Medicare A Strategy for Quality Assurance, Volume II: Sources and Methods (1990) / Chapter Skim
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7. Medicare Conditions of Participation and Accreditation for Hospitals
7. Medicare Conditions of Participation and Accreditation for Hospitals
Pages 292-342
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From page 292... ...
or the American Osteopathic Association (AOA) have been automatically "deemed" to meet all the health and safety requirements for participation except the utilization review requirement, the psychiatric hospital special conditions, and the special requirements for hospital providers of long-term-care services.
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From page 293... ...
was created in 1951 to accredit hospitals that met its minimum health and safety standards. In 1987, JCAH changed its name to the Joint Commission on Accreditation of Healthcare Organizations in recognition that since 1970 it had developed accreditation programs for additional health services organizations delivering long term care, ambulatory health care, home care, hospice care, mental health care, and "managed" care [for example, health maintenance organizations (HMOs)
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Medical staff 6. Nursing services 7.
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Orgaruzanon and policies (b) Responsibilities of chief executive officer, medical staff, and director of nursing services (a)
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H McGEARY The Joint Commission's standards for the 5,400 hospitals it accredits currently are contained in the Accreditation Manual for Hospitals, some sections of which are revised each year through an elaborate process of professional consensus coordinated by its department of standards (see Table 7.3 for the outline of the Joint Commission's hospital standards)
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From page 297... ...
1 Organization, direction, staffing, and integration DT.2 Orientation, education, and training DT.3 Policies and procedures DT.4 Facility design and equipment DT.5 Medical record DT.6 Quality control mechanisms DT.7 Monitoring and evaluation ER. 1 Plan ER.2 Organization, direction, and staffing ER.3 Integration ER.4 Training and education ER.5 Policies and procedures ER.6 Facility design and equipment ER.7 Medical record ER.8 Quality control mechanisms ER.9 Monitoring and evaluation GB.1 Responsibilities GB.2 Conflict of interest GB.3 Fulfillment of responsibilities HO.1 Availability HO.2 Education and training HO.3 Policies and procedures HO.4 Safety, equipment, and utilities management and life safety HO.5 Medical record HO.6 Quality control mechanisms HO.7 Monitoring and evaluation IC.
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Medical Record Services (MR) Medical Staff (MS)
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SA. 1 SA.2 SA.3 SA.4 Utilization Review (UR)
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The medical staff had to develop policies and rules approved by the governing body that governed the professional work of the hospital. The rules had to require medical staff meetings at least monthly and periodic reviews of patient care in each department, based on patient records.
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A series of studies and surveys in the late 1950s and early 1960s also found that the hospital survey programs of the states varied greatly in focus, intensity, and composition of the inspection team (Taylor and Donald, 1957; McNerney, 1962; Foster, 1965; Fry, 1965~. Nearly all emphasized fire safety and sanitation, but fewer than 40 looked at nurse staffing and practices and fewer than 30 looked at medical staffing and practices.
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From page 302... ...
The 1965 amendments to the Social Security Act that established Medicare contained certain minimum requirements for hospitals? including the maintenance of clinical records, medical staff bylaws, a 24-hour nursing service supervised by a registered nurse, utilization review planning, institutional planning and capital budgeting, and state licensure.
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From page 303... ...
And experience informs us that without this capacity, achievement of quality is difficult, if not impossible." BHI proceeded to draft Conditions of Participation that would be eguivalent to those of JCAH. Except for utilization review, the 16 standards corresponded to the areas covered in JCAH's 1965 hospital accreditation standards.
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From page 304... ...
were too narrowly focused on medical staff and medical record issues. The council recommended that the Secretary of BW be given authority to set standards higher than those of JCAH and that state agencies be given the authority to inspect accredited hospitals (Health Insurance Benefits Advisory Council, 1969~.
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From page 305... ...
, which, JCAH argued, were not significantly related to quality of patient care or safety. In contrast, JCAH surveyors found more deficiencies-than state inspectors concerning patient care; that is, in such areas as medical staff, medical records, and radiology.
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From page 306... ...
