That was a Modern Healthcare headline eleven years ago, and little has changed when The Joint Commission (TJC) shows up at your hospital for a surprise inspection. That remains true because TJC inspections are relied upon by Medicare, Medicaid, and Insurers, among others. Few hospitals ultimately fail to receive accreditation, but often remedial measures are required. The costs of failure are too high to deny full cooperation and a measure of fear.
Ask any hospital safety officer what he or she will do next after going through a TJC survey, and the answer will be simple: prepare for the next one. The threat of an unannounced Joint Commission survey is one of the most stressful and important parts of hospital administration. Having a team of inspectors descend upon your facility with a critical eye toward your staff, safety and life safety procedures, regulatory compliance, and facilities and equipment can be agonizing.
The federal government, through HHS and CMS, Centers for Medicare and Medicaid Services, allows states to arrange for inspections, and most are done by TJC with findings sent to state and federal regulators. In years past, visits were scheduled, and hospitals had time to prepare. This, of course, led to play-acting that did not reflect ordinary behavior, and so TJC advised hospitals that a surprise inspection might occur at any time within three years of the previous certification. Thus, the watchword became “be ready at all times.”
Medicare has instituted Conditions of Participation, called CoPs. Violations of CoPs are at three levels: moderate (called “standard level”), in which the hospital is in substantial compliance; serious (called “condition level”), in which there is substantial noncompliance; and catastrophic (called “immediate jeopardy”), which may cause termination of hospital participation in Medicare within 23 days. In 2016, CMS began to do a limited number of inspections on its own through which it could compare the stringency of examination done through outsourcing to TJC and others.
In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors. In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity raised concerns that led to new CMS regulations and also raised the question of making all inspection findings available to the public. Transparency remains a topic of heated discussion, but it seems to be the trend to allow increased public access to inspection findings. More on that tomorrow.