type: other

jurisdiction: US

text: b'Department of Health and Human Services\n\n OFFICE OF\n INSPECTOR GENERAL\n\n\n\n\n The External Quality Review of\n Psychiatric Hospitals\n\n\n\n\n JUNE GIBBS BROWN\n Inspector General\n\n MAY 2000\n OEI-01-99-00160\n\x0c OFFICE OF INSPECTOR GENERAL\n\nThe mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, is to\nprotect the integrity of the Department of Health and Human Services programs as well as the\nhealth and welfare of beneficiaries served by them. This statutory mission is carried out through a\nnationwide program of audits, investigations, inspections, sanctions, and fraud alerts. The\nInspector General informs the Secretary of program and management problems and recommends\nlegislative, regulatory, and operational approaches to correct them.\n\n Office of Evaluation and Inspections\n\nThe Office of Evaluation and Inspections (OEI) is one of several components of the Office of\nInspector General. It conducts short-term management and program evaluations (called\ninspections) that focus on issues of concern to the Department, the Congress, and the public. The\ninspection reports provide findings and recommendations on the efficiency, vulnerability, and\neffectiveness of departmental programs.\n\nOEI\'s Boston\xe2\x80\x99s regional office prepared this report under the direction of Mark R.Yessian, Ph.D.,\nRegional Inspector General. Principal OEI staff included:\n\nBOSTON HEADQUARTERS\n\nJoyce M. Greenleaf, Project Leader Elise Stein, Program Specialist\nNorman J. Han, Program Analyst Bambi Straw, Program Specialist\nChaletta M. Clark, Program Analyst\n\n\n To obtain copies of this report, please call the Boston Regional Office at (617) 565-1050.\n Reports are also available on the World Wide Web at our home page address:\n\n http://www.dhhs.gov/progorg/oei\n\x0c EXECUTIVE SUMMARY\n\nPURPOSE\n\n To assess the external quality review of free-standing psychiatric hospitals that participate\n in Medicare.\n\nBACKGROUND\n\nConcerns About Psychiatric Hospitals\n\n Recently, the media has drawn attention to the quality of care in psychiatric hospitals due\n to deaths attributed to the inappropriate use of restraints and seclusion. This has raised\n fundamental questions about how care is delivered and overseen in psychiatric hospitals.\n Medicare requires such hospitals to meet two special conditions of participation (staff\n requirements and medical records) that apply only to psychiatric hospitals. The Health\n Care Financing Administration (HCFA) relies upon contracted psychiatric nurses and\n psychiatrists to assess compliance with these two special conditions. Like general\n hospitals, psychiatric hospitals are also subject to all the Medicare conditions of\n participation and can be deemed to meet them through either accreditation (usually by the\n Joint Commission on Accreditation of Healthcare Organizations) or certification (by State\n agencies). Currently 611 psychiatric hospitals participate in Medicare; all but 39 are\n accredited.\n\n This inquiry follows-up our recent series on the external review of hospital quality. In this\n related inquiry, we focus on the overall system of external review as it applies to\n psychiatric hospitals. That system includes HCFA\xe2\x80\x99s contracted surveyors, the Joint\n Commission, State agencies, and HCFA itself. We devote particular attention to the\n review provided by HCFA\xe2\x80\x99s contracted surveyors. We based our inquiry on national data\n on psychiatric hospital surveys, survey observations, and stakeholder interviews, among\n other sources of information.\n\n\nFINDINGS\n\nThe current system of external review for psychiatric hospitals has some\nstrengths that help protect patients.\n\n The system includes a patient-centered approach aimed at ensuring patients receive\n active treatment as opposed to custodial care. HCFA\xe2\x80\x99s contracted surveyors choose a\n sample of patients and trace them through the hospital by reviewing their medical records,\n\nThe External Quality Review of Psychiatric Hospitals 1 OEI-01-99-00160\n\x0c observing them on the wards and in sessions, interviewing them, and speaking with their\n caregivers. Neither State agencies nor the Joint Commission survey with this approach.\n\n It has achieved some balance between the collegial (aiming to educate and improve)\n and the regulatory (aiming to investigate and enforce) approaches to oversight.\n Both HCFA\xe2\x80\x99s contracted surveyor and State agency activities lean toward the regulatory\n approach. The Joint Commission surveys lean toward the collegial approach, with an\n educational bent. However, the Joint Commission has added some regulatory elements to\n its approach by increasing its unannounced surveys of psychiatric hospitals and\n maintaining more control over the selection of medical records.\n\nBut the external review system also has major deficiencies.\n\n The extent to which it holds psychiatric hospitals accountable for patient care is\n questionable. HCFA\xe2\x80\x99s contracted surveyors take an in-depth look at patient care, but the\n two special conditions that guide their survey are limited to medical records and staff\n requirements. Joint Commission surveyors\xe2\x80\x99 approach to patient care is less in-depth, but\n their official findings are much less limited and more far ranging. State agency\n involvement in psychiatric hospitals is more episodic and driven by complaints and adverse\n events, but they too have a broader range of official findings than HCFA\xe2\x80\x99s contracted\n surveyors.\n\n These limitations are particularly apparent with regard to discharge planning and restraints\n and seclusion. All external reviewers give marginal attention to discharge planning. The\n Joint Commission gives more attention to restraints and seclusion than HCFA\xe2\x80\x99s contracted\n survey or State agencies, but its effectiveness is questionable.\n\n Some psychiatric hospitals are falling through the cracks, rarely being subjected to\n contracted or State agency surveys. The number of surveys conducted by HCFA\xe2\x80\x99s\n contracted surveyors fell from a high of 413 in FY 1993 to 146 in FY 1998, a drop of 65\n percent. The elapsed time between such surveys is growing, and some psychiatric\n hospitals have not been surveyed in over 5 years.\n\n HCFA\xe2\x80\x99s contracted surveyors, State agencies, and the Joint Commission tend to\n carry out their psychiatric hospital oversight on independent tracks with little\n coordination. HCFA\xe2\x80\x99s contracted surveyors sometimes survey hospitals on the heels of\n the Joint Commission or State agency. Thus, in short order, a hospital could be visited by\n each. But HCFA\xe2\x80\x99s contracted surveyors rarely have the results of the other reviews.\n\nThe contracted surveyors are held just minimally accountable for their\nperformance in overseeing psychiatric hospitals.