CMS report focuses on AOs’ life safety short-comings

Briefings on Accreditation and Quality, October 1, 2017

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Report to Congress finds that accreditation organizations have a lot of work to do

The annual CMS evaluation of accreditation organizations (AO) is out and in the hands of Congress. CMS thinks all the AOs aren’t doing as well as they should in catching violations and is promising Congress that it’s actively working to change that.

The annual report to Congress on AO performance is required by law. This year’s report covers survey discrepancies between CMS and AOs in the fiscal year 2015.

In the report, CMS compared its surveys to those of AOs, noting how many times CMS surveyors found violations and Conditions of Participation (CoP) deficiencies at a hospital that AO surveyors missed. The report found that Life Safety Code® (LSC) and physical environment (PE) violations posed the greatest challenge for hospitals and other healthcare organizations (HCO).

If you got the sense that surveyors were focusing more than usual on fire safety and the physical environment in the last year or so, it wasn’t just because of the newly adopted 2012 LSC.

With the report made public, expect The Joint Commission and other AOs to even further intensify scrutiny of fire and smoke barriers, hazardous areas, sprinkler systems, fire doors, and the means of egress. This is part of an effort to reduce what Medicare leaders said was an unacceptable disparity between deficiencies found during AO inspections and those identified in follow-up CMS validation surveys.

AOs improving but CMS wants more

On the positive side, the report states that AOs have been improving from year to year since 2000. But the authors also say that more improvement is needed, especially within the environment of care.

“The PE CoP contains multiple standards; however, 94 percent of the PE citations were comprised of the LSC standard within the CoP," according to the report’s conclusions. "Within the LSC standard catego-ries, Fire/Smoke Barrier, Hazardous Areas, Sprinklers, Doors, and Means of Egress were the top deficiency citations not cited by AOs, with the Fire/Smoke Barrier noted in four of the program’s top five missed citations.”

CMS noted it was largely unable to compare many of the current AOs on hospital performance because so little information was available from the most recent AOs.

That includes the newest AO, the Center for Improvement in Healthcare Quality (CIHQ), which gained deemed status in 2013, and DNV GL-Healthcare, which was first approved as an AO in September 2008.
The two oldest AOs are The Joint Commission and the Healthcare Facilities Accreditation Program (HFAP), which was the first organization to be approved by Medicare as an AO in 1965, when it oversaw accreditation under the auspices of the American Osteopathic Association.

Richard Curtis, RN, MS, HACP, CEO of CIHQ, is pleased to see that CMS recognized how well the AO performed.

 “This is the second year in a row that CIHQ has had (proportionally) the highest number of hospitals that have received a condition-level deficiency during either an initial or re-accreditation survey,” he says. “I believe it is a reflection of how rigorous our process is. It’s a tough survey, but our hospitals emerge in a much stronger compliance position as a result.”

While CIHQ doesn’t have a calculated disparity rate for CIHQ yet, Curtis says, based on their limited experience to date, there are legitimate concerns regarding the validity of the data. Only 102 hospital surveys were validated by CMS for the report, out of the 3,515 AO surveys conducted in fiscal 2015. That’s a sample size of less than a 3%.

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