Hospitals’ Watchdog Raises Violation Threshold

Times Staff Writers

The group that gives a seal of approval to the nation’s hospitals -- already accused of being too lenient -- now will allow medical centers to rack up more patient care lapses and other violations before sanctioning them.

The Joint Commission on Accreditation of Healthcare Organizations last month raised the number of deficiencies a hospital may accumulate during an inspection before being punished.

Critics say that the new rules are a step back for the influential group and that it may be more eager to please hospitals than protect patients.

“I don’t know how far below zero they intend to go,” said Rep. Pete Stark (D-Fremont), who has called for more federal oversight of the commission. “They’re not doing the job of making sure that hospitals are delivering quality, safe care.”


Commission accreditation is not purely symbolic; state regulators and private insurers consider it a key measure of a hospital’s quality.

The commission, which accredits more than 4,500 hospitals nationwide, is private, and hospitals pay it for the cost of the inspections. It also owns a consulting business that helps hospitals prepare for its reviews.

Stark and others question whether the new standards render accreditation meaningless. If the new rules had been in place in 2004, for example, Martin Luther King Jr./Drew Medical Center in Los Angeles County would have kept its accreditation after myriad problems with care that led to some patients’ deaths.

Commission officials defended their decision this week, saying the group would prefer to identify more problems and have hospitals fix them than strip more facilities of accreditation. Two major factors cited in the decision were a rise in the number of deficiencies found by better-trained inspectors and a switch this year to surprise reviews.

“We shouldn’t deny accreditation to 10 or 15 or 20% of all the hospitals in the United States,” said Joseph L. Cappiello, vice president of accreditation field operations. Patients are better served when the group’s findings are not a punishment but a “catalyst for improvement,” he said.

Dr. Dennis S. O’Leary, the commission’s president, predicted that the number of hospitals sanctioned this year would actually increase from years past. O’Leary said the commission made the changes not because of outside pressure but because it found that too many decent hospitals were being referred for punishment this year.

Sanctions against hospitals inspected earlier this year were put on hold while the new rules were discussed. Commission officials declined to say how many hospitals would have been punished this year had the rules not changed.

Sen. Charles E. Grassley (R-Iowa) said in a statement Wednesday that he found the changes “puzzling.”


“Government investigators already have documented that the Joint Commission misses too many serious problems and rarely drops any hospital’s accreditation,” said Grassley, who heads the Senate Finance Committee and has taken an active role in overseeing healthcare quality. “This move to weaken standards seems to be going in the opposite direction of what makes sense for quality of care.”

In 2004, the Government Accountability Office issued a harsh appraisal of the thoroughness of commission reviews. The federal watchdog agency found that commission reviewers missed about 69% of the problems found by government hospital inspectors in a sample of 500 hospitals accredited by the commission over a three-year period. Government inspections help determine whether a hospital keeps its Medicare and Medicaid funding.

After the report was issued, Grassley and Stark introduced a bill seeking to allow Medicare to restrict or remove the commission’s authority if it wasn’t doing its job. The bill did not become law.

Under the commission’s new rules, a large hospital is not downgraded to conditional accreditation (akin to probation) unless it has violated 14 standards, up from 10. It can’t be recommended to lose its accreditation unless it has violated 20, up from 15. A small hospital must violate 11 instead of 10 standards for probation and 16 instead of 15 standards to lose accreditation. (Some small California hospitals may face a different standard because of a unique inspection process.)


The threshold for large hospitals is higher because more inspectors are sent to review them, the commission said.

Discipline is not automatic; it must be approved by an accreditation committee.

Some hospital officials say the commission might have found itself with too much work after toughening its inspections under pressure from health advocates and politicians.

In fact, the commission sanctioned more hospitals last year than in years past. In 2005, 14 hospitals were recommended to lose accreditation, compared with nine in 2004 and one in 2003.


Also last year, 52 hospitals were placed on conditional accreditation, up from 41 in 2004 and 17 in 2003.

The organization’s inspectors now pull active medical charts of patients and backtrack to see whether medications were given and whether lab work was done promptly, among other things.

Alta Bates Summit Medical Center in Berkeley initially was recommended to lose its accreditation after a November 2004 survey, but it was placed on conditional accreditation after an appeal. Hospital officials estimate they have had the equivalent of 10 full-time employees working for 19 months to address issues raised by the commission.

“Certainly their process has been an extreme punishment for us,” said Merrilee Newton, administrative director of quality for the hospital. Newton noted that the hospital would not have been sanctioned under the new rules.


“I think it’s an opportunity for us to say certainly we had to fix some of our documentation problems,” Newton said. But, she added, “I think it has hurt us in that our public has felt insecure.”