oversight

Health Care: Criteria Used to Evaluate Hospital Accreditation Process Need Reevaluation

Published by the Government Accountability Office on 1990-06-11.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                                                 HEALTH CARE
                                                 Criteria Used to
                                                 Evaluate Hospital
                                                 Accreditation Process
                                                 Need Reevaluation

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                   United States
iSA0               General Accounting Office
                   Washington,   D.C. 20648

                   Human Resources Division

                   R-234279

                   June 11,199O

                   The Honorable Fortney H. (Pete) Stark
                   Chairman, Subcommittee on Health
                   Committee on Ways and Means
                   House of Representatives

                   Dear Mr. Chairman:

                   In a November 2, 1988, letter, you asked several questions related to the
                   effectiveness of the Health Care Financing Administration’s (HCFA)
                   validation of the Joint Commission on Accreditation of Healthcare Orga-
                   nizations’ accreditation process. In addition, you asked whether the Con-
                   gress should consider any alternatives to the present system of Joint
                   Commission surveys backed up by HCFA validation efforts. As agreed
                   with your office, we divided our work into two phases. This report
                   addresses the questions you raised on HCFA'S survey process (see app. I)
                   and discusses the problems HCFA is encountering in comparing its survey
                   results with those of the Joint Commission. In a later report we will
                   address alternatives to the present system being used to protect Medi-
                   care beneficiaries.


                   The Social Security Act, as amended in 1972, requires HCFA to review
Results in Brief   hospitals serving Medicare patients that have previously received an
                   accreditation survey by the Joint Commission. The purpose of this
                   review is to assess the Joint Commission’s accreditation process and
                   assure that Medicare conditions of participation are being met. HCFA per-
                   forms this task through surveys conducted by state agencies, But, under
                   its current survey process, HCFA cannot be certain that the Joint Com-
                   mission’s process is assuring that hospitals receiving Joint Commission
                   accreditation are meeting Medicare conditions of participation.

                   HCFA and the Joint Commission use different criteria to measure a hospi-
                   tal’s performance. HCFA surveyors measure a hospital’s compliance with
                   Medicare conditions of participation. Joint Commission surveyors mea-
                   sure a hospital’s compliance with the Commission’s accreditation stan-
                   dards. However, since Medicare conditions and Joint Commission
                   standards are not identical, the findings of these surveys are often
                   different,

                   In its most recent reports to the Congress, HCFA has concluded that the
                   Joint Commission and HCFA survey processes are equivalent. This con-
                   clusion is not based on a direct comparison of the two processes. Rather,


                   Page 1                              GAO/I-IRIS90-89   Hospital   Accreditation   Process
             B-234279




             it is based on the assumption that because the results of HCFA validation
             surveys of hospitals that the Joint Commission accredits are similar
             from year to year, and closely parallel the results of HCFA surveys of
             nonaccredited hospitals, the two processes must be equivalent. Officials
             of both organizations maintain that while HCFA conditions and Joint
             Commission survey standards differ, the intent behind them is the same.
             However, HCFA has not made a comprehensive comparison of the condi-
             tions and standards to (1) identify any significant differences or
             (2) develop a basis that analysts can use to compare the validation and
             Joint Commission survey processes and results.


             To be approved for participation in the Medicare program, a hospital
Background   must be in compliance with health, safety, and organizational standards
             (referred to as conditions of participation) prescribed in the Code of
             Federal Regulations. HCFA applies 19 conditions of participation to its
             Medicare hospital program. These conditions relate to such areas as
             quality assurance, nursing services, infection control, and state and local
             law (see app. 11).The conditions are subdivided into standards and
             elements.