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 2 OEI-01-99-00160\n\x0c HCFA obtains limited information on the performance of its contracted surveyors.\n Validation surveys, HCFA\xe2\x80\x99s main source of information on the performance of external\n reviewers and hospitals, exclude the two special conditions for psychiatric hospitals. Also,\n HCFA asks for little aggregate or routine reporting on the contracted surveys.\n\n HCFA provides some feedback to its contracted surveyors, mostly through its\n review of the survey documentation. HCFA lacks a formal or routine mechanism for\n providing feedback to its contracted surveyors on their performance. Its feedback tends\n to be sporadic.\n\n Public disclosure plays a minimal role in holding the contracted surveyors\n accountable. HCFA makes little information available to the public on the performance\n of the psychiatric hospitals or the contracted surveyors.\n\n\nRECOMMENDATIONS\n\n HCFA and Joint Commission responses to the recommendations we posed in our recent\n series on the external review of hospital quality help address the deficiencies identified in\n this study. Below we offer five additional recommendations that emerge primarily from\n the findings in this inquiry, but also draw on those in our previous series, which included\n acute care hospitals with psychiatric units. Our recommendations call for HCFA to exert\n its leadership in shaping the external review of psychiatric inpatient care. If enacted, these\n recommendations will further strengthen external quality review systems intended to\n protect psychiatric inpatients.\n\nHCFA should deploy its contracted surveyors more strategically and take better\nadvantage of their expertise.\n\n HCFA\xe2\x80\x99s 76 contracted surveyors serve as an important resource, providing expertise that\n HCFA and the State agencies would be hard-pressed to duplicate. To take better\n advantage of this expertise, we recommend that HCFA strengthen the contracted\n surveyors\xe2\x80\x99 background in the full range of Medicare conditions of participation for\n hospitals and make them available for:\n\n Responding to complaints and adverse events involving psychiatric care: The\n contracted surveyors\xe2\x80\x99 special expertise should be available to enhance the States\xe2\x80\x99 ability to\n respond appropriately to complaints and events.\n\n Surveying in both psychiatric hospitals and psychiatric units of acute care hospitals:\n We suggest that the contracted surveyors\xe2\x80\x99 expertise would be valuable to these units,\n which typically receive just a fraction of surveyors\xe2\x80\x99 time during an accreditation survey.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 3 OEI-01-99-00160\n\x0c We are aware of the resource implications of this recommendation. HCFA currently\n estimates the costs of each contracted survey at $8,300. HCFA could use its estimates to\n seek additional funding or seek authority to establish a user fee to help defray the costs.\n\nHCFA should hold its contracted surveyors more fully accountable for their\nperformance. Toward that end, it should\n\n Conduct periodic observation surveys of the contracted survey process. HCFA now\n lacks any such oversight mechanism of the contracted survey process.\n\n Obtain timely and useful performance reports. These should cover, at a minimum, the\n contracted surveyors\xe2\x80\x99 activities, such as types of surveys conducted, findings, and trends.\n\n Provide feedback and guidance to the contracted surveyors. Given their part-time\n status and the decline in scheduled surveys, HCFA should stay in closer contact with the\n contracted surveyors and consider facilitating a network through a newsletter or website.\n\n Increase public disclosure. HCFA should make more information available on the\n oversight and performance of psychiatric hospitals by, at a minimum, posting information\n on the Internet.\n\nHCFA should determine an appropriate minimum cycle for the contracted survey\nat psychiatric hospitals.\n\n No mandated cycle for these contracted surveys exists. In determining one, HCFA should\n take steps to strengthen its ability to track all participating hospitals and their survey\n history in such a way that allows HCFA to easily determine whether the survey was\n conducted by the contracted surveyors or State agencies. It should also take steps to\n coordinate the survey activity among the external reviewers.\n\nHCFA should negotiate with the Joint Commission to achieve both a more\npatient-centered survey approach and a more rigorous assessment of discharge\nplanning.\n\n The Joint Commission does not currently use the patient-tracing approach employed by\n HCFA\xe2\x80\x99s contracted surveyors. The Joint Commission is well-positioned to apply this\n approach more broadly in psychiatric units as well as psychiatric hospitals. Also, the Joint\n Commission has a significant base of experience in addressing discharge planning issues in\n nonhospital settings and is therefore well-positioned to apply this expertise to the hospital\n setting.\n\nHCFA should consider applying special Medicare conditions of participation both\nto psychiatric hospitals and psychiatric units of acute care hospitals.\n\n\nThe External Quality Review of Psychiatric Hospitals 4 OEI-01-99-00160\n\x0c Many experts suggest that psychiatric inpatients face vulnerabilities that warrant greater\n scrutiny than most other hospital patients. But the external review system that HCFA\n relies upon falls short in two important ways. First, it does not apply the special\n conditions to psychiatric units of acute care hospitals, which is where the great majority of\n Medicare beneficiaries receive inpatient psychiatric care. Furthermore, in psychiatric\n hospitals, the contracted surveyors are limited to assessing compliance with only the two\n special conditions (medical records and staff requirements) even though their patient-\n based review exposes a broad array of treatment issues.\n\n Given this situation, it would appear timely for HCFA to consider special conditions that it\n would use for both inpatient settings. If HCFA moved in this direction, the following are\n among the key questions it would have to address:\n\n C Do the proposed Medicare conditions of participation for hospitals and the interim\n final rule on patient rights provide sufficient authority for the external reviewers to\n apply the extra scrutiny warranted for psychiatric inpatients?\n\n C Are additional authorities needed for key patient-care issues, including discharge\n planning?\n\n\nCOMMENTS ON THE DRAFT REPORT\n\nWithin the Department of Health and Human Services, we received comments on our draft report\nfrom HCFA. Outside the Department, we received comments from the Joint Commission, the\nNational Association of Psychiatric Health Systems, the National Alliance for the Mentally Ill, and\nPublic Citizen\xe2\x80\x99s Health Research Group. Below is a summary of those comments followed by our\nresponses, in italics.