,
the agency that oversees the giant federal insurance program.
"We work together," Sokolik said, "but there is no requirement they do
anything."
The joint commission, which is based outside Chicago, boasts that its
imprimatur represents a "Gold Seal of Approval." And to advertise that, it
suggests that the 15,000 groups it oversees purchase banners, decals, coffee
mugs and enamel pins to tout their accomplishments.
" 'We Are Accredited' products are available exclusively to Joint
Commission accredited organizations," the group's Internet site proclaims.
The cost of a 5-by-2-foot blue and burgundy banner: only $98. "No one who
walks into your reception areas or waiting rooms can miss the message," the
Web site says.
The money from these vanity sales is pocket change for the group, which
takes in millions from its accreditation surveys, consulting services and
educational materials. Still, it helps to drive home a message that the
joint commission has been selling in one way or another for more than half a
century: If you have our stamp of approval, you are the best.
The "best," it turns out, includes almost every institution that pays the
joint commission's fees, which for a large hospital average $26,000 per
survey. The nonprofit inspects hospitals once every three years.
Some critics point to the approval rate as evidence that the joint
commission is captive to hospitals. The joint commission notes in its
literature that the group wants to work together with the facilities it
accredits, referring to them as "customers" and "clients." The commission
still tells hospitals in advance when its survey teams are coming but says
it will switch to surprise reviews next year.
The board of directors of the joint commission is dominated by
representatives of the American Hospital Association and the American
Medical Association.
"I agree that on the surface if you look at our board, you'd have those
concerns and you would probably wonder how in the hell it even works,"
O'Leary said. "But I would say you have to look at what we have done and not
how we look. I think our record speaks for itself."
The joint commission serves as more than just a gatekeeper for Medicare,
O'Leary said. It collects and analyzes data on medical mistakes, works to
improve patient safety and has won praise for lifting the overall
performance of hospitals.
One initiative of the joint commission is relatively new. Its subsidiary,
Joint Commission Resources, was established in the 1990s to consult with
hospitals on how to gain accreditation and improve their performance. It
also operates the nonprofit's busy publishing and conference business.
JCR solicits hospitals so that they can "achieve peak performance on their
next survey," one brochure notes, and also sells its services to state
hospital associations.
The average bill for one of its 300 annual consultations runs about
$10,000, said Karen H. Timmons, JCR's president and chief executive.
Directly or indirectly, most of JCR's nearly $33 million in revenue comes
from helping hospitals win the joint commission's seal of approval.
Timmons said that there is a firewall between the subsidiary and the joint
commission, and no inspection information is exchanged. "The joint
commission would have no knowledge who we're dealing with," she said. "We're
in a separate building several miles away" from the commission's Oakbrook
Terrace, Ill., headquarters.
While officials say no information flows between the two groups, tax
returns show that a substantial amount of money does change hands.
In the past three years, JCR has paid its parent about $10.5 million in
management fees and $867,000 in royalties. And according to its 2003 tax
return, JCR owes the joint commission nearly $8.4 million. In addition, the
affiliate helps to underwrite two money-losing joint ventures of the
commission.
O'Leary said the joint commission has been careful to properly isolate its
potentially conflicting missions.
"From a technical standpoint, I don't believe we can be much purer,"
O'Leary said. "But we still have to deal with perception issues and it's
problematic."
Medicare performs some spot checks on the joint commission's work to make
sure the accredited hospitals meet federal standards. But the number of
validation surveys has dwindled in recent years because of a lack of
funding.
Medicare used to review 5 percent of all hospital accreditation surveys
annually, but that was slashed to 1 percent in 2003. This year, Medicare had
again hoped to check 5 percent but was forced to scale back to 2 percent
because of budget constraints.
A few states have opted out of the commission's accreditation program in
recent years because of concerns about accountability. In 2001, Pennsylvania
regulators decided to survey their own hospitals again after relying for
years on the private group.
Dick Lee, state deputy secretary of health for quality assurance, said his
department "found serious problems" with the commission's inspections.
"It was true across hospitals," he said. "We got a complaint one week after
[the joint commission] had gone into a hospital and done an inspection."
Maryland regulators used to conduct their own hospital inspections until a
wave of deregulation swept the state in the 1980s and state legislators
agreed to accept joint commission accreditation for licensing purposes.
According to Carol Benner, director of the state Office of Health Care
Quality, Maryland "had no authority" over the joint commission: "We couldn't
tell them what to look for in their surveys, and they didn't consult us."
The flaws in the state's inspection program were exposed by the massive
problems in the laboratory at Maryland General Hospital last year.
The joint commission had given the hospital its approval in 2001 and 2004.
Another private group -- the College of American Pathologists, or CAP -- had
also awarded the hospital's laboratory its highest distinction in 2003,
shortly before allegations of faulty equipment and shoddy testing became
public. (Maryland General has since made numerous changes and is once again
fully accredited.)
The state regulators and private accrediting groups blamed one another for
missing the problems. The joint commission said it relied on CAP to inspect
the laboratory. CAP officials said whistle-blowers at the hospital didn't
share critical information with them. Benner said CAP didn't give the state
copies of its surveys.
"There was no relationship between CAP and this office. That's just the way
it was," Benner said.
"Everyone in this case failed: the state, the federal government, the joint
commission and CAP," she said. "It's not pretty."
|