             Section 1865 of the Social Security Act requires HCFA to accept Joint
             Commission accreditation of a hospital as evidence that it meets the
             Medicare conditions of participation. But the act also requires HCFA to
             review hospitals accredited by the Joint Commission to validate its
             accreditation process. HCFA performs this review function through
             surveys conducted on a selective sample basis (validation surveys) or in
             response to allegations of deficiencies (complaint surveys). Both types
             of surveys are conducted by state survey agencies under contract with
             HCFA. HCFA procedures require validation surveys to be performed within
             60 days of the completion of Joint Commission accreditation surveys
             and to include an examination of all conditions of participation. This
             timing is designed to provide a fair basis for comparing the survey
             results of the Joint Commission with those of the state agencies.

             HCFA authorizes state survey agencies to conduct complaint surveys
             when allegations (1) indicate that the health and safety of patients at a
             specific hospital may be at risk and (2) raise doubts as to a hospital’s
             compliance with Medicare conditions of participation. Complaint
             surveys address the specific area cited as being a problem. If the prob-
             lem is substantiated and a hospital is found to be out of compliance with
             a condition of participation, HCFA can authorize the state agency to
             expand the survey to include a review of all conditions of participation.


             Page 2                               GAO/HRD-9989   Hospital   Accreditation   Process
e.A.-.“,.,m..,m.m.w,s...

                           8234279




-.----_                               -
                           The Joint Commission surveys each hospital seeking accreditation at
                           least every 3 years. If a hospital does not choose to be accredited by the
                           Joint Commission, it is termed a nonaccredited facility and is to be
                           examined annually by state survey agencies under contract with HCFA.'
                           As with accredited hospitals that receive validation surveys, the
                           surveys performed in nonaccredited hospitals are meant to determine if
                           they are meeting the Medicare conditions of participation.

                           HCFA'S central office analyzes the survey data obtained from each state
                           agency and reports annually to the Congress on the results of these
                           analyses. As of May 1990, HCFA was finalizing its report on the results of
                           its 1987 survey analysis and was in the initial stages of drafting a report
                           on its 1988 survey analysis.


                           In performing this review, we examined pertinent Medicare legislation,
Scopeand                   HCFA regulations and operating manuals, HCFA'S annual reports to the
Methodology                Congress from 1980 to 1986, and drafts of HCFA reports to be submitted
                           to the Congress on the results of its 1987 and 1988 analyses of survey
                           results. At HCFA'S central office we (1) interviewed officials of the Health
                           Standards and Quality Bureau to determine how they validate the Joint
                           Commission’s accreditation process and (2) reviewed the files main-
                           tained by HCFA on each of the hospitals in which a validation survey was
                           conducted in fiscal years 1987 and 1988. These files contained the state
                           agency survey reports, the results of the Joint Commission accreditation
                           surveys, HCFA'S comparison of problems identified by the state agency
                           and the Joint Commission, and pertinent correspondence relating to the
                           surveys.

                           We also visited HCFA regional offices in Philadelphia and Chicago and
                           health departments of three of the states in those regions (Pennsylvania,
                           Illinois, and Wisconsin) to obtain information missing from central office
                           files on sample validation and complaint surveys. In addition, we inter-
                           viewed Joint Commission officials to discuss its survey process. Our
                           review was conducted between December 1988 and January 1990 in
                           accordance with generally accepted government auditing standards.




                           I Hospitals that choose not to be accredited by the Joint Commission are called “nonaccredited” by
                           IICFA and “unaccredited” by the Joint Commission.



                           Page 3                                            GAO/HID90-89      Hospital   Accreditation   Process
                             B-224279




