Accrediting organizations (AO) like the Joint Commission evaluate hospitals against established standards of care upon invitation and payment for services. State licensing groups and the Centers for Medicare Medicaid Services (CMS) inspect hospitals for compliance with state regulations and Medicare’s Conditions of Participation.

There is a bit of duplication and overlap between the two types of surveys, and perhaps this led to CMS’ decision to allow hospitals accredited by a CMS-approved accreditation program to substitute accreditation under that program for survey by the State Survey Agency.

If adopted, a new CMS proposed rule will require accrediting organizations to make their findings publicly available.

The change would require these private corporations to "make all Medicare provider or supplier final accreditation survey reports (including statements of deficiency findings) as well as acceptable PoCs publicly available on its Web site within 90 days after such information is made available to those facilities for the most recent 3 years. This provision would include all triennial, full, follow-up, focused, and complaint surveys, whether they are performed onsite or offsite."

I have actively participated in and/or led preparations, site visits and corrective action for numerous accreditation surveys, as well as state licensing and Medicare Conditions of Participation inspections.

Since the 1990’s, as scientific approaches to quality and performance improvement were adopted, surveyors increasingly encouraged hospital staff to openly share challenges and performance information. We were told an open collaborative environment would allow surveyors to support and guide facilities along their journey of continuous improvement.

This proposed rule is troubling from a risk and safety perspective for a variety of reasons, including the potential for misuse, misunderstanding and other unintended consequences. However, it is especially concerning because survey reports can include confidential internal quality/performance improvement information.

This information is shared when trust has been established between staff and surveyors who agree to maintain that confidence. Making the details of survey reports available will impede the flow of information and interfere with this the performance of this important component of every hospital’s quality improvement program.

A recent ProPublica article points to “…increasing concern by regulators private accreditors aren’t picking up on serious problems at health facilities..” as the motivating factor for the change.

The article also suggests that the availability of this information will help consumers make more informed decisions. I think this is the wrong approach to addressing these issues and the risk of unintended consequences is too great.

It seems to me that CMS must do a better job working with their approved accrediting organizations, instead of releasing all details of accreditation reports to the public, who may not be able to make informed decision given the low health literacy rates. An estimated 77 million adults have basic or below basic health literacy — the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.

As noted in the proposed rule, "CMS has responsibility for oversight and approval of AO accreditation programs used for Medicare certification purposes, and for ensuring that providers and suppliers that are accredited under an approved AO accreditation program meet the quality and patient safety standards required by the Medicare conditions and requirements."

One way they do accomplish this is by conducting validation site visits of a sample of those surveyed by AOs. Another technique would be to bring their concerns to the attention of AOs and working together to identify the root causes when significant variations occur between CMS and AO findings.

The Joint Commission, the oldest standards-setting and accrediting body in healthcare expressed its support for making “…reliable and valid quality data about health care organizations public…

I, too, support making reliable and valid quality data available for the public, as well as the position that survey reports are not healthcare quality data. They are quality improvement tools for healthcare providers.

What should be done instead?

Standards of care, state regulations and federal conditions of participation each contribute to the quality of care delivered by hospitals in the United States. My recommendations for reducing variation, increasing transparency for consumers, and avoiding unintended consequences is to adhere to the current policy and:

  1. Respect the delineation of responsibilities and functional boundaries by avoiding the scope creep that comes from shifting private accrediting organizations further away from their role evaluating adherence to standards of care and toward inspecting for regulatory compliance.
  2. Summarize some information from accreditation reports that would be of value to the public and consumers as they compare facilities. Hospitals, accrediting organizations and CMS should work together to create a dashboard of findings and trends; presented it in a way that consumers can understand and act upon.
  3. CMS and their AOs must comply with the terms of their agreements and do what they insist hospitals do when there are serious mishaps and errors — investigate the causes of variation, identify breakdowns in the system and make needed improvements.