oversight

HCFA Needs Better Assurance That Hospitals Meet Medicare Conditions of Participation

Published by the Government Accountability Office on 1990-06-21.

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

                  United states General Accounting Oface
                  Testimony
GAO

For Release         HCFA Heeds Better      Assurance
on Delivery         That Eiospitals   Meet I4edicare
Expected at         Conditions    of Participation
10:00 a.m. EDT
Thursday,
June 21, 1990

        ,




                    Statement of
                    David P. Baine, Director
                    Federal Health Care Delivery           Issues
                    Human Resources Division
                    Before the
                    Subcommittee  on Health
                    Committee on Ways and Means
                    House of Representatives




GAO/T-HRD-90-44                                                     GAO   Form160(12/W)
      The Department of Health and Human Services'         Health Care
Financing Administration    (HCFA) currently     relies   on the Joint
Commission on Accreditation      of Healthcare   Organizations     to act on
its behalf to assure that problems in most hospitals           serving
Medicare patients   are identified    and resolved.      HCFA does not now
have the necessary assurance that hospitals         surveyed by the Joint
Commission are complying with Medicare requirements.
       HCFA does not know the extent to which it can direct           the Joint
Commission to alter its accreditation        process to meet HCFA's
needs.     GAO believes,   however, that HCFA should attempt to guide
the Joint Commission's activities       to assure that hospitals        meet
Medicare requirements.       If this effort    is unsuccessful,
alternatives     to the present system of reliance       on the Joint
Commission's accreditation      process can be considered.       But none of
the alternatives      appears to be clearly    superior   to the current
system if it were operating       well.   Therefore,    GAO makes several
suggestions    to improve that system.
Mr. Chairman and Members                of the Subcommittee:


          I appreciate      the opportunity            to present         our views on the
system being         used to assure that             hospitals      are capable            of providing
quality      care to Medicare           patients.


          Since 1987, several           large     hospitals       in major U.S. cities                 have
been identified           in the media as providing                substandard         care.
Various      articles      have cited        incidents        involving      questionable
patient      deaths,      incorrect      medications,          infections       due to poor
quality      care,      and generally       unsanitary         conditions,       together         with
graphic      examples of the impact                such care is having           on patients.                 In
essence,       the effectiveness           of the systems to assure                 that     quality
care is provided           in our nation's            hospitals      is being       guestioned.               We
found that,          in some cases,        this      challenge      is justified.


          The Department         of Health        and Human Services'           (HHS) Health             Care
Financing       Administration          (HCFA) relies          on the Joint         Commission on
Accreditation           of Healthcare        Organizations          to act on its           behalf       to
assure that          problems     in most hospitals            serving       Medicare       patients
are identified           and resolved.            The Joint       Commission accredits               over
5,000 of the approximately                 6,700 hospitals           participating           in
Medicare.         HCFA contracts          with      state   agencies        to conduct       surveys
of those hospitals              that   choose not to be accredited                    by the
Commission to assure that                 they are in compliance               with     Medicare
 requirements.
       HCFA also contracts                     with      state     agencies      to conduct             a small
number of surveys                  in hospitals           accredited        by the Joint               Commission.
HCFA uses these               surveys        to help       it    assess the validity                   of the Joint
Commission survey                  process      and to assure that               Medicare             conditions      of
participation            are being met.I                  But,     to date,      HCFAls reviews                of the
Commission's            accreditation             process        have not provided               it     the
necessary        assurance            that     hospitals          serving     Medicare      patients            are
complying        with        its     conditions          of participation.


       Until      2 days ago, HCFA had relatively                             limited      access to Joint
Commission survey                   data.      Thus, the extent              to which specific
problems        existed            in hospitals,          and whether         they were corrected,
were generally               unknown to HCFA. However, under P.L.                                101-239,          HCFA
is now authorized                   to obtain         any survey data it               wants from the Joint
Commission.             If    HCFA requests              the right      information         from the
Commission and uses it                       properly,          HCFA should      be able to identify
any accredited               hospital         serving       Medicare        patients      that         has serious
problems        identified,             and be aware of efforts                  made by the Commission
to assure        that        corrective          actions         are being      taken.


       HCFAls access to Joint                         Commission data and the opportunities
it   presents       for        federal        intervention          does, however,          raise          a


lconditions       of participation      are health,    safety, and quality
standards which were developed to help HCFA assure that hospitals
participating       in the Medicare program are capable of providing
quality     care.    There are 20 conditions        prescribed  in the Code of
Federal Regulations          relating   to such areas as quality     assurance,
nursing services,         and infection    control.
                                                            2
significant        issue:       What should           the roles           of HCFA and the Joint
Commission be in assuring                  that      hospitals       serving          Medicare        patients
can provide        quality      care,      and how should            those          roles     be played       out?