\n\nHCFA Comments\n\nHCFA concurred with all of our recommendations and noted its ongoing work with the Joint\nCommission to improve hospital oversight. It is willing to explore more strategic uses of the\ncontracted surveyors and anticipates funding increases that will allow it to reduce the interval\nbetween the contracted surveys. It also noted its plans for redesigning its information system to\nsupport better reporting of survey trends. Finally, HCFA indicated that it will develop\ninterpretive guidelines, with a corresponding plan for the contracted surveyors to enforce them,\nfor existing regulations that apply to psychiatric units of acute care hospitals, which generally\nparallel the special conditions for psychiatric hospitals.\n\nWe appreciate HCFA\'s positive response to our report. In implementing the recommendations,\nHCFA will strengthen the system of external review intended to protect psychiatric inpatients.\nWe have added some text on funding contracted surveys, which is relevant to our call for HCFA\n\n\nThe External Quality Review of Psychiatric Hospitals 5 OEI-01-99-00160\n\x0cto use the surveyors more strategically as well as to determine an appropriate minimum cycle for\nsurveys. We hope this new text will be helpful to HCFA as it explores further funding increases.\n\nComments from the Joint Commission\n\nThe Joint Commission identified many changes either already implemented or underway that\nenhance the accreditation process and promote a patient-centered approach to oversight. In\nparticular, it noted its ongoing process to strengthen its standards for discharge planning.\n\nThe Joint Commission took issue with how we characterized the authority of the contracted\nsurveyors\xe2\x80\x99 ability to hold psychiatric hospitals accountable for patient care issues and our point\nthat Medicare bears the cost of external review either directly or indirectly.\n\nWe appreciate the Joint Commission\xe2\x80\x99s continued responsiveness to our recommendations. The\nJoint Commission\xe2\x80\x99s leadership on these issues can influence improvements in accredited\nhospitals. In response to the Joint Commission\'s concerns, we clarified our discussion of the\nlimits of the contracted surveyors\xe2\x80\x99 authority and the extent to which Medicare bears the cost of\nexternal review.\n\nComments of Other External Associations\n\nTo varying degrees, the external parties supported our findings and recommendations, but also\nreflected some concerns. Both the National Alliance for the Mentally Ill and Public Citizen noted\ntheir concerns about accreditation and called for increased funding for the contracted surveys.\nThe National Association of Psychiatric Health Systems opposes \xe2\x80\x9cwidespread dissemination of\ninformation [about the performance of hospitals and surveyors] without adequate explanation and\nprotection\xe2\x80\x9d whereas Public Citizen expressed its concern that without disclosure, "public\ndiscontent will grow."\n\nIn its comments, the National Alliance recommended its State organizations as additional\nresources for the external review of psychiatric hospitals and pointed to other resources on\ndischarge planning in the Substance Abuse and Mental Health Services Administration of the\nDepartment.\n\nWe suggest that HCFA consider the concerns raised by these stakeholders as it works to improve\nthe system of hospital oversight. They offer perspectives that can be informative to HCFA.\n\nOn the matter of public disclosure, we emphasize our position that such disclosure represents an\nimportant step toward enhancing the public accountability of the contracted survey process and\nparallels recommendations we made in our earlier series, "The External Review of Hospital\nQuality."\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 6 OEI-01-99-00160\n\x0c TABLE OF CONTENTS\n\n\n PAGE\n\nEXECUTIVE SUMMARY\n\nINTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8\n\nPROFILE OF OVERSIGHT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13\n\nFINDINGS\n\n Strengths of Psychiatric Hospital Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14\n\n Deficiencies of Psychiatric Hospital Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16\n\n Minimal Accountability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20\n\nRECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22\n\nCOMMENTS ON THE DRAFT REPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26\n\nAPPENDICES\n\n A: Summary of Series on the External Review of Hospitals . . . . . . . . . . . . . . . . . . . . . 29\n B: Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36\n C: Framework for the External Review of Hospitals . . . . . . . . . . . . . . . . . . . . . . . . . . . 38\n D: Comments on the Draft Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40\n E: Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 7 OEI-01-99-00160\n\x0c INTRODUCTION\n\n\nPURPOSE\n\n To assess the external quality review of free-standing psychiatric hospitals that participate\n in Medicare.\n\n\nBACKGROUND\n\nConcerns about Psychiatric Hospitals\n\n Recently, the media has drawn attention to patient deaths attributed to inappropriate use\n of restraints and seclusion. In October 1998, The Hartford Courant published an\n investigative series that detailed 142 such deaths from around the country over the past 10\n years. Over half of those deaths occurred in hospitals. In April 1999, the television news\n show 60 Minutes II highlighted the inappropriate use of restraints and seclusion, lack of\n trained staff, and questionable record-keeping at psychiatric hospitals in the Charter\n Behavioral Hospital chain. In response to these concerns, three restraint bills have been\n introduced in Congress. The bills variously call for restricting the use of restraints,\n reporting restraint-related deaths and injuries, strengthening protection and advocacy\n systems, and assuring the rights of individuals receiving mental health services.\n\n In response to requests from members of Congress, the General Accounting Office\n recently issued a report examining the extent to which restraints and seclusion are used in\n various inpatient settings.1 The report found both underreporting of deaths and injuries\n involving restraints and seclusion as well as variation among State and Federal policies on\n restraints and seclusion.\n\n This attention has raised fundamental questions about how care is delivered and overseen\n in psychiatric hospitals.\n\n\nInpatient Psychiatric Care\n\n Patients needing inpatient psychiatric care generally receive that care in free-standing\n psychiatric hospitals or psychiatric units within acute care hospitals. Currently, 611 free-\n standing psychiatric hospitals operate around the country, all but 39 of which are\n accredited.2 Of about 6,000 acute care hospitals, about 25 percent operate inpatient\n\n\n\nThe External Quality Review of Psychiatric Hospitals 8 OEI-01-99-00160\n\x0c psychiatric units. Psychiatric care can also be provided in an acute care bed, outside of a\n specialized psychiatric unit or hospital.