Government Report Blasts JCAHO's Hospital Oversight Record

In order to come to its conclusions, GAO analyzed CMS data on hospitals state surveyors found to have deficiencies in Medicare requirements that JCAHO surveyors did not detect, analyzed CMS's measure of JCAHO's ability to detect noncompliance with Medicare requirements, and interviewed JCAHO officials. In comparing the results of the two surveys, CMS also took into account whether it was reasonable to conclude that the deficiencies found by state survey agencies existed at the time JCAHO surveyed the hospital.

In a sample of 500 JCAHO-accredited hospitals, the GAO report said, state agency validation surveys conducted in fiscal years 2000 through 2002 identified 31% (157 hospitals) with deficiencies in Medicare requirements. Of these 157 hospitals, JCAHO did not identify 78% (123 hospitals) as having deficiencies in Medicare requirements. For the same validation survey sample, JCAHO also did not identify the majority (about 69%) of deficiencies in Medicare requirements found by state agencies. Examples of noncompliance issues that were identified were deficient nursing practices and inadequate fire safety provisions.

New Accreditation Process

JCAHO implemented a new hospital accreditation process in January of 2004, but its potential to improve the detection of deficiencies in Medicare requirements is unknown, the report said, because the new program has not been in place long enough. (As part of its reforms, JCAHO plans to move from using announced to unannounced surveys in 2006.) The pilot test of the new accreditation process was found to be of limited value in predicting whether the post-2004 process would better detect deficiencies because the hospitals included in that test were not randomly selected to participate; observers from JCAHO accompanied each surveyor, thus possibly affecting surveyors' actions; and JCAHO evaluated the results instead of having an independent entity do it.

Finally, the report asserts that CMS has limited oversight authority over JCAHO's hospital accreditation program because the program's unique legal status effectively prevents CMS from taking actions that it has the authority to take with other health care accreditation programs to ensure satisfactory performance. For example, it cannot require JCAHO's hospital accreditation program to submit to a direct review process or place the program on probation while monitoring its performance. Further, the GAO found that CMS relies on a measure to evaluate how well JCAHO's hospital accreditation program detects deficiencies in Medicare requirements that provides limited information and can mask problems with program performance. CMS also uses statistical methods that are insufficient to assess JCAHO's performance.

JCAHO's response to the findings was one of apparent outrage over what it deemed to be untrue allegations and an “irresponsible use of statistics.” In a release issued by JCAHO immediately following the publication of the GAO report, JCAHO charged that by “not providing the context for the [missed deficiency rate statistics], the GAO is misleading the public into an inference that the Joint Commission fails to detect the majority of all hospitals that have serious deficiencies, and also fails to identify the majority of out-of-compliance Medicare [Conditions of Participation].”

GAO Recommendations

The GAO has recommended to Congress that, based on its findings, it should consider giving CMS the same authority over JCAHO's hospital accreditation program that it has over other accreditation programs. CMS agrees with that recommendation.

The day after the release of the GAO report, legislation was introduced in the U.S. Senate that could be used to limit or withdraw JCAHO's authority to accredit hospitals. The bill, H.R. 4877, proposes to “amend title XVIII of the Social Security Act to revoke the unique ability of the Joint Commission for the Accreditation of Healthcare Organization to deem hospitals to meet certain requirements under the Medicare Program and to provide for greater accountability of the Joint Commission to the Secretary of Health and Human Services.” The bill has now gone to the House Committee on Ways and Means.

The federal Government Accountability Office (GAO – formerly, General Accounting Office) has for several years been examining the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to determine 1) the extent to which its pre-2004 hospital accreditation process identified hospitals not complying with Medicare requirements; 2) the potential of JCAHO's new (post-2004) process for improving the detection of deficiencies in Medicare requirements; and 3) the effectiveness of the Centers for Medicare and Medicaid Services' (CMS) oversight of JCAHO's hospital accreditation program. A report detailing the findings of that study, “Medicare: CMS Needs Additional Authority to Adequately Oversee Patient Safety in Hospitals,” GAO-04-850, published July 20, levels some serious charges against JCAHO.

