Medicare Bill Could Lead to Tougher Hospital Inspections

Reel back to 1965, the year Medicare and Medicaid legislation was passed. That year Congress gave the “Joint Commission,” a professional accreditation organization established in 1951, the unique authority to inspect hospitals and determine whether they meet the patient health and safety standards required to treat Medicare patients.

And who do you suppose pays the Joint Commission?

The hospitals that are being inspected. “Today, the Joint Commission collects $113 million in annual revenue, mainly from the fees it charges hospitals for telling them whether they comply with federal regulations,” observes Lisa Venn, J.D. M.A., writing on Advocate Alliance. 

Venn, who is the Manager of Compliance at a large teaching hospital, explains that “Deeming authority means that if Joint Commission gives its seal of approval to a hospital, CMS is satisfied that the hospital is following federal regulations. In other words, hospitals enrolling in the accreditation program only have to please one master. And that master is really nice, accrediting 99% of all hospitals it surveys.”

Thanks to the Medicare bill that passed Congress earlier this month, however, the Joint Commission will no longer enjoy unique authority over hospital inspections. The legislation revokes that power, opening the door for CMS or other agencies to inspect hospitals, and requiring that, beginning in 2010, the Commission, like any other organization, will have to apply to CMS for hospital deeming authority, and prove that its program meets or exceeds Medicare requirements for patient safety.

To understand why this represents a major win for patients, consider the history of the Commission.  Over the years criticism has mounted. In July, 1999 the Department of Health and Human Services Office of Inspector General published a report titled "The External Review of Hospital Quality: A Call for Greater Accountability." The report concluded that Joint Commission surveys are “unlikely to detect substandard patterns of care or individual practitioners with questionable skills.”

In its July 2004 report, the Government Accountability Office (GAO) went further, concluding that 78% of the time the Joint Commission survey process did not identify serious deficiencies that were found by State Survey Agencies. The GAO recommended that “given the serious limitations in (Joint Commission’s) accreditation program and that efforts to improve this program through informal action by the Centers for Medicare and Medicaid (CMS) have not led to necessary improvements, Congress should consider giving CMS the same kind of authority over (Joint Commission’s) hospital accreditation program that it has over all other Medicare accreditation programs.”

For a sense of what GAO might mean by “serious deficiencies, consider what a 2002 Chicago Tribune investigation (“Clean bills of health are awarded despite deaths, infection outbreaks”, Michael J. Berens and Bruce Japsen, Tribune staff reporters, November 10, 2002) revealed about how the Commission handled a crisis at Connecticut’s Bridgeport Medical Center. “In early 1997, hospital-borne germs were infecting dozens of patients. Up to one in five contracted antibiotic-resistant germs after open-heart surgery. Dust and flies littered the operating room during surgeries, according to internal hospital records obtained by the Tribune.

“The Joint Commission learned of a potential infection outbreak after receiving complaints filed by a patient. But the organization decided not to visit the hospital or conduct interviews with patients or doctors, hospital and court records show.

“Instead, the Joint Commission reviewed patient files selected and mailed by hospital officials.

“A Joint Commission regional supervisor telephoned the Bridgeport hospital on Feb. 25, 1997, according to a hospital memo. ‘Based on the review, he stated that while they appreciated the information which they have received, no follow-up was deemed by the Joint Commission to be necessary at this time,’ according to the memo.”

The Bridgeport hospital had been accredited in June 1996, ranked as one of the top 1 percent best medical centers nationally. It retained a high ranking even after the hospital settled four lawsuits involving patients who contracted infections.

“But during the same month that Joint Commission officials closed their inquiry, state public health investigators conducted a surprise inspection and found myriad patient care and infection control violations, such as failure by surgical assistants to wash hands.

“The hospital initiated dozens of reforms after the state inspection and currently is in compliance with all standards, according to state public health agencies. Infection rates have been reduced to less than 1 percent from a high of 20 percent.”

It other words, the problem could be solved—if someone put pressure on the hospital.

More recently, over 100 patients and survivors sued Palm Beach Garden Medical Center, a hospital owned by the for-profit Tenet Healthcare Corporation, alleging that the hospital performed open-heart surgery in such unsanitary conditions that patients wound up with gruesome infections.

Reportedly, dust and dirt covered some surgical equipment. Trash cans and soil linens were stored in hallways. One patient’s wife said she saw a medical assistant tear surgical tape with his teeth.

Then there were the bugs. When TheStreet.com’s Melissa Davis dug into the story, she obtained documents which revealed that over a period of years the hospital had struggled with, but failed to contain an insect problem in its operating rooms. “Correspondence between multiple exterminators and the hospital repeatedly mention...a flying insect issue in the O.R. The exterminators identify specific insects—crazy ants, fruit flies, fungus beetles…”

The infections contracted in the operating room led to open, draining chest wounds. In some cases, the only remedy was “radical reconstructive surgery—including complete or partial removal of the patient’s sternum…” according to one complaint

In a four year-period, 106 heart patients at Palm Beach Gardens developed infections after surgery according to the 2004 lawsuits. Sixteen died.