In other words, HCFA has concluded that compliance with the Conditions of Participation is about the same in accredited and unaccredited hospitals.~2 This does not, however, preclude the possibility that Joint Com m~ss~on accreditation has a greater positive impact on quality of patient care than the federal-state survey and certification program, because in recent years, as will be seen below, the former's standards have been higher TABLE 7.4 Noncompliance of Joint Commission on Accreditation of Hospitals (JCAH) -Accredited and Unaccredited Hospitals with One or More Medicare Conditions of Participation, Fiscal Year 1985 Medicare-Certified Hospitals JCAH-Accredited Hospitals Unaccredited Hospitals Surveyed by State Agencies Number Percentage Number Percentage In compliance 328 70.7 1,168 75.6 Out of compliance 136 29.3 377 24.4 Total 464 100.0 1,545 100.0 NOTE: The JCAH-accredited, Medicare-certified hospitals surveyed by state agencies included 66 randomly selected for validation purposes and 398 hospitals surveyed on the basis of allegations of serious deficiencies that could affect the health and safety of patients.
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From page 307... ...
Despite the drastic revision and expansion of the accreditation standards in 1970, the JCAH standards still emphasized He structure and process features of hospital organization and administration that were believed to create the capacity to deliver quality patient care rather than evaluating the hospital's actual performance (JCAlIO, 1987~. In the early 1970s, aware of criticism of the emphasis on organizational and clinical capacity rather than actual performance (Somers, 1969)
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From page 308... ...
In 1976 a new section of the accreditation manual for hospitals on quality of professional services called for a certain number of medical audits depending on hospital size, but it soon became apparent that the methodology was being applied mechanistically with little impact on medical practice. Meanwhile, JCAH survey results indicated that surgical case review, drug and blood utilization review, and review of appointments and reappointments by the medical staff were subjective and informal and often ineffective in finding or resolving patient care and clinical performance problems (Affeldt et al., 1983~.
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From page 309... ...
For example, there was no quality-of-care or quality assurance condition or standard. Instead, the medical staff condition had a meetings standard, calling for regular meetings of the medical staff to review, analyze, and evaluate the clinical work of its members, using an adequate evaluation method.
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The new standard would have required a hospitalwide quality assurance program involving the medical staff in peer review and requiring performance evaluations by each organ .
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Other states with smaller numbers of unaccredited hospitals had higher rates of noncompliance: 6 of 10 in South Carolina; 2 of 4 in Virginia, and 1 of 3 in New Jersey. MEDICARE CERTIFICATION AND JOINT COMMISSION ACCREDITATION STANDARDS AND PROCEDURES FOR ASSURING QUALITY OF PATIENT CARE IN HOSPITALS Although one is governmental and the other private, both HCFA and the Joint Commission are regulatory in their approach.
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From page 312... ...
Both HCFA and the Joint Commission are severely constrained in their efforts to assure quality of care in hospitals or other health care organizations by this fundamental lack of knowledge about relations between the aspects of care that can be most easily regulated (such as building specifications, staff credentials, regular committee meetings, complete medical records, written quality assurance plans, and number of medical care audits) and those aspects of patient care that pertain more directly to quality (such as how well each patient is treated, how each patient's health status is affected by the care provided, or how the health status of the population served is being affected by a hospital's services)
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From page 313... ...
Shift from Capacity Standards to Performance Standards In recent years, HCFA and the Joint Commission have tried to revise their standards in ways that would impel hospitals to examine and, hopefully, improve the quality of their organizational and clinical performance. Thus, for example, both organizations have adopted quality assurance standards that call for hospitals to set up structures and processes for monitoring patient care, identifying and resolving problems, and evaluating the impact of quality assurance activities.
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From page 314... ...
The standards for governing bodies, medical staffs, management and administrative services, medical records, and quality and appropriateness review for support services were revised first. Despite the intention to simplify the standards and make them less prescriptive and more goaloriented, the revision process ended up involving substantial expansion and formalization of quality assurance activities in each chapter of the hospital accreditation manual, including an increasing specification of processes needed to achieve the objectives of JCAH's new quality assurance standard.
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From page 315... ...
In 1984, after four field reviews of several drafts, revised medical staff standards were included in the hospital accreditation manual but not used for accreditation decisions until 1985. The standard for medical staff monitoring and evaluation of the quality and appropriateness of patient care now included departmental review of the clinical performance of all individuals with clinical privileges and went on to specify the same required characteristics included in the other chapters on clinical services (JCAH, 1984a)
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From page 316... ...
