Quality & Patient Safety

Hospital near-death ­experience

Briefings on Accreditation and Quality, October 1, 2012

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

The threat of loss of accreditation is one that keeps survey coordinators and hospital leaders awake at night, but for most hospitals, it's more of a bogeyman than an actual threat-there are many stages an organization must go through and fail before their accrediting bodies slam the hammer down. However, a recent case of decertification and recertification by Medicare stands as a cautionary tale for hospitals across the country to never lose sight of the goals of quality and safety.

Compass Clinical Consulting, an independent consulting group, recently had the experience of helping one hospital recover from the rare event of decertification from CMS. (For the privacy of the organization, the hospital's name has been omitted from this article.)

"How we got here is pretty straightforward," says Kate Fenner, RN, PhD, managing director of Compass Clinical. "It was an organization with a very strong leader, and they were focused on entrepreneurship and building the base of the organization."

The organization had been fairly aggressive in acquisition and reservice, and its board of trustees was on board with this concept. An unintentional downside to this approach, however, was the neglect of day-to-day clinical operations, says Fenner.

"They got very involved with growth-it became their mantra," she says. "But making certain that their core business was well served did not hit high on the radar. Board meetings were dominated by financial discussions, acquisition discussions, real estate, and building, with little to no discussion about clinical quality or issues going on at the hospital."

This lack of attention to clinical operations did not go unnoticed. Physicians became concerned-so much so that one physician submitted a complaint to CMS, bringing the state survey office in. The physician's fears turned out to be legitimate, and the organization received an immediate jeopardy finding.


Too little too late

CMS wanted an action plan on how the deficiencies it found would be addressed. Amazingly, the board did not even know about the immediate jeopardy finding, says Fenner. Instead, the CEO-that same leader who had led the charge toward acquisition and growth-delegated addressing the CMS finding to the chief nursing officer (CNO), who was an interim CNO at the time.

"She did her best," says Fenner. But despite the CNO's efforts, CMS came back in and found the facility still out of compliance.

"The second immediate jeopardy had a tight timeline on it," says Fenner. "Their CEO chose to say, 'You can't do that to us.' Well, they can! CMS is like the IRS-they have a lot of power. And this was a legitimate clinical concern."

Despite this, the state government gave the facility another opportunity to save itself-the surveyors even chose to stay in the area over a weekend, coming back on Sunday night, to give the organization one more chance to clean up and comply.

It failed.

"At this point they received notice of decertification," says Fenner, whose organization was brought in to help. "I wish they'd called us a week or two earlier."


Precipitation of the event

So what was happening at this hospital to bring it to this point? A complete lack of attention to the clinical side of things, says Fenner.

"I think what happens in cases like this is that leadership assumes that it's being attended to," she says. "Many leaders are not clinicians, and what we do in the areas of safety and quality can appear incredibly ­boring-wash your hands, two identifiers, the Universal Protocol™. This is not glamorous."

Nonclinicians assume these steps are being taken care of-but that's not the case if no one is paying attention to them, says Fenner.

There were several core issues that helped bring this organization's quality challenges to a head. First and foremost, there was a horrendous turnover rate in the nursing staff, as well as a high use of traveling and agency nurses.

What's more, the facility's temporary staff was being overseen by an interim CNO.

"If everyone is a temp, who owns this process?" says Fenner.

Further complicating matters was how the hospital handled its medical staff. "They had a superb medical staff, incredibly well trained, and they were kept completely out of medical operations," says Fenner. "There was not a tight relationship between quality, clinical, leadership, and staff. If you don't have all the players on the same page, it's hard to flow in the right direction."

This is an excerpt from a member only article. To read the article in its entirety, please login or subscribe to Briefings on Accreditation and Quality.

Most Popular