       Two existing           situations          illustrate        why the roles              of HCFA and
the Joint      Commission should              be clarified.


-- First,      HCFA has not clearly                  identified           its     Medicare      conditions
    of participation            withjn       the Joint           Commission standards.
    Further,       HCFA has not developed                      a usable         guideline      to determine
    whether      the findings           in the Commission survey                      reports     relate         to
    Medicare       conditions        of participation.                    As a result,          HCFA does
    not know whether             accredited          hospitals       are capable              of providing
    high-quality         health      care.                 *


-- Second, the Joint              Commission process                for         following      up on
    corrective        actions      taken by hospitals                 in which problems                have
    been identified            takes much longer                 than HCFA believes              is
    appropriate.             As a result,          HCFA does not know whether                     serious
    problems       in hospitals            serving      Medicare          patients          are being
    corrected       promptly.




                                                       3
HISTORICAL PERSPECTIVE ON
  E ROLES OF THE JOINT
COMMISSIONAND HCFq


       To provide        a better         understanding        of the current        relationship
between HCFA and the Joint                    Commission,      a quick     review    of the
legislative        history       regarding        Medicare     certification        of hospitals
is in order.


       Under the Medicare                 law adopted       in 1965, the Joint           Commission's
accreditation         of hospitals            providing      care to Medicare        patients        was
to serve as evidence               that      hospitals      were also     in compliance         with
Medicare        conditions       of participation.2             The Commission's
accreditation         process       was not subject           to federal       review.  Also, the
Commission%          survey      reports       were confidential          and available    only to
its   personnel       and officials            associated      with     the concerned
hospitals.          Further,       conditions        of participation          established         by the
Secretary        of HHS could         be no more stringent              than related       Joint
Commission standards.


       The Medicare            legislation        drew criticism         in two areas.          First,
the federal         government        was unable          to determine     the extent        to which
specific        deficiencies        existed       in the majority         of hospitals




2The Medicare law also required hospitals                             to have effective
internal utilization  review processes.
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participating            in Medicare.           Second, the law permitted                    a private
organization           to develop          hospital       standards         for Medicare.


        In 1972, the Congress amended the 1965 legislation                                         and
required        HHS to review          hospitals          accredited           by the Joint         Commission
to validate        the Commission's                 accreditation           process.        HHS was also
given    authority          to develop         or modify            conditions      of participation          if
it   determines          that    existing       requirements             are inadequate.             Late last
year,    the Congress enacted                  P.L.      101-239,        which gives        HCFA access
to any Joint            Commission data relating                      to Commission surveys              of
hospitals        serving        Medicare       patients.


MEDICARE CONDITIONS OF PARTICIPATION
WED TO BE CLEARLY IDENTIFIED IN JOINT
COMMISSIONSTANDARDS


        As we reporteq             to you last           week, HCFA analysts               often     find
differences            in the problems             identified          at hospitals        by state
survey      agencies        and the Joint             Commission.3             This does not mean,
however,        that     there     are significant                  problems     in the Commission's
accreditation            process.          State      agency survey            findings     relate       to
problems        involving         Medicare         conditions          of participation.     Joint
Commission survey                reports      identify          problems       in terms of Commission
standards        that     are not being             adhered to.            But the two sets of


3Health Care: Criteria    Used to Evaluate Hosnital Accreditation
Process Need Reevaluation    (GAO/HRD-90-89, June 11, 1990).
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criteria           are different,           and there          is no means to easily              identify
which Medicare             conditions           of participation           relate         to specific
Commission standards.                      As a result,          the significance            and causes of
differences            in survey          findings      are difficult          for HCFA analysts              to
assess.


           Before      Joint      Commission survey              results     can be meaningfully
interpreted            by HCFA, a connection                   must be made between the
Commission's             findings         and applicable          Medicare      conditions             of
participation.                 To do this,           a comprehensive         and usable         guideline
(crosswalk)            is needed to establish                   a direct     relationship              between
each Medicare             condition          and the comparable            Commission standards.
We understand             that      HCFA and the Commission are working                          to develop
such a crosswalk.                   We must await             the outcome of this             effort        to see
how effective             it     will     be.


CORRECTIVEACTIONS ON PROBLEMS
IDENTIFIED BY THE JOINT COMMISSION
NEED


           After      accreditation             surveys       have been completed,             the Joint
Commission often                 takes      up to a year to conduct                 its    analyses         and
 follow-up           of survey          findings.         As a result,       there        is no assurance
that       significant           problems        identified       by the Commission are being
corrected            promptly.           In contrast,          for hospitals         outside      the



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Commission's         accreditation             process,        HCFA generally           takes       about 40
days to follow         up on problems               identified           by state     survey        agencies.