\n\n In 1997, 497,159 Medicare discharges were related to psychiatric care.3 Sixty-six percent\n of those discharges were from psychiatric units that are part of acute care hospitals, 27\n percent were from free-standing psychiatric hospitals. The remainder were from acute\n care beds outside of specialized hospitals or units.\n\nMedicare Conditions of Participation\n\n When Congress enacted the Medicare Act in 1965, it required hospitals to meet certain\n minimum health and safety requirements to participate in the program.4 Those minimum\n requirements are called the Medicare conditions of participation. In addition to these\n conditions that apply to all participating hospitals, free-standing psychiatric hospitals are\n subject to two special conditions.5 One concerns record-keeping and one, staff\n requirements.6 These two special conditions stemmed from Congress\xe2\x80\x99 concerns that\n patients in psychiatric hospitals would be warehoused and receive only custodial care,\n rather than active treatment.7\n\n The Health Care Financing Administration (HCFA) published the Medicare conditions of\n participation in 1966, revised them in 1986, and, except for the two special psychiatric\n conditions, are revising them again.8 On July 2, 1999, HCFA issued an interim final rule\n on patient rights, which includes the right to be free from restraints and seclusion as a\n means of coercion, convenience, and retaliation by staff.9 It also calls for hospitals to\n report restraint-related deaths to HCFA.10 This interim final rule applies to all hospitals,\n both general and psychiatric.\n\nExternal Review of Psychiatric Hospitals for Participating in Medicare\n\n Because the two special conditions for psychiatric hospitals, the Federal government relies\n on an additional external reviewer for their oversight: a panel of psychiatric surveyors\n under contract to HCFA (hereafter referred to as contracted surveyors). These contracted\n surveyors conduct reviews that cover only the special conditions. HCFA does not\n consider surveys by the Joint Commission on Accreditation of Healthcare Organizations to\n cover these special conditions. HCFA\xe2\x80\x99s contracted surveyors include mostly psychiatrists\n and psychiatric nurses, but also psychiatric social workers and pharmacists. All are part-\n time surveyors.\n\n Within the Medicare Act itself, Congress provided that hospitals accredited by the Joint\n Commission were deemed to be in compliance with the conditions of participation.11\n However, the two special conditions that psychiatric hospitals must meet are excluded\n from that deemed status. Thus, psychiatric hospitals accredited by the Joint Commission\n are also subject to a review by the contracted surveyors.\n\n\nThe External Quality Review of Psychiatric Hospitals 9 OEI-01-99-00160\n\x0c Psychiatric hospitals wishing to participate in Medicare without accreditation must go\n through a Medicare certification process. HCFA funds State survey and certification\n agencies (hereafter called State agencies) to conduct certification surveys at these\n hospitals to determine compliance with the Medicare conditions. Although HCFA trains\n the State surveyors in all the conditions (including the two special psychiatric conditions),\n the contracted surveyors may be involved in certifying the nonaccredited psychiatric\n hospitals as well.\n\n Regardless of the route a psychiatric hospital takes to Medicare participation, Medicare\n generally bears a cost for the external review, either directly by funding State agencies or\n HCFA\xe2\x80\x99s contracted surveyors, or indirectly through hospital charges that include the\n overhead cost of periodic accreditation surveys.12\n\n Accreditation, contracted surveys, and Medicare certification (by State agencies) involve a\n team of trained surveyors visiting a hospital, interviewing staff, reviewing documents, and\n inspecting the facility.\n\n Other external parties also have roles in overseeing psychiatric hospitals. Medicare Peer\n Review Organizations, for example, have broad authority in overseeing the quality of care\n paid for by Medicare, although they have no responsibilities specific to psychiatric\n hospitals. Each State also has a federally funded Protection and Advocacy grantee to\n protect the rights of and advocate for individuals with mental illness. These grantees have\n the authority to investigate reports of abuse and neglect in all facilities that care for or\n treat individuals with mental illness, including psychiatric hospitals. And, depending upon\n the circumstances, even the Department of Justice and the Food and Drug Administration\n can become involved with patient deaths and abuses in psychiatric hospitals.\n\nRecent Reports by the Office of Inspector General\n\n In July 1999, the Office of Inspector General released four reports that assessed the\n system in place for reviewing hospitals generally. These reports covered the key roles\n played by the Joint Commission, the State agencies, and HCFA. See appendix A for a\n more detailed summary of these reports.\n\n The great majority of psychiatric hospitals are accredited by the Joint Commission, thus,\n the findings from our recent series apply also to psychiatric hospitals. In our series, we\n found that Joint Commission surveys are undertaken in a collegial manner and are tightly\n structured, an approach that fosters consistency but leaves little room for probing. They\n also provide an important vehicle for reducing risk and fostering improvement in hospitals.\n The hospitals take the surveys seriously and prepare for them. But the surveys are\n unlikely to detect substandard patterns of care or individual practitioners with questionable\n skills.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 10 OEI-01-99-00160\n\x0c Likewise, our findings on the role of Medicare certification are relevant to those few\n nonaccredited psychiatric hospitals, which, without a complaint or adverse event, State\n agencies are unlikely to survey. In fact, the backlog for surveying nonaccredited hospitals\n is growing: in 1997 half of all such hospitals had not been surveyed in over 3 years, up\n from 28 percent in 1995.\n\n We also found that HCFA does little to hold either the Joint Commission or the State\n agencies accountable for their performance in overseeing hospitals.\n\n In our reports, we called for HCFA to exert leadership in addressing the shortcomings we\n identified. First, as a guiding principle, we urged HCFA to steer the external review\n process so that it represented a balance between the educationally oriented approaches of\n the Joint Commission and the enforcement-oriented approaches of the State agencies.