Accreditation

Options to CMS' proposed transparency rule

Accreditation Insider, July 11, 2017

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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, The Joint Commission and accreditation specialists have voiced worries that the 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. 

“This proposed rule is troubling from a risk and safety perspective for a variety of reasons, including the potential for misuse, misunderstanding and other unintended consequences, writes Christina Thielst, FACHE, for MultiBriefs. “However, it is especially concerning because survey reports can include confidential internal quality/performance improvement information. This information is shared when trust has been established between staff and surveyors who agree to maintain that confidence. Making the details of survey reports available will impede the flow of information and interfere with this the performance of this important component of every hospital’s quality improvement program.”

While many disagree with CMS’ proposed method, that doesn’t mean there aren’t options to promote transparency. Theilst says that CMS can reduce variation and increase transparency for consumers while avoiding unintended consequences using its existing policy.  Her suggestions include:

1.    Respecting the delineation of responsibilities and functional boundaries. This avoids the scope creep which comes from shifting private AOs away from their role evaluating adherence to standards of care and toward inspecting for regulatory compliance instead.

2.    Produce summaries of the information most relevant to consumers from accreditation reports.

3.    Have hospitals, AOs, and CMS team up to create a dashboard of findings and trends that consumers can understand and act upon.

4.    CMS and their AOs must comply with the terms of their agreements and investigate the causes of variation, identify breakdowns in the system, and make needed improvements.



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