This www page examines the failure of
accreditation. It has been no less susceptible to market pressures
and the influence of corporate interests than the rest of society. It
has consequently failed and failed repeatedly. This is not an attack
on the concept of accreditation but an illustration of the
vulnerability of the structures of society when it is controlled by
powerful self interested groups.
The Accreditation Process:- Accreditation is desirable and the motives of those who support it are excellent. It can and does have a positive impact in the sort of not for profit system we have had in Australia. It is not ideal. The process of preparation for accreditation can results in patient care being put on the back burner. The changes made sometimes last only for a few months. The fall away rate is higher when financial pressures cause job cuts. I suggest that accreditation would be improved, become less intrusive and less crisis driven in a cooperating system where data collection was ongoing and simply needed confirmation.
The JCAHO:- The Joint Commission in the USA (JCAHO) is the model on which other countries build their accreditation systems. They have advised internationally and are now accrediting international hospitals - a wonderful advertising opportunity for the hospitals accredited. The Joint Commission sets the world standard. Our aged care minister has placed particular stress on accreditation processes in our newly privatised aged care system.
It is increasingly clear that accreditation
does not protect patients in a health and aged care marketplace. The
pressures are too great. There have been repeated failures.
Psychiatry in the late 1980's and early 1990's:- The psychiatric hospitals involved in the scandalous conduct in Texas and in most of the rest of the USA were all accredited by both the US Joint Commission and by a psychiatric accreditation body. What was happening in these hospitals was no secret. There was a ground swell of concern. The JCAHO had even been advised of problems by doctors. They advisewd the hospitals of the complaint so that the doctor could be penalised. Quality of care committees, specified in accreditation requirements simply did not meet in some Tenet/NME hospitals. An administrator from Tenet/NME in his evidence to the April 1992 senate hearing described how the various oversight procedures including those by the private corporate insurance companies were no more than a facade. No regulatory or accreditation body took any steps to stop what was happening.
The 1992 "Profits of Misery" congressional hearing revealed that the body accrediting psychiatric hospitals was funded by corporate interests which appointed the board and staff. It did not inspect the hospitals and was simply a marketing exercise.
Ongoing failures:- Since that time the Joint Commission has had periodic bad press publicity. It has reformed and revamped its processes on a number of occasions. I took the question of failure of accreditation processes up with them some years ago when their failures were receiving publicity. I received a brief explanation and a set of brochures describing an increasingly elaborate process of accreditation - the changes they were making. I doubted that such a complex process could be made to work. Some time after this I again questioned their appointment of someone from Tenet/NME to a post in the commission. The response explained that the appointment was peripheral and as I recall detailed its arms length approach.
Nursing homes:- In the USA today
corporate facilities would not be competitive if they were not
accredited. One has only to examine the extent of the problems in US
nursing homes to realise how badly accreditation has failed this
time. It is likely that most if not all corporate nursing homes were
accredited by at least one accreditation body and used it in
marketing. If so then this accreditation was of less value to the
nursing home occupants than the paper on which it was printed. The
money would have been better spent on care.
Columbia/HCA attained a record number of accreditation commendations in 1995/6 yet the not for profit homes which performed better on government surveillance criteria did not do as well. Columbia/HCA, like Tenet/NME had enormous credibility. It took massive fraud and long periods of sustained adverse publicity to dent this and influence stock prices.
Political Influence:- Political influence is now very important and health care corporations of various sorts donate more money to politicians and to lobbying than any other group in the USA including tobacco companies. Thomas Frist (senior) the founder of HCA was a US senator. Thomas Frist (junior), the past chairman of HCA is the current chairman of Columbia/HCA. His brother is a US senator. All this gives these groups enormous status and credibility. They have "presence". Regulators are rather overawed and can be intimidated. The company is the industry leader and knows it all. Assessors are easily ridiculed if they assess something as incorrect or substandard. It is simply not an option.
Relationships:- In addition to these pressures it is clear that arms length structures do not survive interpersonal relationships on the golf course or even in the workplace as inspectors go about their business. Corporate staff and directors cultivate and relate well to accreditation staff and to the Joint Commission's directors.
Blowing the Whistle in Nevada:- With this in mind lets look at what happened in Nevada. A psychiatrist who has asked me not to use his name lodged a complaint with the Joint Commission about the HCA hospital in which he worked. Instead of coming to investigate the Commission notified the hospital who promptly reduced his privileges in the hospital so penalising him financially. In April 1992 he tried again. He supplied information and testimony to the federal government's "Profits of Misery" inquiry into the abuse of children. His hospital privileges were terminated, a major problem financially. This is only the beginning of another long and sad story of someone who tried to do the right thing.
HCA in Texas 1992:- During 1991 and 1992 psychiatric hospitals in Texas were the subject of a national outcry. HCA and a number of other groups were soon shown to be implicated and eventually paid significant settlements. The company had adequate opportunity to address any problems elsewhere.