\n Then we offered two sets of recommendations. In the first, we presented a number of\n steps HCFA should take to hold both the Joint Commission and the States more fully\n accountable for their performance in reviewing hospitals. Second, we called for HCFA to\n determine the appropriate minimum cycle for conducting certification surveys of\n nonaccredited hospitals. HCFA responded positively to our recommendations by\n presenting a detailed hospital oversight plan that incorporates our recommendations and\n an accompanying strategy for hospital performance measurement.\n\nThis Inquiry and Report\n\n This inquiry focuses on the oversight of free-standing psychiatric hospitals and, in\n particular, on the role of HCFA\xe2\x80\x99s contracted surveyors. It does not address the\n implementation of the interim final rule on patient rights. Nor does it address the roles of\n Medicare Peer Review Organizations, Protection and Advocacy grantees, the Department\n of Justice, or the Food and Drug Administration. Forthcoming Office of Inspector\n General reports will address the current Federal and State data systems for reporting\n patient abuses, particularly those involving restraints and seclusions that occur in\n psychiatric hospitals.\n\n Our inquiry draws on a variety of sources including: national data from HCFA on its\n contracted surveys; policies and guidelines on the contracted survey process; interviews\n with current and former contracted surveyors, HCFA officials, and other stakeholders;\n survey observations of contracted surveys and Joint Commission surveys in psychiatric\n hospitals; aggregate data from the Joint Commission; and reviews of laws, regulations,\n and articles from newspapers and journals, among others. See appendix B for more\n details on our methodology.\n\n While our findings emerge primarily from the above-noted data sources, we also draw on\n our observations from our prior reports on the external review of general acute care\n hospitals, which often have psychiatric units.\n\n\nThe External Quality Review of Psychiatric Hospitals 11 OEI-01-99-00160\n\x0c We conducted this inspection in accordance with the Quality Standards for Inspections\n issued by the President\xe2\x80\x99s Council on Integrity and Efficiency.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 12 OEI-01-99-00160\n\x0c PROFILE OF PSYCHIATRIC\n HOSPITAL OVERSIGHT\n\n The table below profiles the roles of the three major external reviewers for psychiatric hospitals. See\n appendix C for more details on the five-part framework.\n HCFA\xe2\x80\x99s Contracted Joint State Survey\n Element Surveys Commission Agencies\n\n Routine, CCore of contracted CCore of accreditation CApplies to nonaccredited\n Announced surveyor activity process psychiatric hospitals only\n CPatient-centered CRoutine presence on a 3- CLow priority\n On-site Surveys approach that leans toward year cycle CMean elapsed time\n the regulatory mode CCollegial between surveys=3.4\n CNo set cycle for review CSignificant attention to years\n CNo clear policy on restraints and seclusion C55 percent of\n announced versus nonaccredited hospitals\n unannounced surveys have gone over 3 years\n CFewer surveys being done without a survey;\n CElapsed time between 31 percent, over 4 years;\n surveys growing 21 percent, over 5 years\n\n Random CNot Applicable CIncreasingly aimed at CNot Applicable\n Unannounced (although some contracted psychiatric hospitals\n surveys are unannounced, CCustomized surveys\n On-site Surveys none are random) CTruly unannounced\n\n Responses to CRarely involved: CRecent improvements to CCore activity\n Complaints contracted surveyors the complaint process CConducted an average of\n responded to a few per hold promise 314 complaint surveys in\n year. FY96, FY97, and FY98\n CPublicly accountable\n\n Responses to CSame as complaints; CApproach is oriented CCore activity in\n Major Adverse HCFA makes no toward research and accredited and\n distinction prevention nonaccredited hospitals\n Events CRelies on self-reporting CPublicly accountable\n CEnsures hospital\n confidentiality\n CNo public accountability\n\n Collection and CNot Applicable CNot Applicable CNot Applicable\n Dissemination of (core psychiatric\n measures under\n Standardized development)\n Performance\n Measures\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 13 OEI-01-99-00160\n\x0c FINDINGS\n\nThe current system of external review for psychiatric\nhospitals has some strengths that help protect patients.\nThe system includes a patient-centered approach aimed at ensuring patients\nreceive active treatment as opposed to custodial care.\n\n HCFA\xe2\x80\x99s contracted surveyors spend much of their time at psychiatric hospitals following\n the care of a sample of patients. They choose the sample at the outset of the survey and\n begin by reviewing the medical records of the chosen patients. Spending an hour or more\n on a single record, they become familiar with their sample patients\xe2\x80\x99 treatment plans,\n whether they are being\n implemented, and what outcomes\n are being achieved. The Observing Patients\n contracted surveyors follow the in a Substance Abuse Session\n record reviews by directly\n observing patients in different A contracted psychiatric nurse surveyor sat in\n settings, for example on the ward on a substance abuse discussion group, led by a\n and in activities class. Thus, they hospital therapist. She chose the session\n can see for themselves the extent because one of her sample patients, whose\n to which the treatment plan is medical record she had already reviewed, was a\n being implemented. They also participant. Her review of the medical record\n interview the patients\xe2\x80\x99 caregivers, revealed the patient\xe2\x80\x99s hearing deficiency. She\n thereby eliciting the staff\xe2\x80\x99s quietly observed the 45-minute session, paying\n particular attention to whether the therapist\n awareness of the sample patients,\n appeared to be aware of that deficiency in his\n such as why they are hospitalized\n interactions with the patient.\n and what their treatment plans\n are. The contracted surveyors\n interview the patients themselves, asking them how they are treated, what brought them to\n the hospital, what their plans for discharge are, and gauging their awareness of their\n treatment plans. Finally, where possible they observe the treatment team discussions,\n when the psychiatrist, social worker, and other professionals meet to discuss individual\n patient\xe2\x80\x99s treatment and progress.\n\n This approach gives the contracted surveyors a picture of the hospital\xe2\x80\x99s performance by\n using discrete patient experiences as lenses. Already experienced as psychiatric nurses,\n social workers, and psychiatrists, the contracted surveyors use these lenses to identify\n concerns regarding active treatment ranging from the qualifications and language skills of\n hospital staff to the participation of the art therapist in treatment team meetings. The\n focus on active treatment pervades the survey process, with surveyors relying on each\n\nThe External Quality Review of Psychiatric Hospitals 14 OEI-01-99-00160\n\x0c portion of the process--record review, patient observation, and caregiver and patient\n interviews--to confirm the others.