                             HCFA'S validation survey program is designed to evaluate the premise
HCFA Does Not Know           that a hospital receiving Joint Commission accreditation is, in fact,
Whether the Joint            meeting Medicare health and safety requirements. To make such an
Commission’s                 evaluation, however, HCFA must be able to compare its survey processes
                             and findings with those of the Joint Commission. At present, there is no
Accreditation Process        accurate basis for making such comparisons.
Is Effective
                             From 1980 to 1986, HCFA reported to the Congress that, on an overall
                             basis, the Joint Commission and HCFA survey processes were similar.”
                             HCFA generally based its conclusions on (1) a comparison of the number
                             and types of deficiencies found in HCFA validation surveys and Joint
                             Commission accreditation surveys, (2) the percentage of accredited hos-
                             pitals surveyed by state agencies that were out of compliance with
                             Medicare conditions of participation in the current assessment year as
                             compared to the percentage in prior years, and (3) a comparison of the
                             number and type of deficiencies found in validation surveys and in HCFA
                             surveys of nonaccredited hospitals. None of these comparisons, how-
                             ever, gives HCFA sufficient information to enable it to draw a conclusion
                             about the equivalency of the two survey processes or the extent to
                             which HCFA can rely on the Joint Commission’s accreditation process to
                             identify hospitals that are out of compliance with Medicare conditions
                             of participation.


Comparison of HCFA and       HCFA   analysts often find differences in the deficiencies identified by
Joint Commission Findings    state survey agencies and the Joint Commission. This is primarily due to
                             differences in the scope and content of Medicare conditions of participa-
Provides Little Insight on   tion and Joint Commission standards, which are the basis for the two
Effectiveness of             organizations’ surveys. For example, the condition of participation relat-
Accreditation Process        ing to nursing services consists of 3 standards and 16 elements. Joint
                             Commission requirements relating to nursing services consist of 8 stan-
                             dards, 47 required characteristics, and over 80 subelements under the
                             required characteristics. Because of the differing survey criteria, the
                             significance and cause of differences in survey findings is difficult for
                             HCFA central office analysts to assess. But, although differences in sur-
                             vey findings do not necessarily mean that the surveys of either the Joint
                             Commission or HCFA were deficient, they can be a sign of problems in the
                             process that warrant attention. For example, at one hospital HCFA sur-
                             veyors found that hazardous areas (for example, storage areas for oxy-
                             gen) had neither automatic sprinklers nor walls or doors that could

                             "As of May 1990, HCFA's reports to the Congress for fiscal years 1987 and 1988 were in the draft
                             stage and no issue dates had been established.



                             Page 4                                            GAO/IUD-90-89     Hospital   Accreditation   Process
B-234279




withstand fire for 1 hour. The Joint Commission survey report did not
cite this as a problem. The HCFA analyst with whom we discussed this
difference said that the situation represents a major fire hazard.

In fiscal year 1988, HCFA conducted 98 validation surveys. In at least 14
of these surveys, state agency and Joint Commission findings relating to
Medicare conditions of participation were different. The areas in which
the differences occurred were: quality assurance, physical environment
(with emphasis on life safety code), emergency services, pharmaceutical
services, laboratory services, nursing services, and respiratory care
services.

In fiscal year 1987, HCFA conducted 61 validation surveys but concen-
trated its analysis of state agency and Joint Commission survey findings
in three areas: physical environment with emphasis on life safety code,
infection control, and laboratory. These areas were selected because, in
the opinion of HCFA officials, they are where most problems are found in
hospitals. HCFA found that in nine hospitals that its surveyors cited as
having failed to meet the life safety code requirements, the number and
scope of deficiencies found by HCFA and Joint Commission surveyors
varied. In its draft report to the Congress, HCFA concluded that the Joint
Commission findings could provide better assurance of safety if Com-
mission surveyors devoted more attention to the hospitals’ physical
environment.

To determine the significance of differing survey findings and the extent
to which they can be attributed to different survey criteria, HCFA and
Joint Commission requirements must be extensively compared. In doing
this, a comprehensive guideline (crosswalk) is needed to allow HCFA ana-
lysts to determine which of the Joint Commission standards and
required characteristics apply to Medicare conditions of participation
and associated standards and elements. In January 1989, the Joint Com-
mission prepared such a “crosswalk” and concluded that the intent of
the two sets of requirements are similar. In January 1990, a HCFA ana-
lyst completed a similar crosswalk, but HCFA has not yet drawn any con-
clusions from this effort.!’



