Medicare: CMS Needs Additional Authority to Adequately Oversee Patient Safety in Hospitals
GAO-04-850
Published: Jul 20, 2004. Publicly Released: Jul 20, 2004.
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Highlights
Hospitals accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are considered in compliance with Medicare participation requirements. GAO examined the extent to which JCAHO's pre-2004 hospital accreditation process identified hospitals not complying with Medicare requirements, the potential of JCAHO's new process for improving the detection of deficiencies in Medicare requirements, and the effectiveness of CMS's oversight of JCAHO's hospital accreditation program. GAO analyzed CMS data on hospitals state surveyors found to have deficiencies in Medicare requirements that JCAHO surveyors did not detect, analyzed CMS's measure of JCAHO's ability to detect noncompliance with Medicare requirements, and interviewed JCAHO officials.
Recommendations
Matter for Congressional Consideration
| Matter | Status | Comments |
|---|---|---|
| Given the serious limitations in JCAHO's hospital accreditation program and that efforts to improve this program through informal action by CMS have not led to necessary improvements, Congress may wish to consider giving CMS the same kind of authority over JCAHO's hospital accreditation program that it has over all other Medicare accreditation programs. | As stated in our Matter for Congressional Consideration, Congress took steps through Public Law 110-275, Section 125 to remove JCAHO's deemed status as a Medicare accreditation program. As a result, CMS will have the same authority over JCAHO as it has over other Medicare accreditation programs. |
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Centers for Medicare & Medicaid Services | To strengthen the ability of CMS to identify and report to Congress on JCAHO's ability to ensure that the hospitals it accredits protect the safety and health of patients through compliance with the Medicare conditions of participation (COPs), the Administrator of CMS should modify the method used to measure the rate of disparity between validation survey findings and accreditation program findings to provide a reasonable assurance that Medicare COPs are being met and consider whether additional measures are needed to accurately reflect an accreditation program's ability to detect deficiencies in Medicare COPs. |
CMS reports that it does not have sufficient funding to implement this recommendation and has closed the recommendation as not implemented. However, Congress took steps through Public Law 110-275, Section 125 to remove JCAHO's deemed status as a Medicare accreditation program. As a result CMS will have the same authority over JCAHO as it has over other Medicare accreditation programs. When JCAHO's deemed status is removed CMS will be able to change the survey validation method it uses to ensures that the hospitals JCAHO accredits protect the safety and health of patients through compliance with Medicare conditions of participation. As a result, this recommendation may no longer apply.
|
| Centers for Medicare & Medicaid Services | To strengthen the ability of CMS to identify and report to Congress on JCAHO's ability to ensure that the hospitals it accredits protect the safety and health of patients through compliance with the Medicare COPs, the Administrator of CMS should provide in the annual report to Congress an estimate, based on the validation survey sample, of the performance of all JCAHO-accredited hospitals, including the limitations and protocols for these estimates based on generally accepted sampling and statistical methodologies; and develop a written protocol for these calculations. |
CMS considers this recommendation closed and stated that the fundamental limitation on disparity calculations is the small sample size for validation surveys and the agency does not have the funding necessary to increase the sample size. CMS further stated that statistic refinements in the disparity rate calculations will not remedy this more fundamental problem of a small sample size for validation surveys of JCAHO accredited hospitals. However, Congress took steps through Public Law 110-275, Section 125 to remove JCAHO's deemed status as a Medicare accreditation program. As a result CMS will have the same authority over JCAHO as it has over other Medicare accreditation programs. When JCAHO's deemed status is removed CMS will be able to change the survey validation method it uses to ensures that the hospitals JCAHO accredits protect the safety and health of patients through compliance with Medicare conditions of participation. As a result, this recommendation may no longer apply.
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| Centers for Medicare & Medicaid Services | To strengthen the ability of CMS to identify and report to Congress on JCAHO's ability to ensure that the hospitals it accredits protect the safety and health of patients through compliance with the Medicare COPs, the Administrator of CMS should annually conduct traditional validation surveys on a sample of JCAHO-accredited hospitals that is equal to at least 5 percent of all JCAHO-accredited hospitals. |
CMS reports that it has not increased the sample size of its traditional validation surveys of JCAHO-accredited hospitals to at least 5 percent of all JCAHO-accredited hospitals because it does not have the necessary funding. CMS considers this recommendation closed. However, Congress took steps through Public Law 110-275, Section 125 to remove JCAHO's deemed status as a Medicare accreditation program. As a result, CMS will have the same authority over JCAHO as it has over other Medicare accreditation programs. When JCAHO's deemed status is removed CMS will be able to change the validation survey method it uses to ensures that the hospitals JCAHO accredits protect the safety and health of patients through compliance with Medicare conditions of participation. As a result, this recommendation may no longer apply.
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