\n\n Neither the Joint Commission nor the State agencies use this approach of tracing the\n treatment of a sample of patients through medical records, observations, and interviews.\n While they do involve some patient focus, it is less central to the review process.\n\nIt has achieved some balance between the collegial (aiming to educate and\nimprove) and the regulatory (aiming to investigate and enforce) approaches to\noversight.\n\n It is helpful to consider external hospital oversight in terms of a continuum, characterized\n by a collegial approach on one side and a regulatory approach on the other. External\n reviewers in the collegial mode focus on education and improved performance; those in\n the regulatory mode focus on investigation and enforcement of minimum requirements. In\n the continuum below, we list the major characteristics we associate with each side.\n\n Collegial Mode Regulatory Mode\n (Educate and Elevate) ( Investigate and Enforce)\n\n\n\n Cooperative Challenging\n Flexible Rigid\n Foster Process Improvements Enforce Minimums\n Guidance Directive\n Trusting Skeptical\n Professional Accountability Public Accountability\n Confidentiality Public Disclosure\n Systems Focus Outlier Focus\n Improve Patient Outcomes Minimize Preventable Harm\n\n Both approaches to oversight have value. HCFA\xe2\x80\x99s contracted surveyors, State agencies,\n and the Joint Commission all have approaches that represent different aspects of the\n continuum.\n\n The Joint Commission remains the dominant external reviewer for psychiatric hospitals.\n And it has been grounded on the collegial side of the continuum. Its triennial surveys are\n announced in advance, giving hospitals time to prepare. Its process is educational: its\n surveyors share insights from other hospitals and explain the intent and significance of the\n standards. The surveys focus on performance improvement, giving hospitals opportunities\n to present improvement projects throughout the visit. Its approach to adverse events\n stresses research, education, and prevention.\n\n\nThe External Quality Review of Psychiatric Hospitals 15 OEI-01-99-00160\n\x0c However, while the Joint Commission\xe2\x80\x99s approach is still grounded in the collegial mode, it\n recently made some changes in its accreditation of psychiatric hospitals that mark a shift\n toward the regulatory mode. Over the summer of 1999, it conducted 38 completely\n unannounced surveys at Charter psychiatric hospitals in response to the 60 Minutes II\n piece on inappropriate restraint use and lack of staff training in Charter hospitals.13 The\n Joint Commission assigned a special team of psychiatric surveyors to these unannounced\n surveys. During the surveys, the team, rather than the hospital staff, selected the records\n for review. The Joint Commission recently announced its plans to expand its new\n unannounced surveys in other psychiatric hospitals and acute care hospitals as well. It is\n planning tests of an unannounced survey with a focus tailored to the specific hospital and\n expanded background information for surveyors.\n\n These changes by the Joint Commission, coupled with the regulatory approaches of\n HCFA\xe2\x80\x99s contracted surveys and State agencies, introduce a measure of balance among the\n external reviewers and their approaches. HCFA\xe2\x80\x99s surveys lean toward the regulatory side\n of the continuum. Their approach is challenging in nature. For example, rather than\n relying solely on the medical record, they substantiate its documentation with observations\n and interviews. The contracted surveyors focus on ensuring the minimum requirements\n for the two special conditions are met. As directed by HCFA, they avoid an educational\n approach and pay little attention to performance improvement, both hallmarks of a more\n collegial approach. The hospitals have little opportunity for formally presenting\n information to the surveyors.14 The surveyors discourage the hospital\xe2\x80\x99s leadership from\n accompanying them during parts of the survey, such as patient interviews, therapy\n observations, and ward tours. State agencies are also rooted in the regulatory side of the\n continuum. Their oversight tends to be driven by complaints and adverse events. Their\n visits in response to such events tend to be unannounced.\n\n\n\nBut the external review system also has major deficiencies.\nThe extent to which it holds psychiatric hospitals accountable for patient care is\nquestionable.\n\n HCFA\xe2\x80\x99s contracted surveys provide an in-depth look into the patient care at psychiatric\n hospitals. Surveyors can uncover problems ranging from the adequacy of the treatment\n plan to the handling of agitated patients. But their legitimacy in holding the hospital\n accountable for those problems is far more limited. The two special conditions on which\n the contracted survey is based are staff requirements and medical records. Thus, despite\n the far-reaching nature of their inquiry, the contracted surveyors are hard-pressed to hold\n hospitals accountable for problems outside either medical records or staff requirements. If\n the contracted surveyors find problems but the conditions are still met, they can refer the\n problems to HCFA or State agency surveyors, but do not follow-up on the problems\n themselves.\n\n\nThe External Quality Review of Psychiatric Hospitals 16 OEI-01-99-00160\n\x0c On the other hand, both the Joint Commission and State agencies (through HCFA and/or\n their own State authorities) have broader authorities on which to base their survey\n findings. Indeed, the Joint Commission has several hundred standards grouped across 45\n topics, and State agencies can enforce all of the Medicare conditions of participation.\n However, both lack the in-depth look into patient care that the contracted surveyors have.\n And State agencies\xe2\x80\x99 reviews of psychiatric hospitals tend to be further limited by their\n episodic nature. They are driven by complaints and adverse events as opposed to\n regularly scheduled reviews.\n\n Discharge Planning. The limits of the external review system are especially apparent\n in assessing hospitals\xe2\x80\x99 discharge planning.15 Discharge planning refers to hospitals\xe2\x80\x99 efforts\n to ensure continuity of care for their patients after discharge by linking them with their\n families, clinics, schools, and residential programs, among other community services.