In­spect­ing the in­spec­tors

In­ves­ti­ga­tors should ex­am­ine qual­ity: HHS re­port

Modern Healthcare - - THE WEEK IN HEALTHCARE - Joe Carl­son

When in­spec­tors in­ves­ti­gate se­ri­ous ad­verse events at hos­pi­tals, they should keep a tight fo­cus on pa­tient-care qual­ity is­sues, and dis­clos­ing the in­ves­ti­ga­tion re­sults to ad­min­is­tra­tors and ac­cred­i­ta­tion agen­cies, a re­view from HHS’ in­spec­tor gen­eral’s of­fice con­cluded.

In par­tic­u­lar, in­spec­tors should also do a bet­ter job of com­mu­ni­cat­ing the ex­act na­ture of their in­ves­ti­ga­tions to hos­pi­tal ad­min­is­tra­tors, while also tak­ing care not to dis­rupt any on­go­ing ef­forts be­gun in­ter­nally by hos­pi­tals to ad­dress the de­fi­cien­cies be­ing in­ves­ti­gated.

Those were among the key rec­om­men­da­tions in a 49-page re­port ti­tled Ad­verse Events in Hos­pi­tals: Medi­care’s Re­sponses to Al­leged Se­ri­ous Events re­leased Nov. 1 by HHS In­spec­tor Gen­eral Daniel Levin­son’s of­fice.

The re­port is one of sev­eral that have fol­lowed a 2008 study by the in­spec­tor gen­eral’s of­fice that es­ti­mated as many as 25% of all Medi­care ben­e­fi­cia­ries were harmed dur­ing hos­pi­tal stays in Oc­to­ber of that year, in­clud­ing 13% that in­volved a pro­longed hos­pi­tal stay, per­ma­nent harm, life-sus­tain­ing in­ter­ven­tion or death.

Although the rec­om­men­da­tions in the lat­est re­port are ad­dressed to the CMS, the mes­sage is equally in­tended for re­view by state in­spec­tors. The So­cial Se­cu­rity Act re­quires the CMS to con­tract with state in­ves­ti­ga­tors to look into al­le­ga­tions of im­proper care or treat­ment that could re­sult in a ci­ta­tion to the hos­pi­tal for not com­ply­ing with Medi­care’s con­di­tions of par­tic­i­pa­tion rules.

“The com­plaint process, there­fore, rep­re­sents a key part of the CMS’ pa­tient-safety sys­tem be­cause it is a po­ten­tial re­source for iden­ti­fy­ing and re­spond­ing to ad­verse events,” the re­port says.

One of the key rec­om­men­da­tions in the re­port is, when in­spec­tors come in to as­sess a health­care provider’s com­pli­ance with Medi­care’s con­di­tions of par­tic­i­pa­tion af­ter a com­plaint of an “im­me­di­ate jeop­ardy,” they should limit their in­ves­tiga­tive fo­cus exclusively to the in­ci­dent it­self and Medi­care’s qual­ity as­sess­ment and per­for­man­ceim­prove­ment con­di­tion.

That con­clu­sion was based on the re­sults of an in­ten­sive study of 95 in­ci­dents that re­sulted in im­me­di­ate jeop­ardy com­plaints be­ing filed against hos­pi­tals. Those are the most se­ri­ous events, re­quir­ing in­spec­tions within two days. The five most com­mon types of im­me­di­ate jeop­ardy never-events were sex­ual as­saults, med­i­ca­tion er­rors, phys­i­cal abuse by staff, re­straint prob­lems and sui­cide, the study found.

Au­di­tors con­cluded that even though half of the in­spec­tions in­cluded eval­u­a­tions of be­tween two and seven Medi­care con­di­tions of par­tic­i­pa­tion, fewer than half of the in­spec­tions in­cluded a re­view of Medi­care’s qual­ity-re­lated con­di­tions of par­tic­i­pa­tion.

Cen­tral to this con­di­tion of par­tic­i­pa­tion “is the idea that the hos­pi­tal should take re­spon­si­bil­ity for im­prov­ing its per­for­mance rather than re­ly­ing on the sur­vey process and the threat of pu­ni­tive ac­tions,” in­spec­tor gen­eral’s au­di­tors wrote.

A re­sponse from the CMS said the agency will in­crease the promi­nence of qual­ity con­di­tions of par­tic­i­pa­tion in its in­spec­tions fol­low­ing im­me­di­ate-jeop­ardy com­plaints and ex­plore ways to im­prove its com­mu­ni­ca­tions with ac­cred­it­ing agen­cies fol­low­ing in­spec­tions.

Although such in­spec­tions could be a source of feed­back for hos­pi­tals on ways to im­prove qual­ity, in­spec­tors are not al­ways forth­com­ing with in­for­ma­tion. Of the 95 hos­pi­tals sur­veyed for the re­port, 16 re­ported that they first learned of the com­plaint when state agency in­spec­tors ar­rived at their fa­cil­i­ties.

Hos­pi­tal staff “had trou­ble” iden­ti­fy­ing the ex­act na­ture of the com­plaints in 27 of the in­ci­dents, and in three cases, ad­min­is­tra­tors said they never did find out why in­spec­tors had ar­rived.

About two-thirds of hos­pi­tals had al­ready be­gun re­view­ing the in­ci­dents in­ter­nally by the time in­spec­tors be­gan their sur­veys, and in some cases ad­min­is­tra­tors said the state in­spec­tors ac­tu­ally de­layed their own re­sponses to the in­ci­dents, such as staff train­ing. But at the same time, hos­pi­tals said they ap­pre­ci­ated how the in­spec­tors’ pres­ence added ur­gency their own re­views.

The in­spec­tor gen­eral’s of­fice noted that ac­cred­i­ta­tion ex­perts with the Joint Com­mis­sion re­ceived no­tice of only eight of the 88 in­ci­dents that took place at hos­pi­tals it ac­cred­ited. In a re­sponse, the CMS said it no­ti­fied the com­mis­sion of 28 of 88 events at hos­pi­tals ac­cred­ited by the Joint Com­mis­sion.

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