Loma Linda Hospital’s Rating Slips : Health: Medical center renowned for infant heart transplants is given conditional accreditation. Panel cites deficiencies in monitoring care.

Citing deficiencies in the ability to monitor the quality of medical care, the nation’s major hospital review organization has taken the unusual step of placing Loma Linda University Medical Center on conditional accreditation.

Loma Linda, world renowned for its infant heart transplant program, has submitted a plan of correction in response to the action, taken last month by the Joint Commission on the Accreditation of Healthcare Organizations, and will undergo another inspection later this year.

“We are going to meet the standards,” said W. Augustus Cheatham, Loma Linda University’s vice president for public relations and development. “We are sure we can. We hope to have this cleared up as soon as possible, but certainly before the end of the year.”

Of the 1,800 hospitals inspected by the Oakbrook Terrace, Ill.-based organization each year, only 5% to 8% are conditionally accredited, according to Pamela Schumacher, a Joint Commission spokeswoman. Between 1% and 2% of hospitals are not accredited and the others are fully accredited for a three-year period. Loma Linda was fully accredited three years ago.

Since the Joint Commission began announcing the names of conditionally accredited facilities last year, nine California institutions have been so designated. The others include Loma Linda Community Hospital, the Veterans Administration medical centers in Long Beach and Sepulveda, Martin Luther King Jr./Drew Medical Center in Los Angeles, and AMI South Bay Hospital in Redondo Beach.

Conditionally accredited facilities typically have problems with their quality assurance programs and medical staff monitoring systems, which are designed to minimize the risk that patients will be harmed or cared for by unqualified individuals.

The status indicates the commission’s belief, based on an on-site inspection, “that those mechanisms are not working sufficiently well to assure adequate patient protection,” said Dr. William Jessee, the organization’s vice president for accreditation surveys.

Citing confidentiality regulations, Joint Commission officials would not comment on the specific deficiencies found when Loma Linda was surveyed in August, 1989. Loma Linda officials also declined to release a copy of the report or the response the medical center sent to the commission last week.

But Jessee took issue with a statement by Dr. David B. Hinshaw Sr., the medical center’s president, that “none of the recommendations had anything to do with actual patient care.”

Jessee termed Hinshaw’s characterization “hyperbolic.” The recommendations “don’t relate to the care which is received by individual patients but they do relate to the systems which are designed to protect patients and improve their care,” he said.

A conditionally accredited facility must submit a plan of correction within a month of receiving the commission’s final report. If the plan is accepted, the hospital has six months to correct the problems. Then the commission sends out another inspection team.

A hospital that loses its accreditation jeopardizes its participation in the Medicare and Medi-Cal programs. In addition, a teaching hospital jeopardizes the status of its residency programs.

“We told (the commission) that we had instituted new procedures and new criteria for documenting and were expanding our guidelines for reporting requirements within the hospital,” Cheatham said. “So there will be a lot more paper.”

Jessee said that patients are likely to be at increased risk when they are treated at hospitals that do not meet its standards for monitoring and record-keeping. These hospitals also face greater difficulty in identifying problems than hospitals in compliance with the standards.