“In discussing a draft of this report, the president of the Joint Commission stated that, concerning
survey process issues, the core problem relates to how Joint Commission standards or Medicare con-
ditions of participation are interpreted and which standards and conditions are emphasized during
the survey process. In the Joint Commission’s opinion, the answer lies in ongoing close coordination
between HCFA and Joint Commission staffs.



Page 6                                            GAO/HRD-90-89 Hospital Accreditation       Process
                             R-234219




HCFA Needsto Reevaluate      As part of its assessment of the Joint Commission accreditation process,
                             HCFA (1) compares the number of deficiencies found in validation
How It Uses Survey           surveys of accredited hospitals with the number of deficiencies found in
Results to Assessthe Joint   surveys of nonaccredited hospitals and (2) determines the extent to
Commission Accreditation     which accredited hospitals in which a validation survey was conducted
Process                      complied with Medicare conditions of participation in the current year
                             and prior years. But neither of these comparisons uses comparable Joint
                             Commission survey data. Thus, in our opinion, they cannot be used to
                             validate the Joint Commission’s accreditation process.

                             In the reports that HCFA has issued to the Congress from 1980 to 1986, it
                             has concluded that its comparative data demonstrate that the Joint
                             Commission and HCFA survey processes are equivalent. To reach this
                             conclusion, HCFA first compared the results of all validation and com-
                             plaint surveys in a given fiscal year with survey results in all nonac-
                             credited hospitals in that same year. In these comparisons, the number
                             of deficiencies found in each Medicare condition of participation was
                             aggregated for each type of hospital (accredited and nonaccredited) and
                             the frequency with which the deficiencies occurred in each condition
                             was noted. The comparisons showed whether there were similarities
                             between the survey results at accredited hospitals in which validation
                             surveys were conducted and the results at nonaccredited hospitals. For
                             example, in its 1986 report, HCFA stated that 29 percent of accredited
                             hospitals in which validation and complaint surveys were conducted
                             were out of compliance with at least one Medicare condition of partici-
                             pation. In nonaccredited hospitals the noncompliance rate was 26 per-
                             cent. Thus, HCFA concluded that the Joint Commission and HCFA survey
                             processes were similar.

                             HCFA'S  second comparison consisted of matching the compliance rates
                             found in validation and complaint surveys in the current year with simi-
                             lar data from prior Jears, For example, in fiscal year 1986, the last year
                             in which HCFA has reported the results of its validation work to the Con-
                             gress, HCFA stated that 88 percent of all hospitals receiving a validation
                             or complaint survey were found to be in compliance with all Medicare
                             conditions of participation. Since this compared favorably to compliance
                             data from 1983 (85 percent), 1984 (80 percent), and 1985 (80 percent),
                             HCFA concluded that the Joint Commission and HCFA survey processes
                             continued to be equivalent.


                             To accurately assess the Joint Commission’s accreditation process, HCFA
Conclusions                  must change the criteria it is using to perform the assessment. Options


                             Page 6                               GAO/HRD-90-89   Hospital   Accreditation   Process
                    B-234279




                    include (1) using the Joint Commission standards in HCFA surveys,
                    (2) modifying Medicare conditions of participation so they are more con-
                    sistent with Commission standards, (3) requesting the Commission to
                    revise its standards to be more consistent with Medicare conditions of
                    participation, (4) conducting joint surveys, or (6) developing survey cri-
                    teria that can be used to accurately measure the comparability and
                    effectiveness of the Commission survey process.

                    Because our review was not meant to determine whether one set of sur-
                    vey criteria is better than the other, and both sets may be acceptable for
                    their intended purposes, we believe that a means must be established
                    through which existing Medicare conditions and Joint Commission stan-
                    dards can be effectively compared. But, to accomplish this, HCFA must
                    develop a more comprehensive crosswalk between Joint Commission
                    standards and Medicare conditions of participation. Further, it must
                    identify and resolve any significant differences between the two sets of
                    requirements.

