CMS updates transparency and termination notices; Ex-Joint Commission exec calls for fairness in how hospitals are held to standards

Briefings on Accreditation and Quality, July 1, 2017

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Editor's Note: Since this story was written, The Joint Commission has said it's against the proposed rule.

This April, CMS sent out a memo with big proposals for accrediting organizations (AO). If passed, The Joint Commission, DNV, HFAP, and others would have to post final survey reports online within 90 days of that information becoming available to the healthcare organization.

However, there are concerns that this move creates an uneven playing field in hospital quality and oversight. It’s also argued that the public might have trouble deciphering the contents of the report.

More information, more transparency
CMS argues the new requirement would promote more transparency in healthcare. Currently, most AOs post only whether an organization is accredited or not, although recently The Joint Commission has revamped its Quality Check site to go further in some cases. The online reports would include details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoC).

“The provision would include all triennial, full, follow-up, focused, and complaint surveys, whether they are performed onsite or offsite,” according to the proposal, set out in the hospital Inpatient Prospective Payment System (IPPS) proposed rule for fiscal 2018.

The IPPS was published officially on April 28 in the Federal Register. (For a link, see the Resources box.) And in case anyone missed the proposal for more transparency during a reading of that 1,832-page tentative rule, CMS posted a Survey and Certification memo, S&C 17-24-ALL, to its state survey agencies the same day noting the proposed regulation change. The proposal itself is only 13 pages (0.007%) of the proposed rule. 

Just as CMS makes its reports available “in order to advance the department’s and agency’s commitment to transparency in terms of patient access to quality and safety information,” so should AOs, the memo states.

That idea is explained further in the IPPS. “Disclosure of survey findings protects both patient health and safety, in which public disclosure of findings currently only shows the subset of complaint activity. Expanding these requirements through the posting of all survey reports and acceptable PoCs would allow for a more comprehensive way to show a provider’s or supplier’s compliance with all health and safety requirements.”

CMS information available to public
Both the IPPS and the memo note that while AOs do not make their detailed survey reports or the hospital’s PoC available online now, CMS does make information from its inspection reports and the accepted hospital PoCs available to the public.

That said, the proposal appears to require AOs to take steps CMS does not. For instance, while CMS posts a spreadsheet detailing the hospital inspection results quarterly, with protected health information of patients redacted, the PoCs are only available if requested from CMS or the hospital itself. And the process and length of time to acquire those reports is much different than the 90-day, online posting proposed for the AOs.

In addition to the quarterly spreadsheet, CMS Statement of Deficiencies reports, often referred to by their form number as 2567s, are also periodically imported into a searchable database the Association of Health Care Journalists created in partnership with CMS in 2011. The database,, presents the reports in a manner that is more readable than the CMS spreadsheet but does not currently offer online access to PoCs.

Questions and concerns
While more transparency is good for the public, the government needs to first create a level playing field in hospital quality and oversight, says Kurt Patton, a former executive director of accreditation services for The Joint Commission who founded his own consulting firm, Patton Healthcare Consulting.
CMS touts its own transparency in the proposal, he says, but in reality the reports the agency provides to the public are difficult to find or understand in their present form, he observes. Moreover, those reports are not linked to the CMS Hospital Compare site.

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