By Marty Piepoli
In the Fiscal Year 2009 Annual Financial Report to Congress, the Centers for Medicare and Medicaid Services (CMS) reported an 8% decrease in the disparity of findings between The Joint Commission (TJC) and CMS onsite hospital surveys. The disparity rate had been increasing annually over the past decade up to a high of 40% last year, causing increased concern for CMS and TJC. This is the first time the disparity rate has dropped and demonstrates that standards and survey process changes made by TJC in recent years have been effective in reducing the variance.
The disparity rate is identified through validation surveys. The Social Security Act authorizes the Secretary of Health and Human Services to conduct validation surveys of accredited facilities participating in Medicare as a means of validating the accreditation process. The Accreditation Validation Program, a significant component of CMS’ oversight of accrediting organizations (AO), consists of two types of validation surveys: full surveys of a representative sample of deemed facilities and allegation surveys which are focused surveys based on complaints. Over the past nine years, the data collected by CMS demonstrated an increasing degree of disparity and identified multiple opportunities for TJC to improve its survey process, reduce the gap in assuring compliance in surveying the Conditions of Participation thereby providing deemed status for Medicare hospitals.
Deemed status means that if a hospital is compliant with TJC standards then they are “deemed to be compliant” with the CMS Conditions of Participation. You may recall that TJC had a longstanding, unique statutory deeming authority for hospitals that was revoked with the enactment of the Medicare Improvement for Patients and Providers Act of 2008 (MIPPA). In 2009 TJC was required to submit a deeming application to assure current survey process met CMS expectations in surveying the Medicare Conditions of Participation. TJC was successful in that application and received renewed deemed status effective July 15, 2010 through July 15, 2014.
The level of disparity between TJC findings and those found during CMS surveys reached its high point in FY2008, when a 40% difference in findings was identified between the TJC process and State Agency validation surveys. Seventy-three percent of that disparity was in the area of the Environment of Care. As TJC and CMS continued dialogue to close the gap, TJC implemented the Life Safety Specialist, embarked on a Standards Improvement Initiative (SII) to improve their standards, separated the Environment of Care chapter into three chapters, creating the Life Safety and Emergency Management chapters, provided Life Safety education for all surveyors and worked on survey process and scoring methodology to meet CMS expectations.
Prior to the enactment of MIPPA, the validation survey component of CMS’ annual reporting to Congress was limited to those surveys conducted for The Joint Commission hospital program. As a result of MIPPA, expansion of the CMS annual report to Congress includes all accrediting organizations (AOs) and their approved accreditation programs. The validation survey program analysis will now be reported for all AOs and CMS-approved accreditation programs: critical access hospitals, home health agencies, hospice and ambulatory health care centers. The AO’s include The Joint Commission, the Healthcare Facilities Accreditation Program (American Osteopathic Association), DNV Healthcare, Inc., Community Health Accreditation Program, Accreditation Association for Ambulatory Healthcare.
To learn more about the CMS annual report and the related implications for accrediting organizations, join C&A for a webinar on February 17, 2009 addressing the FY 09 CMS Financial Report to Congress and Disparity Results. Click here for more information.
Sources:
The Joint Commission Standards Improvement Initiative (www.jointcommission.org)
CMS Financial Report, Fiscal Year 2009