                    Once a direct relationship has been drawn between these requirements,
                    HCFA should require its analysts to use the crosswalk when comparing
                    state agency and Joint Commission survey findings. This would (1)
                    reduce the subjectivity currently involved when HCFA analysts compare
                    state agency and Joint Commission survey findings and (2) result in
                    more meaningful comparisons. In conjunction with this effort, HCFA
                    should establish criteria to assess the significance of any differences
                    found between HCFA and Joint Commission survey findings and conduct
                    appropriate analyses to determine if these differences represent a trend,
                    a systemic problem, or merely aberrations. The comparisons HCFA is cur-
                    rently making to enable conclusions to be drawn on the validity of the
                    Joint Commission accreditation process are of little analytical value and
                    should be terminated.


                    We recommend that the Secretary of Health and Human Services direct
Recommendations     IICFA'S Administrator to:

                  . Work with the Joint Commission to (1) develop a comprehensive cross-
                    walk between its standards and Medicare’s conditions of participation,
                    (2) identify and resolve any significant differences between the Joint
                    Commission and MCFA survey requirements, and (3) require use of the
                    crosswalk in analyzing and comparing survey results.




                    Page7                                GAO/HRD-90-99   HospitalAccreditation   Process
                    B-234279




                  . Establish a means to measure the significance of differences in state
                    agency and Joint Commission survey results and analyze the differences
                    to determine if any trends or systemic problems exist.


                    In a May 3, 1990, letter, the Department of Health and Human Services
Agency Comments     concurred with our recommendations and cited the actions that either
                    have been, or will be, taken on each (see app. III). Specifically, on March
                    1, 1990, HCFA requested that the Joint Commission review the crosswalk
                    prepared by HCFA in which its conditions of participation for hospitals
                    were compared with Joint Commission requirements for 1989. When a
                    response is received from the Joint Commission, differences will be eval-
                    uated and appropriate modifications effected to assure that Joint Com-
                    mission requirements are comparable to the conditions of participation.
                    The Department also said that HCFA has developed crosswalks for the
                    1988 and 1990 Joint Commission requirements which will be used in
                    analyzing and comparing survey results.

                    The Department also stated that the crosswalks will be used to identify
                    the number, nature, and type of deficiencies identified by the state sur-
                    vey agencies and the Joint Commission. Tests for differences and their
                    significance will be made using a computerized statistical analysis sys-
                    tem. Significant differences will be analyzed to determine if trends or
                    systemic problems exist.


                    Copies of this report are being sent to appropriate congressional com-
                    mittees; the Director, Office of Management and Budget; the Secretary
                    of Health and Human Services; and other interested parties.

                    This report was prepared under the direction of David P. Baine, Direc-
                    tor, Federal Health Care Delivery Issues, who may be reached on (202)
                    275-6207 if you have any questions about this report, Other major con-
                    tributors are listed in appendix IV.

                    Sincerely yours,




                    Lawrence H. Thompson
                    Assistant Comptroller General


                    Page 3                               GAO/HRD-90-39 Hospital Accreditation   Process
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    Page 9   GAO/HRD-90-89   Hospital   Accreditation   Process
Contents



Appendix I                                                                                                 12
Responsesto             Summary
                        Number of Validation Surveys Conducted by HCFA Is
                                                                                                           12
                                                                                                           12
Questions Raised in        Unimportant Until Valid Assessment Criteria Are
the Chairman’s             Established
                        Complaint Survey Findings Not Compared to Joint                                    13
Request                    Commission Survey Findings
                        HCFA Surveys Not Intended to Determine Whether                                     14
                           Problems Identified by the Joint Commission Are
                           Corrected

Appendix II
Medicare Hospital
Program Conditions of
Participation
Appendix III                                                                                               16
Comments From the
Department of Health
and Human Services
Appendix IV                                                                                                19
Major Contributors to
This Report




          Y
                        Abbreviation

                        HCFA      Health Care Financing Administration


                        Page 10                             GAO/HRD-9049   Hospital   Accreditation   Process
.
    -.