JCAHO Accreditation

JCAHO accredits most U.S. hospitals through periodic inspections, and hospitals are considered in compliance with Medicare participation requirements if they meet JCAHO standards. The GAO found in its study, however, that JCAHO's pre-2004 hospital accreditation process failed to identify most of the hospitals that state survey agencies — in separate surveys — found to have deficiencies in Medicare requirements.

In order to come to its conclusions, GAO analyzed CMS data on hospitals state surveyors found to have deficiencies in Medicare requirements that JCAHO surveyors did not detect, analyzed CMS's measure of JCAHO's ability to detect noncompliance with Medicare requirements, and interviewed JCAHO officials. In comparing the results of the two surveys, CMS also took into account whether it was reasonable to conclude that the deficiencies found by state survey agencies existed at the time JCAHO surveyed the hospital.

In a sample of 500 JCAHO-accredited hospitals, the GAO report said, state agency validation surveys conducted in fiscal years 2000 through 2002 identified 31% (157 hospitals) with deficiencies in Medicare requirements. Of these 157 hospitals, JCAHO did not identify 78% (123 hospitals) as having deficiencies in Medicare requirements. For the same validation survey sample, JCAHO also did not identify the majority (about 69%) of deficiencies in Medicare requirements found by state agencies. Examples of noncompliance issues that were identified were deficient nursing practices and inadequate fire safety provisions.

New Accreditation Process

JCAHO implemented a new hospital accreditation process in January of 2004, but its potential to improve the detection of deficiencies in Medicare requirements is unknown, the report said, because the new program has not been in place long enough. (As part of its reforms, JCAHO plans to move from using announced to unannounced surveys in 2006.) The pilot test of the new accreditation process was found to be of limited value in predicting whether the post-2004 process would better detect deficiencies because the hospitals included in that test were not randomly selected to participate; observers from JCAHO accompanied each surveyor, thus possibly affecting surveyors' actions; and JCAHO evaluated the results instead of having an independent entity do it.

Finally, the report asserts that CMS has limited oversight authority over JCAHO's hospital accreditation program because the program's unique legal status effectively prevents CMS from taking actions that it has the authority to take with other health care accreditation programs to ensure satisfactory performance. For example, it cannot require JCAHO's hospital accreditation program to submit to a direct review process or place the program on probation while monitoring its performance. Further, the GAO found that CMS relies on a measure to evaluate how well JCAHO's hospital accreditation program detects deficiencies in Medicare requirements that provides limited information and can mask problems with program performance. CMS also uses statistical methods that are insufficient to assess JCAHO's performance.

JCAHO's response to the findings was one of apparent outrage over what it deemed to be untrue allegations and an “irresponsible use of statistics.” In a release issued by JCAHO immediately following the publication of the GAO report, JCAHO charged that by “not providing the context for the [missed deficiency rate statistics], the GAO is misleading the public into an inference that the Joint Commission fails to detect the majority of all hospitals that have serious deficiencies, and also fails to identify the majority of out-of-compliance Medicare [Conditions of Participation].”

GAO Recommendations

The GAO has recommended to Congress that, based on its findings, it should consider giving CMS the same authority over JCAHO's hospital accreditation program that it has over other accreditation programs. CMS agrees with that recommendation.

The day after the release of the GAO report, legislation was introduced in the U.S. Senate that could be used to limit or withdraw JCAHO's authority to accredit hospitals. The bill, H.R. 4877, proposes to “amend title XVIII of the Social Security Act to revoke the unique ability of the Joint Commission for the Accreditation of Healthcare Organization to deem hospitals to meet certain requirements under the Medicare Program and to provide for greater accountability of the Joint Commission to the Secretary of Health and Human Services.” The bill has now gone to the House Committee on Ways and Means.