The proportion of hospitals with contingencies or recommendations for credentialing was 63 percent and for surgical case review was 45 percent (Roberts and Walczak, 1984~. Despite compliance problems, JCAH increased the level of compliance required with the quality assurance standard during 1983, requiring evidence that quality assurance information was being integrated, that patient care problems were being identified through the monitoring and evaluation activities of the medical staff and support services, and that the problems were being resolved (JCAH, 1982~.
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Task force members agreed that a quality assurance program aimed at the identification and correction of patient care problems should be a condition because it was important and cut across all aspects of direct patient
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Required characteristics QA.2.1 The following medical staff functions are performed: QA.2.1.1 The monitoring and evaluation of the quality and appropriateness of patient care and clinical performance of all individuals with clinical privileges through QA.2.1.1.1 monthly meetings of clinical departments or major clinical services (or the medical staff, for a nondepartmentalized medical staff) to consider findings from the ongoing monitoring activities of the medical staff; QA.2.
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From page 319... ...
QA.2.2.1 Alcoholism and other drug dependence services, when provided; QA.2.2.2 Diagnostic radiology services; QA.2.2.3 Dietetic services; QA.2.2.4 Emergency services; QA.2.2.5 Hospital-sponsored ambulatory care services; QA.2.2.6 Nuclear medicine services; QA.2.2.7 Nursing services; QA.2.2.8 Pathology and medical laboratory services; QA.2.2.9 Pharmaceutical services; QA.2.2.10 Physical rehabilitation services; QA.2.2.11 Radiation oncology services; QA.2.2.12 Respiratory care services; QA.2.2.13 Social work services; QA.2.2.14 Special care units; md QA.2.2.15 Surgical and anesthesia services. QA.2.3 The following hospital wide functions are performed: QA.2.3.1 Infection control; QA.2.3.2 Utilization review; and QA.2.3.3 Review of accidents, injuries, patient safety, and safety hazards QA.2.4 The quality of patient care and the clinical performance of those individuals who are not permitted by the hospital to practice independently are monitored and evaluated through the mechanisms described in Required Characteristics QA.2.1 through QA.2.3.3 or through other mechanisms implemented by the hospitals.
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From page 320... ...
QA.3.2.1 Each department/service participates in QA.3.2.1.1 the development and/or application of criteria relating to the care or service it provides; and QA.3.2.1.2 the evaluation of the information collected in order to identify important problems in, or opportunities to improve, patient care and clinical performance. QA.3.2 The quality of patient care is improved and identified problems are resolved through actions taken, as appropriate, QA.3.3.1 by the hospital's administrative and supervisory staffs; and QA.3.3.2 through medical staff functions, including QA.3.3.2.1 activities of the executive committee, QA.3.3.2.2 activities of departments/services, QA.3.3.2.3 the delineation and renewal or revision of clinical privileges, and
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From page 321... ...
there must be evaluations of all organized services and of nosocomial infections, medicine therapy, and tissue removal. The new quality assurance condition as finally promulgated calls for a formal, ongoing, hospitalwide program that evaluates all patient care services (Table 7.8)
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These may include document-based review (e.g., review of medical records, computer profile data. continuous monitors, patient care indicators or screens, incident reports, etc.~; direct observation of clinical performance and of operating systems and interviews with patients, andlor staff.
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From page 323... ...
If the hospital offers these optional services, they must also be evaluated: anesthesia services; emergency services; nuclear medicine services; outpatient services; psychiatric services; rehabilitation services; respiratory services; surgical services. Each department or service should address: patient care problems; cause of problems; documented corrective actions; monitoring or follow-up to determine effectiveness of actions taken.
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From page 324... ...
However, the governing body condition has a standard for ensuring that the medical staff is accountable for the quality of patient care, and the medical staff condition has a parallel standard: The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. The interpretive guidelines for the medical staff condition also require that periodic appraisals of staff include information on competence from the quality assurance program.
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From page 325... ...
The resources and procedures of Medicare and the Joint Commission for surveying are described and compared in this section. Surveyors and Survey Teams Section 1864 of the Social Security Act directs the Secretary of DHHS to enter into agreements with any "able and willing" state, under which the state health department or other appropriate state agency surveys health facilities wishing to participate in Medicare and certifies whether they meet the federal Conditions of Participation and other requirements.