         Y




             Page 11   GAO/HRD-90-89   Hospital   Accreditation   Process
Appendix I                                                                                            .-
Responsesto Questions Rtised in the
Chairman’s Request

                       Our review of IICFA'S efforts to assure that the Joint Commission’s
                       accreditation process protects Medicare beneficiaries addressed the fol-
                       lowing three questions that the Chairman, Subcommittee on Health,
                       House Committee on Ways and Means, raised in his November 2, 1988,
                       letter.

                       1. Is IICFA performing enough validation surveys to assess the effective-
                       ness of Joint Commission accreditation surveys?

                       2. IIow often do IICFA validation surveys and surveys based on specific
                       complaints identify findings that are at variance with those of the Joint
                       Commission?

                       3. How effective are the validation surveys in determining whether
                       problems identified by the Joint Commission are corrected?


                       The number of validation surveys performed is not important given that
Summary                IWA has no criteria against which to measure survey results; HCFA does
                       not, generally compare the results of complaint surveys with Joint Com-
                       mission findings; and validation surveys are not intended to determine
                       whether problems identified are, in fact, corrected. Data related to the
                       question on the extent to which HCFA'S findings differ from those of the
                       Joint Commission are on pages 4 and 5. The following is a summary of
                       the information we obtained on each question.


                       In fiscal year 1987, HCFA contracted with state agencies to conduct 61
Number of Validation   hospital validation surveys. It concluded, however, that the small num-
Surveys Conducted by   ber of surveys conducted made it impossible to determine the signifi-
HCFA Is Unimportant    cance of the percentage of hospitals out of compliance with Medicare
                       conditions of participation. Therefore, HCFA increased the number of
Until Valid            surveys authorized to be conducted by state survey agencies to 100 in
AssessmentCriteria     fiscal year 1988 and to 200 in fiscal year 1989. HCFA selected these sam-
Are Established        ple sizes to allow its analysts to arrive at valid conclusions about (1) the
                       performance of hospitals accredited by the Joint Commission and (2) the
                       comparability of the Joint Commission’s accrediting process and the
                       state agencies’ survey process. It is interesting to note, however, that
                       from 1980 to 1986, HCFA performed fewer than 80 validation surveys




                       Page 12                               GAO/HRD9089   Hospital   Accreditation   Process
    .
*


                    Appendix   I
                    Responses to Questions RaM+d in the
                    Chairman’s Request




                    each fiscal year and still drew conclusions on the comparability of the
                    Joint Commission’s accreditation process.’

                    However, until HCFA establishes an appropriate crosswalk between Medi-
                    care conditions and Joint Commission standards to assist in determining
                    whether HCFA and Joint Commission survey requirements and results
                    are comparable, the number of validation surveys conducted is not an
                    important consideration in assessing the Commission’s accreditation
                    process. When such a process is available, HCFA can develop a statisti-
                    cally valid sample that would allow conclusions to be drawn on the Joint
                    Commission’s process.


                          analysts do not compare the results of complaint surveys to the
Complaint Survey    HCFA
                    findings developed by the Joint Commission. Complaint surveys are gen-
Findings Not        erally one-issue reviews designed to either substantiate or refute a spe-
Compared to Joint   cific allegation(s) made to HCFA by, for example, a Medicare beneficiary
                    or a state investigating agency. If, however, a significant deficiency is
Commission Survey   found in a condition being investigated, the examination is supposed to
Findings            be expanded to a full survey, in which a hospital’s compliance with all
                    conditions of participation will be examined. The findings cited in a full
                    survey could be compared with Joint Commission survey results but are
                    not.

