Two hospitals' run-in with the JCAHO offers warning for all

May 2, 2005

A California hospital recently lost its accreditation from the Joint Commission on Accreditation of Healthcare Organizations, and another one is at risk of losing it. In both cases, medication-related problems accounted for part of the reason for their predicament. Their experience could signal a tougher approach by JCAHO.

A California hospital recently lost its accreditation from the Joint Commission on Accreditation of Healthcare Organizations, and another one is at risk of losing it. In both cases, medication-related problems accounted for part of the reason for their predicament. Their experience could signal a tougher approach by JCAHO.

Martin Luther King/Drew Medical Center in Los Angeles lost accreditation in February after exhausting the JCAHO appeals process. In Berkeley, Alta Bates Summit Medical Center faces its final appeal on a preliminary denial of accreditation. Both institutions were surveyed in 2004.

"The survey process was renovated in early 2004," said Joseph Cappiello, JCAHO VP for accreditation field operations. "It wouldn't surprise me if we saw a higher preliminary denial and conditional approval status this year." Overall, he said, about 1% of hospitals surveyed last year faced an initial denial of accreditation. About 2% were accredited with conditions that required specific improvements. Both numbers were down slightly from prior years as surveyors and hospitals adapted to changes in the process.

Alta Bates Summit is still fighting JCAHO's decision. The hospital is one of more than two dozen institutions owned by Sutter Health, based in Sacramento. In November 2004, surveyors found 19 areas at Alta Bates Summit that needed improvement, including uniform standards of patient care, pain assessment, use of patient restraints, use of deep sedation or anesthesia, and residency training programs. Problems were also found in several pharmacy areas, including medication storage, drug orders, drug handling, and responses to adverse drug events and medication errors.

The problems were severe enough that JCAHO issued a preliminary denial of accreditation. Alta Bates Summit successfully rebutted several of the initial findings, Cappiello said, but the preliminary denial remains in force. "Accreditation rests on the state of compliance with standards at the time of the survey, not improvements that have been made since that time," he explained.

Alta Bates Summit declined to discuss the survey, the requirements for improvement identified by surveyors, or any programs designed to rectify problem areas. "At the end of this process, we are confident that Alta Bates Summit will remain as we are today ... fully accredited," said spokeswoman Carolyn Kemp in an e-mailed statement. In rebutting the preliminary denial of accreditation, John Gentile, M.D., VP for medical affairs at Alta Bates Summit, noted that almost all of the requirements for improvement relate to documentation of care, not to the actual delivery of care.

That is not a significant distinction, said Paul Lofholm, clinical professor of pharmacy practice at the University of California San Francisco Medical School. He also consults for long-term care facilities accredited by JCAHO. "If you didn't document something, you didn't do it," he said.

Alta Bates Summit faces a final hearing in early May. "The grounds for changing a preliminary denial are a showing that the surveyors were in error or presenting evidence of compliance that was not seen by the surveyors," Cappiello said. "We don't know what Alta Bates will present. But it is not common to succeed at appeal."

King-Drew has been beset by quality and financial problems for years. In 2004, the county hired Navigant Consulting to take over administration of the hospital and appointed an independent board to oversee the institution. The new administrators pursued all avenues of appeal, but finally lost JCAHO accreditation in February.

The Centers for Medicare & Medicaid Services placed King-Drew in immediate jeopardy status, the final step before pulling Medicare and Medicaid patients and about $200 million in annual funding.

By the time CMS inspectors arrived in February, Navigant had made enough changes to retain deemed status and keep its federal funding. Wells said the hospital would reapply for JCAHO accreditation toward the end of 2005. Under normal circumstances, he explained, JCAHO assesses compliance over a 12-month period. But once an institution has lost accreditation for six months or longer, it can reapply as a new institution seeking initial accreditation. An initial accreditation requires compliance with the relevant standards over four rather than 12 months.