\n Increasing acuity and decreasing lengths of stay make successful discharge planning\n increasingly crucial for psychiatric patients.16 And the external review system--which is\n hospital-based--only goes so far in assessing how well a hospital links patients with\n community providers or connects with a patient\xe2\x80\x99s family. For example, HCFA\xe2\x80\x99s\n contracted surveyors have just an indirect and narrow window to assess discharge\n planning through either the medical records or the staff requirements condition. Likewise,\n the Joint Commission lacks a scheduled session dedicated to discharge planning. Both\n HCFA\xe2\x80\x99s contracted and Joint Commission surveyors review records of discharge\n planning, which document contacts, but fall short of assessing adequacy. Furthermore,\n neither HCFA\xe2\x80\x99s contracted surveyors nor Joint Commission surveyors know much\n background about a hospital--such as average length of stay, where the patients come\n from, the extent of local services, or staff turnover--prior to the survey, making a\n meaningful assessment of discharge planning unlikely. Surveyors are hardpressed to\n assess whether hospitals are taking adequate advantage of external services.\n\n Restraints and Seclusion. Like discharge planning, the appropriate use of restraints\n and seclusion are critically important patient care topics. Unlike discharge planning,\n restraints and seclusion receive considerable attention from the external reviewers.\n HCFA\xe2\x80\x99s contracted surveyors review restraint logs, ask patients and caregivers about\n restraints, examine seclusion rooms, and review any documentation in the medical records.\n But as with discharge planning, HCFA\xe2\x80\x99s contracted surveyors have a limited regulatory\n basis to hold a psychiatric hospital accountable for inappropriate use of restraints.17\n\n The Joint Commission gives restraints and seclusion more attention, and has for some\n time. Since 1984, when it first adopted restraint standards, it has been working to\n improve them: it revised them in 1989, broadened their application in 1991, revised them\n again in 1993, appointed a Board Task Force on restraints in 1996 and a Restraint Use\n Task Force in 1998.18 Even more recently, the Joint Commission held a series of three\n public hearings on restraint use.19\n\n\n\nThe External Quality Review of Psychiatric Hospitals 17 OEI-01-99-00160\n\x0c Attention to restraints and\n seclusion pervades the Joint Words of Warning to the Medical Staff\n Commission survey process.\n Surveyors stop orderlies and \xe2\x80\x9cPsychiatric hospitals are under a\n custodians in the hallways to ask microscope...Everyone is upset about how you\n them what they should do if a use restraints. The 60 Minutes Show reflects the\n nearby patient became agitated. peoples\xe2\x80\x99 perceptions of your hospital. You are\n They review medical records for obligated to make them change their minds...It is\n proper documentation and a challenge to be attentive and thoughtful with\n personnel records for evidence of restraints. Some hospitals put their staff and\n proper training. They examine physicians in them to see what it is like. And in\n seclusion rooms for safety. In every case those staff and physicians will be less\n fact, for the past 2 years, restraint- likely to use restraints. It\xe2\x80\x99s a question of\n dignity. Restraints are dehumanizing. You must\n related deficiencies have been\n ask yourselves: Are you using them only when\n among the top five most\n you\xe2\x80\x99ve tried everything else?\xe2\x80\x9d\n commonly identified deficiencies\n in psychiatric hospitals.20 -A Joint Commission psychiatrist, in his remarks\n to the medical staff leadership at a psychiatric\n Nevertheless, as evidenced by the hospital, during the triennial accreditation\n 60 Minutes II segment on restraint survey (spring, 1999).\n abuses in an accredited hospital,\n the ability of the surveyors to\n identify such abuses is questionable. Hospitals usually know the Joint Commission is\n coming and prepare for the survey, thereby perhaps presenting surveyors with only a slice\n of the hospital\xe2\x80\x99s actual operations.\n\n Of course, no system of hospital oversight is foolproof. The continued evidence of abuses\n concerning restraints and seclusion reinforces that external reviewers serve to reduce\n risks--not guarantee appropriate treatment. They also serve to reinforce the important\n safety valve that responding to complaints provides.\n\nSome psychiatric hospitals are falling through the cracks, rarely being subjected\nto contracted or State agency surveys.\n\n Since FY 1993 the number of contracted surveys at psychiatric hospitals has dropped 65\n percent: from a high of 413 to 146 in FY 1998.21 This drop reflects the reduced resources\n available for these surveys. From FY 1993 to FY 1999 the budget for these surveys fell\n from $3,000,000 to $670,000.22 During that same time, the number of contracted\n surveyors fell from 147 to the current 76. Fewer contracted surveys means psychiatric\n hospitals go longer without surveys. Since FY 1993, the average elapsed time between\n contracted surveys has tripled from 14 months to 3.5 years. In fact, we identified 37\n hospitals that have gone 5 or more years without a contracted survey, including 3 that\n have gone 10 years. HCFA relies on input from its regional offices in selecting which\n\n\nThe External Quality Review of Psychiatric Hospitals 18 OEI-01-99-00160\n\x0c psychiatric hospitals to survey each year. But regional participation in that process varies\n greatly, and no mandated cycle for review of the special conditions exists.\n\n As fewer and fewer contracted surveys have been conducted, HCFA\xe2\x80\x99s contracted\n surveyors are finding more hospitals out of compliance with the two extra conditions of\n participation. In FY 1993, they found 13 percent of the psychiatric hospitals out of\n compliance with one or both conditions. By FY 1998, 21 percent were out of compliance.\n\n HCFA\xe2\x80\x99s system for tracking psychiatric hospitals often misses hospital mergers, closures,\n and name changes, making it difficult to accurately and easily identify which hospitals have\n gone the longest without a contracted survey. The situation is even worse for\n nonaccredited hospitals. HFCA\xe2\x80\x99s records indicate that 65 of the 611 psychiatric hospitals\n are nonaccredited. However, we determined that 26 of those 65 were, in fact, accredited.\n Over half--55 percent--of the nonaccredited psychiatric hospitals for which we had data\n have gone longer than 3 years without a State agency survey; a third, 4 years; and a fifth,\n 5 years.\n\nHCFA\xe2\x80\x99s contracted surveyors, State agencies, and the Joint Commission tend to\ncarry out their psychiatric hospital oversight on independent tracks with little\ncoordination.\n\n HCFA schedules the contracted surveys with little regard for any other external reviewer.