HCA in Nevada 1993:- In June 1993 DAY ONE television program set up a sting operation in Nevada. They first showed the glowingly human and very misleading HCA advertisements targeted at children. The sting consisted of two "parents" with a mock slightly grumpy teenage patient who clearly did not need admission or psychiatric care. They visited several HCA hospitals using hidden cameras. They first phoned saying that they were coming and also disclosed the requested patient insurance number. In each instance the insurance agency had been phoned by the time the teenager arrived to determine what he was covered for and the duration. In each case every effort was made to persuade the parents to admit the teenager to hospital with a diagnosis covered by the insurance.
Political influence in Nevada:- A number of teenagers who were recent patients then described how they had been mistreated and mishandled. Nursing staff and a doctor then confirmed this and added more details. The Nevada chief prosecutor was interviewed. He agreed it was blatant fraud but would not prosecute the company. When asked why he was perfectly honest. HCA had too much support in the state legislature and there was nothing he could do.
Frist had known that with political support
he could do whatever he liked in Nevada so did not bother to make
changes to these lucrative profit generating practices. As the new
president of Columbia/HCA he has promised to reform the company and
make it kinder and more friendly, - he claims like when he was
chairman of HCA - before it merged with Columbia!. Memory is short
and a whole gullible nation, but particularly the stock market
More recently representative Pete Stark has
been scathing about the failure of accreditation. He attributed it to
the lack of independence from corporate influence and the lack of
accountability to citizens. He proposed legislation to remedy this.
It is the involvement of people in the
community which has been the most effective system of "quality
control". This has been repeatedly demonstrated in the USA and
more recently in Australia in the not for profit nursing home which
houses the minister for aged care's father. It is citizens in the
community who have repeatedly exposed the problems in the health care
market, as well as the failure of regulatory processes and the
political intrigue which is associated with it. They are vitally
interested. This is the care which they and their families will get.
These are the people who should be involved in providing oversight.
In the sort of system I have suggested be considered each health care service as well as the central administration will have continuous ongoing information. They will be able to identify any disturbing trends and immediately get someone out there to help in remediation. Oversight, accountability and remediation are built into the integrated system so that they are ongoing. Everyone can look in and see the overall picture - the spread of costs - the distribution of services and complications. There would be no competitive pressures, profit priorities, or loyalty to shareholders to impede the processes.
This is not to suggest that no government oversight would be required or that accreditation be abandoned. Because the data which it requires would be collected in an ongoing manner the oversight process would be simplified. It would be possible to examine the data, confirm that the processes of collection are valid and accurate. Spot checks across the service will not be to detect adverse practices but to check that the data collected does indeed reflect what is happening, that bad spots are picked up and that it has been responded to. Any interested community group will know exactly what is happening and will have access to the analysis and broad sweep of the data, but not of course to patient details. They can propose changes and press for them.
Between the 1st and 6th September the Courier Mail in Queensland ran a series of articles and an editorial describing the exploitation of the elderly in retirement homes and in nursing homes. The thrust of the articles was the failure of the accreditation process which the government had claimed would prevent just this.
The large numbers of insiders on the JCAHO board illustrate the tensions and conflicts in the system. Two were from Tenet Healthcare. Not only are past present and future staff from facilities that are accredited part of the processes but their bosses make up 80% of the board and are there to see that the companies are looked after.
Buie Seawell, a professor of business ethics at the University of Colorado, sees no "smoking gun" in the arrangement. He says oversight boards often benefit from the business knowledge of experts in the industry. Still, he feels industry insiders -- who fill more than 80% of the commission's board seats -- should make a lot more room for outside representation. And he admits that a corporate director like Biondi would need to be "pretty careful" to avoid potential conflicts of interest.
Untangling Tenet's Ties to Watchdog (Melissa Davis) The Street.Com Aug 7, 2003
Tenet Healthcare as an example of failures
One of the new 2007 Tenet Healthcare pages documents the extensive failures of the accreditation process and the JCAHO during the NME and Tenet scandals.
CLICK HERE to link to the Tenet Accreditation story
Other web sites
The Semmilweis Society <http://www.semmelweissociety.net> and the Alliance for Patient Safety <http://allianceforpatientsafety.org/> are two groups which have extensive material on their web sites related to failures in peer review in the USA and its misuse to penalise doctors who speak out about corporate practicises. They also contain material about the JCAHO and other failures in oversight. Whistle blowers might also be interested.
The GAO Report on JCAHO.
The Government Accounting Office report in July 2004 found that the JCAHO missed 80% of falures to meet Medicare requirements when compared with state based inspections. You can download the report as a pdf file from http://www.gao.gov/cgi-bin/getrpt?GAO-04-850. The JCAHO responded by criticising the report and initiating with another revision of its practices.
CLICK HERE to go to a page written in 2006 examining the recurrent failure of the accreditation process in aged care in Australia
This page created April 2000 by
Update comment Sept 2004 and June 2007