                    According to data contained in HCFA’S draft report on fiscal year 1987
                    survey results, state survey agencies investigated complaints at 606 hos-
                    pitals based on allegations of significant deficiencies that could affect
                    the health and safety of patients. HCFA found 62 of these hospitals out of
                    compliance with one or more conditions of participation. Data on the
                    number of hospitals that received a full survey because of their compli-
                    ance problems were unavailable because HCFA’S central office did not
                    request its regional personnel to provide it.

                    In fiscal year 1988, state survey agencies conducted over 200 complaint
                    surveys. As a result of these surveys, 32 hospitals were found to have
                    deficiencies of sufficient severity to place them under state agency sur-
                    veillance. According to HCFA, each of these hospitals received a full sur-
                    vey. The most frequently occurring deficient condition-which      occurred
                    in 16 of the 32 hospitals-involved    quality assurance. This condition

                    ‘HCFA conducted 79 validation surveys in 1980,76 in 1981,76 in 1982,64 in 1983,66 in 1986, and
                    48 in 1986. No data were available on the number of validation surveys conducted in fiscal year
                    1984.



                    Page 13                                         GAO/.J#&tM9-89 Hospital Accreditation    Process
                                                                                                                                    .
                          AppendLx I
                          Responses to Questious    Raised in the
                          Chairman’s Request




                          consists of standards and elements designed to assure that each hospital
                          has an effective hospitalwide quality assurance program to evaluate the
                          care provided to patients.


                          Validation surveys conducted by state survey agencies are not intended
HCFA Surveys Not          or designed to determine whether problems identified by the Joint Com-
Intended to Determine     mission are corrected. In accordance with HCFA procedures, state agen-
Whether Problems          ties are required to conduct validation surveys within 60 days of a Joint
                          Commission accreditation survey.2 But state agency surveyors are not
Identified by the Joint   provided with Joint Commission survey results and generally do not
Commission Are            know what problems the Commission surveyors identified. Further,
                          HCFA surveyors are instructed not to discuss Joint Commission findings,
Corrected                 if known, in their survey reports. If a state agency finds a hospital to be
                          out of compliance with a condition of participation, HCFA will authorize
                          follow-up action to assure that the deficiency is corrected.

                          In November 1989, HCFA'S Director, Health Standards and Quality
                          Bureau, wrote to executives of several organizations, including the Joint
                          Commission, American Hospital Association, and American Medical
                          Association, citing several changes he is considering in selecting hospi-
                          tals for validation surveys. The intent of these changes is for HCFA to
                          obtain better information on the effectiveness of the Joint Commission’s
                          accreditation process throughout the 3-year period of a hospital’s
                          accreditation.”




                          “The 60-day time limitation begins on the last day of the Joint Commission survey.

                          “Under the director’s proposal, about one-third of I-ICFA’ssample would be derived from the Joint
                          Commission’s monthly survey schedule (as it currently is), about one-third would be taken from the
                          Commission’s list of hospitals that have been found to be in less than substantial compliance with its
                          standards, and the remainder would be randomly selected to represent various intervals over the
                          accreditation period.



                          Page 14                                            GAO/HRD-90.89     Hospital   Accreditation   Process
‘Appendix II

Medicare Hospital Program Conditions
of Participation

               1, Compliance with federal, state, and local laws
               2. Governing body
               3. Quality assurance
               4. Medical staff
               6. Nursing services
               6. Medical record services
               7. Pharmaceutical services
               8. Radiologic services
               9. Laboratory services
               10. Food and dietetic services
               11. Physical environment
               12. Infection control
               13. Surgical services
               14. Anesthesia services
               16, Nuclear medicine services
               16. Outpatient services
               17. Emergency services
               18. Rehabilitation services
               19. Respiratory care services

               An additional condition relating to hospital utilization review is nor-
               mally waived by HCFA because hospitals are subject to independent utili-
               zation reviews by Medicare Peer Review Organizations or state survey
               agencies.