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Survey Cycle HCFA does not have a fixed survey cycle for hospitals. Beginning in FY 1991, state agencies were funded to survey 100 percent of unaccredited hospitals (currently, 75 percent)
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The services provided by each practitioner with hospital privileges must be periodically evaluated to determine whether they are of an acceptable level of quality and appropriateness." Finally, a surveyor may refer to the survey procedures column: "Determine that the hospital is monitoring patient care including clinical performance. Determine that a review of medical records is conducted and that the records contain sufficient data to support the diagnosis and to determine that the procedures are appropriate to the diagnosis." The Joint Commission survey report forms (one for each surveyor discipline, e.g., physician, nurse, etc.)
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aAll Joint Commission standards and required characteristics are scored on a scale from 1 to 5, depending on degree of compliance: 1. Substantial compliance (the organization consistently meets all major provisions of the standard or required characteristic)
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More recently, 99 percent of the accredited hospitals have been receiving contingencies, several hundred of them serious enough to trigger tentative nonaccreditation procedures, but, due to serious lags in computerizing the new procedures, only four lost accreditation in 1986 and five in 1987 (Bogdanich, 1988~. As a result, several hospitals with very serious problems identified in Joint Commission surveys were able to retain their accreditation status for months and even years.
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The accreditation decision grid, then, aggregates the hundreds of scores given by surveyors into 43 summary scores under lO headings (e.g., medical staff, monitoring functions, nursing services, quality assurance, medical records)
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From page 331... ...
This "distance" problem is another reason why the standard-setters have tried externally to impose quality assurance standards that make the hospital itself conduct such surveillance continuously after the inspectors leave (Vladeck, 1988~. A third impediment to using regulatory, or self-regulatory, standards to assure quality is the ambivalent attitude of Medicare officials, the state agencies that actually survey the facilities, and Joint Commission leaders toward the use of sanctions.
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From page 332... ...
It also could develop a more statistically credible survey validation program to check the performance of the Joint Commission and the states.~5 Conclusion: Certification and Accreditation Could Play a Role in Quality Assurance Many of the obstacles to more effective quality assurance facing HCFA's survey and certification and the Joint Commission's accreditation efforts are those facing Medicare's Utilization and Quality Control Peer Review Organizations (PROs) : lack of knowledge about the relations among structure, process, and outcome; distance; and political pressure.
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. Cons: The inherent limits on the ability of periodic facility inspections to find problems in the quality of patient care are too great (compared to, say, a peer review approach)
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From page 334... ...
Cons: · It is not realistic to expect that the conditions, which must go through the formal federal rule-making process, can be updated continuously. Little or no relation has been shown between facility-based standards and quality of patient care.
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From page 335... ...
335 These steps are not worth the cost, given the limits on their effective Major Issue 2: Role of the Joint Commission in Assuring Quality of Care for Medicare Patients Deemed status should continue, and the Joint Commission should be encouraged in its efforts to develop a state-of-the-art quality assurance prograrn, but, at the same time, federal oversight of the Joint Commission should be increased to ensure accountability and there should be more disclosure of information about hospitals with quality problems discovered by the Joint Commission. Pros: Joint Commission standards are higher and more up-to-date than the Conditions of Participation.
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From page 336... ...
. The resources for increasing federal oversight more funding for more Intensive state inspections, more federal inspectors to conduct validation surveys- would be better used elsewhere in the federal quality assurance program.
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. Also, certain structural standards, such as those for fire safety, that continue to be mandated and enforced through the certification and accreditation standards may not be closely related to patient care but are important factors in patient safety.
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in the hope that accredited hospitals could be deemed to meet all federal requirements without state agency inspection. The Secretary of the DHHS, however, has never agreed to let this accreditation standard be deemed to meet the federal utilization review requirement.
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Also, beginning in FY 1989, the number of validation surveys performed by state agency staff was increased to approximately 200 per year (HCFA, personal communication, 1989~. REFERENCES Affeldt, J.E., Roberts, J.S., and Walczak, R.M.
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From page 340... ...
Measuring the Quality of Patient Care: The Rationale for Outcome Audit. Cambridge, Mass.: Ballinger, 1976.
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From page 341... ...
ICAH. JCAH Board Approves New Medical Staff Standards.
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Hospitals, Journal of the American Hospital Association 49:61-62, 64, 66, 1975. Roberts, J.S.
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