Yet the hospital continued to do a brisk business—with the blessing of the Joint Commission.  According to the Tribune, “Joint Commission officials said they sent investigators to tour the hospital in August and October 2002. But their findings were withheld from the public. ‘If we want any modicum of cooperation from the hospitals, they have to feel we're not going to put it [investigative findings] right out on the street,’ the head of the Joint Commission said.”

When the Joint Commission inspected Palm Beach Gardens in October of 2002, it gave the hospital 94 out of 100 possible points. Later that month, the Chicago Tribune reports, “inspectors from the federal Centers for Medicare & Medicaid Services staged a surprise inspection at Palm Beach Gardens and declared that uncorrected infection-control deficiencies represented ‘immediate jeopardy’ to patients.”

In March of 2003, state regulators fined the hospital $323,800—but then quickly reduced the penalty to $95,000. In 2004, Tenet forked over $31 million to settle more than 100 civil lawsuits—without admitting wrong-doing.

Bridgeport Medical Center and Palm Beach Gardens are just two examples of cases where the Joint Commission failed to do its job.  The Tribune's computerized review found 2,352 hospitals that had received state or federal citations during 2001 for life-threatening deficiencies after the Joint Commission issued its stamp of approval.  In response, “Joint Commission officials said surveys represent a ‘snapshot of quality,’ not guarantees of patient safety.” 

The Joint Commission has made some efforts to improve. In 2006, for instance, it announced that it would begin conducing on-site accreditation surveys and certification reviews on an unannounced basis. (In the past, the Commission always politely informed the hospital when it was coming.)

Given the Commission’s history, legislators’ recent decision to revoke the unique authority over hospitals might not seem surprising. But in truth, it took real political will to make this decision. In October of 2007, Venn described how a similar provision simply disappeared from a bill when legislators were debating SCHIP (State Children’s Health Insurance Program) funding: “The House version of the bill called for revoking the Commission’s authority. The Senate’s version did not. When the House and Senate hammered out a final version, the Joint Commission wasn’t mentioned anywhere.” It was there—and then it wasn’t.

“This Joint Commission legislative Houdini act is a curious thing,” Venn commented last year. “It seems that [anything that might alter] the fate of the nation’s most influential health group would really raise a raucous.”

But a few weeks ago, when voting on Medicare legislation, Congress managed to stand up to the Commission’s protectors—and override a veto by President Bush to boot. Given their success, some legislators may be thinking, “Hey, this spine thing really works.”

Comments

[James Goldberg]

Have a look at www.bumrungraddeath.com

I worked as a consultant to the Senate Finance Committee and Medicare to get the charlatans who are the Joint Commission displaced...something which has been long overdue.

Please call me if you'd like to know more about the outrageous and rogue activities of the Joint Commission and its many subdivisions....Your figure of $113million does not include their offshore activities and consulting revenues...nor the benefits reaped by the "commission" members resulting from the policies of the JC.

Jim Goldberg
415 686 7139

[David Hahn]

Why do you think federal or other inspections will be any better when they become more widespread? You are just helping another bureaucracy build up its staff. The same thing happens. Quality should not mean adding more and more staff and hence cost. If you don't know what's going on in hospitals, find out. Layer upon layer of checkers are established and still there are problems. How about letting health care professionals attend to the patients/

[Den-Den]

The Feds have neither the manpower nor the expertise to take over the inspection process. I agree with those who say that the Joint Commission is far from perfect. The biggest complaint I hear from hospital administrators is that the cost of the accreditation process is exorbitant given the declining reimbursement hospitals are now receiving from most payers. However, it will take the Feds at least a decade to develop the know how and the staffing to do the job. This is just another example of "Big Government" in the making.

[maggiemahar]

Thanks for your comments.

This is not a question of adding layers of government agencies--it is a matter of acting on the very good inspections already being down by state agencies and others.

Until this legislation passed, the Joint Commission had sole authority, so even when state regulators (or other inspectors)found violations, the hospitals could not be shut down.

As I said in the post: "2,352 hospitals received state or federal citations during 2001 for life-threatening deficiencies after the Joint Commission issued its stamp of approval."

In addition,in an independent evaluation by the Health Care Financing Administration it was found that JCAHO surveyors repeatedly missed instances where residents suffer actual harm because of inadequate care. In more than half of 179 cases where both Health Care Financing Administration (HCFA) and JCAHO conducted inspections of the same nursing homes, JCAHO failed to detect serious problems identified by HCFA.

As one cancer patient advocate put it when commenting on my blog (HealthBeat) : "The bottom line is, it is proven, over and over again, what the problems are. But no one who has the power to hold them accountable also has the balls to draw that line in the sand."

So it's not a matter of the government having the
manpower or the expertise to do the inspections
properly, it's a matter of political will.

It looks as if Congress has finally found the
political will. It be interesting to see what
happens in the future when state inspects find
violations that could kill patients.

[CMyers]

notice a pattern here despite Ms Mahar's well written piece.

There is literally NO comment and no mention re how-why earnest attending physician input on patient care is not relevant to ongoing hospital and JCAHO boondoggles