               Page 16                              GAO/~99-99     Hospital   Accreditation   Proms8
Appendix III

Comments F’rom the Department of Health and
Human Services


                     DEPARTMENT    OF HEALTH & HUMAN      SERVICES                        Office    of Inspector   General


                                                                                          Washington.       DC.    20201




                                                          MAY 3 1990


                   Mr. David P. Baine
                   Director,     Federal Health    Care
                    and Delivery      Issues
                   United States General
                      Accounting    Office
                   Washington,     D.C.    20548
                   Dear Mr. Baine:
                   Enclosed are the Department's            comments on your draft     report,
                   Wealth      Care:     Criteria    Used to Evaluate   Hospital   Accreditation
                   Proceee Needs Reevaluation."             The comments represent     the
                   tentative     position      of the Department and are subject       to
                   reevaluation      when the final      version  of this report    is received.
                   The Department appreciates   the opportunity              to comment on this
                   draft report  before its publication.
                                                          Sincerely      yours,



                                                          Richard P. Kusserow
                                                          Inspector General
                   Enclosure




               Y




                       Page16                                        GAO/HRD-9089   Hospital       Accreditation           Process
         Appendix III
         Ckunmenta Ibm the Department   of HeaIth
         and Human Services




                                Process Needs Reevaluation”




    The Social Security Act, as amended in 1972, requires HCPA to conduct surveys
    of hospitals previously accredited by the Joint Commission on Accreditation of
    Healthcare Organizations to assessthe Joint Commission’s accreditation process.
    GAO believes HCFA does not know with any degree of certainty whether the
    Joint Commission’s process can be relied upon to ensure that hospitals receiving
    Joint Commission accreditation are meeting Medicare conditions of participation.
    GAO believes that Medicare conditions and Joint Commission standards are not
    the same; as a result, the findings which result from these surveys are often
    dissimilar.

         0 Recommendation

    We                                                        S     ’ es di      t     CFA

                                        * *
           --   w      th the Joint Commrssron to II) develoD a comtnehensive
                             . .
                crosswalk @rdehne) between Joint Commission standards and




    On March 1, 1990, HCPA wrote to the Joint Commission requesting its review of
    HCFA’s crosswalk comparing the conditions of participation for hospitals with the
    1989 Joint Commission requirements. This crosswalk identified 11 significant
    differences, that is, 11 condition and standard-level Medicare requirements that
    lack comparable Joint Commission requirements. We are awaiting a response
    from the Joint Commission. Differences will be evaluated and appropriate
    modifications effected to ensure that Joint Commission requirements are
    comparable to the Medicare conditions of participation.




Y




         Page 17                                    GAO/HRD-99-99     Hospital       Accreditation   Process
    Appendix III
    Comment6 From the Department     of Health
    and Human !3ervicea




Page 2


Crosswalks have also been developed for the 1988 and 1990 Joint Commission
requirements. The appropriate crosswalk will be used in analyzing and comparing
survey results for all full surveys.



          mutoe                           the sionlficance of differences in State
          mssion                          survey results. and analvze the differences
                  * *                                   lems exist.
          IQ demuumbaaa



Use of the crosswalks will identify the number, nature and type of deficiencies
identified by the State survey agencies and the Joint Commission. Tests for
differences and their significance will be accomplished through use of a
computerized statistical analysis system. Significant differences will be analyzed to
determhre if trends or systemic problems e&t.




     Page 18                                       GAO/HRIk90-89   Hospital   Accreditation   Process
Appendix IV

Major Contributors to This Report


                   A
                       James A. Carlan, Assistant Director, (202) 708-4228
Human Resources        Michelle L. Roman, Assignment Manager
Division,              Mary Ann Curran, Evaluator-in-Charge
                       Gary Machnowski, Evaluator
Washington, D.C.




              Y




(101348)               Page 19                            GAO/HRD-99-99   Hospital   Accreditation   Promss
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