HOSPITAL ACCREDITATION – WHERE DO WE GO FROM HERE?
Never willing to let go of the idea that the public had a right to see the behind the scene workings of the accreditation process, this issue provided a synopsis and revealed once again reports considered confidential by the industry. While each state had some regulatory role over the health field and its providers, many states failed to define clear responsibility for the health and safety of those seeking medical care. This was most apparent with large powerful medical centers as hospitals increasing were called.
At the point of passage of the Medicare legislation, the government sought the cooperation of the various elements of the medical system. Failing cooperation the then President Johnson demanded the various representative organizations to submit their demands. In exchange for their cooperation or silence he put into the law the principles that caused the problem in the first place: the failure of America to provide adequate care at an affordable price for seniors.
These trade-offs which were the hallmark of the original legislation included for the medical doctors special regional fee schedules that would increase over time and a clear statement that the physician-patient relationship was sacrosanct; cost-plus reimbursement of hospital and other institutional services; and that hospitals to be eligible for participation in this new Medicare program needed to be certified by the state in which the hospital or other facility was located and in the case of hospitals in lieu of certification by the state, accreditation by the Joint Commission of the Accreditation of Hospitals, JCAH, (now renamed The Joint Commission on the Accreditation of Healthcare Organizations, JCAHO).
And that was the rub: JCAH/JCAHO was an organization whose board consisted of representatives of the AMA, AHA, etc. There were no consumers on the board nor was there any requirement that the rather routine surveys made by the JCAH/JCAHO be anything more than business as usual.
That meant that the hospitals were notified in advance when the so-called inspection team would arrive; the areas of inquiry were delineated in materials provided with the notice of the dates and that all information collected, reviewed and summarized in a written report of findings would be kept strictly confidential. All the hospital had to do was pay the fee for the survey, sit back with the surveyors all of whom were former hospital administrators for a few hours, respond to the findings and wait for the accreditation certificate’s arrival so it could be prominently display for all the world to see. Any person being admitted to the hospital or having any reason to visit the administration had to be impressed and overwhelmed to know that the hospital had been surveyed and met muster.
What the public did not see were the reports on which this seal of approval (something akin to the Good Housekeeping Magazine’s Seal of Approval including the same criticisms) was based. Consumers had no role in the accreditation process which this issue covered. Based on these accreditations, state governments had no role to prevent a hospital with significant defects from participating in Medicare and sharing in the billions of dollars that would flow their way. Many states yielded their public safety role by closing their own review efforts and as with the federal government accepting the sham accreditation by the JCAH as the equivalent of what they were charged to do by state law. Even more troubling was the fact that the expense of this accreditation process was then reimbursed by Medicare (as it was by the Blues and the private insurance companies). So the public was paying for a process it had no input and no access to the results other than a simple certificate on the wall of the hospital. In the 1970’s almost all hospitals received accreditation and the same certificate.
This publication also reprinted some of the findings of the JCAH and the New York State agency responsible for surveying hospitals. Both until publication were considered confidential and had never been released to the public. What was not reported but known in the industry which viewed these surveys as a threat and educational was the use of employment services which staffed the hospitals to ensure adequate staffing. Since the dates of the survey and the period that hospital records would be reviewed, it was often alleged that the records were doctored.
The one immediate impact of this publication was learning that the JCAH did have a before then unknown process for public information interview referred to as PII. Individuals could request a PII at which members of the public could voice their concerns and compliments. Other CCAHS publications (add examples if not all) will report on those PII experiences after which the industry demanded changes to make the PIIs more difficult to request and to participate in. As could be predicted, the JCAH met the hospitals’ demands.