         From July     1, 1989 to April                23, 1990, the Joint               Commission
identified       28 hospitals           that       had serious           problems     and were in
jeopardy     of losing         their      accreditation.                 The Commission gave these
hospitals       what is called            conditional            accreditation.            But these
problems     were not new.               In 25 of the 28 hospitals,                     several       problems
cite,d    in 1989 surveys           were also present                in 1986, when previous
accreditation         surveys       were performed.                For example,          in 1989, Joint
Commission surveyors              reported          that      one hospital          did not have a
system in place           to monitor           whether        patients      with     bloodstream
infections       received       antibiotics.               As a result,            physician        surveyors
reported      that    needless         deaths were possible.                   In 1986, the same
problem was cited           and the same conclusion                       reached.


         The Joint      Commission's              follow-up       of problems          identified        in
surveys      conducted      in 1986 was slow.                    In fact,      it    did not follow           up
on most of the problems                  until      late      1987 and early           1988.      Further,
it   did not notify         the affected             hospitals           of the results          of the
follow-up       actions     until         1989.      Since the next scheduled
accreditation         surveys          at most of these hospitals                    were only a few
months away, the Joint                  Commission deferred                taking      actions       on their
accreditation         status      until          completion       of the 1989 surveys.




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         The timeliness               problem     encountered          could       recur     in 1989.        The
Joint     Commission took               from 3 to 6 months to analyze                        survey      data
before      it     notified       any of the 28 hospitals                   that     they were about to
receive          a conditional          accreditation.             Each hospital             was then given
time to submit              a corrective          action       plan.       As of April          23, 1990, the
Commission had scheduled                    only    2 hospitals            for     follow-up.            These are
scheduled          within      6 months from the date that                       the hospitals'
corrective           actions      'were approved.              The first         follow-up        is scheduled
for July          1, 1990.


         Until       recently,          HCFA was not aware of how long the Joint
Commission took to follow                       up on these hospitals'                 corrective
actions.           Further,       it     did not know that             the Commission decided                   to
defer      action       on these hospitals'                accreditation            status       until     after
the 1989 surveys                had been completed.                The President             of the Joint
Commission told               us that      the Commission allows                   longer     time       frames
for     follow-up           actions      so that     hospitals         can develop           sufficient
documentation               to show that         they have corrected                identified
problems.            The Director          of HCFA's Health             Standards           and Quality
Bureau informed               us that      the Joint           Commission's         time frame of up to
 1 year to analyze               and follow        up on problems                is unacceptable.


CONCLUSION


          Mr. Chairman and Subcommittee                         Members, HCFA needs to be sure
 that     hospitals           serving     Medicare       patients       are capable             of providing

                                                           a
high-quality             care.        At present,      HCFA does not have that               assurance
because its          efforts          to validate      the Joint       Commission's
accreditation             process       are hampered by the problems                  we have
discussed          today.        Moreover,      HCFA is unsure of the extent                   of its
authority          to require          the Commission to alter             its    accreditation
process         to meet HCFA's needs.


        We believe           that      HCFA should       attempt     to guide      the Joint
Commission's             activities         to assure that         hospitals      meet Medicare
requirements.               Specifically,           HCFA and the Commission need to work
together         to assure that             Commission standards           relating        to Medicare
conditions          of participation            are identified          and that       Commission
survey         reports      can be used to determine                whether      hospitals          are out
of compliance             with      Medicare    conditions         of participation.                Further,
HCFA and the Joint                  Commission should         reach a mutually             satisfactory
solution          on the best way to assure that                     (1) hospitals         promptly
correct         problems         the Commission identifies              that     relate      to Medicare
conditions          of participation            and (2) HCFA is quickly                informed         of
these         actions.


         If     HCFA and the Joint             Commission cannot           agree on these
issues,         alternatives           to HCFA's reliance           on the present           system of
Commission accreditation                     can be considered.            Options        include       (1)
establishing             an organization            within   HCFA to conduct           hospital
surveys,          (2) contracting            with    state   agencies      to conduct         all
hospital          surveys,        and (3) contracting          with     private       organizations
other     than the Joint            Commission to perform                 hospital        surveys     under
the auspices             of HCFA.       Each of these potential                    alternatives       would
be time consuming and expensive                         to establish,             and would likely
require        changes to existing                 Medicare       legislation.


         None of the above alternatives                       appears to be clearly                 superior
to the current             system if          it    were operating         well.       Thus, we believe
that     if    HCFA finds        that    it        cannot make the system work effectively
within        its     existing    legislative           authority,          the Congress should
consider            providing    HCFA the authority                it   requires       to be sure that
the Joint            Commission's       accreditation             process        is effectively       serving
the Medicare             population.




          This concludes          my prepared            statement.          We will      be pleased      to
respond        to your questions.




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