In a letter to CMS Administrator Seema Verma, the committee on Energy and Commerce is asking for what could be reams of information from the agency about patient harm and incidents of misconduct at acute care hospitals. The committee has also asked for similar information from each of the four hospital accrediting organizations (AOs).
The committee was particularly concerned about information in a report to Congress published last summer that indicated AOs “conducting hospital surveys did not report 39% of ‘condition level’ deficiencies that were subsequently reported following validation surveys conducted by [CMS] State Survey Agencies no later than 60 days following the AO survey.”
“Although CMS has worked to strengthen its oversight of AOs, the committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the accrediting organization survey process,” wrote the committee leaders.
Noting that the Department of Health and Human Services, through CMS, must provide oversight of accrediting organizations, including CMS’ own survey agencies, “the Committee is concerned about the adequacy of CMS’ oversight as well as the rigor of the AO survey process,” read the letter to Verma.
You can view a copy of this letter at this link: https://energycommerce.house.gov/wp-content/uploads/2018/03/20180309CMS.pdf
In 2017, approximately 67% of the surveys performed by HFAP and The Joint Commission received a Condition Level Deficiency in the Life Safety or Environment of Care chapters. This percentage of Condition Level Findings was up in 2017 compared to 2016. How much more does the committee expect the AOs to cite Condition Level Findings?
What does all of this mean for the future…? From my point of view, I believe you will see CMS tighten their reigns on the hospital AOs such as Joint Commission, HFAP, DNV-GL and CIHQ…. especially on issues of Life Safety, Environment of Care, and Emergency Management. The reason for this is based on the high disparity rates that most of the AOs have when compared to state agency validation surveys in the area of Life Safety.
Many observers have said that the method CMS uses to compare the efficiency of findings between the AOs and the state agencies is unfair based on the state agencies allowed to have more LS surveyors for more days on their surveys than the AOs.
I also claim that not all surveyors are the same: Most AOs hire current or former hospital facility managers who are operation minded. So they will focus on Life Safety issues pertaining to operations, such as corridor clutter, obstructions to doors and medical gas valves, etc. On the contrary, most state agencies surveying on behalf of CMS hire architects and engineers as LS surveyors, who focus on design issues (such as construction type and egress capacity) and mechanical systems (such as fire alarm systems and sprinkler systems).
Just because the surveyors have different backgrounds does not make them right or wrong: But it does make them different. So naturally, state agency surveyors will gravitate to cite deficiencies that are more along their specialty. And AO surveyors will do likewise. There will always be a disparity when the survey teams are different. To prove that point, the high disparity rate of AO findings compared to state agencies findings, is just as high when you make the comparison the opposite way: When you compare state agency findings to AO findings. The point is…. it is normal to have a high disparity rate when there are so many variables in the mix.
I don’t see this ever being fixed in my lifetime… The people in power seem to be too stubborn to acknowledge this issue and take appropriate action to resolve it. In the mean-time, I foresee CMS cracking down even harder on the AOs to cite even more findings, which will result in tougher Life Safety surveys.