\n Thus a hospital could, in short order, be surveyed by the contracted surveyors, the Joint\n Commission, and the State agency. This could present a burden to the hospital being\n reviewed. For example, both of the contracted surveys we observed were at hospitals that\n had other reviews within 3 to 4 months: one had a Joint Commission survey prior to the\n contracted survey; the other, a State agency survey to validate the results of the Joint\n Commission\xe2\x80\x99s survey. In neither case did the contracted surveyors have the results of\n those surveys in advance.\n\n Even in cases of complaints or adverse events, HCFA rarely coordinates with the Joint\n Commission. For example, a State agency received six complaints about a psychiatric\n hospital with the highest level of accreditation (accredited with commendation). It\n received the complaints within 7 months of the Joint Commission\xe2\x80\x99s survey. These\n complaints triggered a series of announced and unannounced surveys over the ensuing 12\n months, beginning with a simultaneous State agency complaint investigation and\n contracted survey. The State agency and contracted surveyors found the hospital to pose\n an immediate and serious threat to its adolescent patients. Problems ranged from lack of\n patient supervision, inappropriate use of restraints, and even sexual abuses. Even while\n the local media picked up the story and the State agency and HCFA\xe2\x80\x99s contracted\n surveyors conducted more surveys and follow-ups, HCFA did not coordinate any of its\n response with the Joint Commission.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 19 OEI-01-99-00160\n\x0cThe contracted surveyors are held just minimally\naccountable for their performance in overseeing psychiatric\nhospitals.\nHCFA obtains limited information on the performance of its contracted surveyors.\n\n While validation surveys represent HCFA\xe2\x80\x99s main vehicle for information on the\n performance of the Joint Commission, they play no role in the oversight of the contracted\n surveys.23 Over the past 3 years, 23 psychiatric hospitals ended up in the random sample\n HCFA draws for validation surveys. But the special psychiatric conditions that the\n contracted surveyors focus on are excluded from the validation process. Furthermore,\n HCFA rarely observes the contracted surveyors conducting their surveys as a way to\n obtain performance information.24\n\n HCFA asks for little in the way of aggregate reporting on its contracted surveyors,\n despite contractual requirements calling for regular reports highlighting trends in surveys\n conducted and their results.25 Occasionally, HCFA will ask for special reports, such as its\n recent request for a rundown on survey activity in Charter facilities. Even HCFA\xe2\x80\x99s own\n data system is ill-equipped to provide insights into psychiatric hospital oversight. For\n example, the database contains survey dates, but HCFA was unable to readily determine\n whether the dates entered reflected contracted surveys or State agencies surveys. It was\n also unable to determine through its database whether surveys were announced or\n unannounced.\n\nHCFA provides some feedback to its contracted surveyors, mostly through its\nreview of the survey documentation.\n\n Given the drop in contracted surveys conducted, many contracted surveyors conduct only\n a few surveys each year.26 Thus feedback and guidance from HCFA become important\n avenues for the contracted surveyors to keep their survey skills sharp. Yet HCFA lacks\n any formal system for providing feedback to them. Rather, the contracted surveyors\n submit their survey documentation to HCFA\xe2\x80\x99s central office, where one or two staff\n review the paperwork and provide any guidance or feedback on a case-by-case basis. This\n feedback focuses on the documentation, not the skills of the surveyors.\n\n Contracted surveyors with whom we spoke expressed interest in receiving more feedback\n and guidance from HCFA. One remembered an instance over her 10 years of surveying\n when she received written feedback from HCFA, which she found useful. Others\n suggested simply knowing more about the current trends in surveyor findings or recent\n problems surveyors faced would be helpful to them. Although HCFA does convene the\n contracted surveyors for training, this happens about once every 3 years.27\n\n\n\nThe External Quality Review of Psychiatric Hospitals 20 OEI-01-99-00160\n\x0cPublic disclosure plays a minimal role in holding the contracted surveyors\naccountable.\n\n Publicly disclosing information about psychiatric hospitals and their reviewers can convey\n an assurance that a process exists for the external review of hospitals for which the\n reviewers are accountable. Public disclosure can spur improvements on the part of the\n hospital as well as the reviewers. HCFA will disclose survey findings on psychiatric\n hospitals upon request, but lacks a web page or central number from which to request\n such information. HCFA has little to disclose on the performance of the contracted\n surveyors.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 21 OEI-01-99-00160\n\x0c RECOMMENDATIONS\n\n HCFA and Joint Commission responses to the recommendations we posed in our recent\n series on the external review of hospital quality help address the deficiencies identified in\n this study (see appendix A for more detail on those recommendations). In its response,\n HCFA committed to an action plan that incorporates most of our recommendations. It\n identified specific steps it will take to hold the Joint Commission and State agencies more\n accountable for their performance. It also committed to identifying an appropriate\n minimum cycle for certifying nonaccredited hospitals. Since the reports came out, the\n Joint Commission announced that it will increase its unannounced survey visits to\n hospitals. It also set forth other plans that will contribute to a more challenging survey\n process.\n\n Below we offer five additional recommendations that emerge primarily from the findings\n in this inquiry, but also draw on those in our previous series, which included acute care\n hospitals with psychiatric units. Our recommendations call for HCFA to exert its\n leadership in shaping the external review of psychiatric inpatient care. If enacted, these\n recommendations will further strengthen external quality review systems intended to\n protect psychiatric inpatients.\n\n\n\nHCFA should deploy its contracted surveyors more\nstrategically and take better advantage of their expertise.\n The 76 contracted surveyors serve as an important resource for HCFA. They are\n psychiatrists, psychiatric nurses, and social workers with extensive experience with\n psychiatric patients and facilities. They provide expertise that HCFA and the State\n agencies would be hardpressed to duplicate. To take better advantage of this expertise,\n we recommend that HCFA strengthen the contracted surveyors\xe2\x80\x99 background in the full\n range of Medicare conditions of participation for hospitals and make them available for:\n\n Responding to complaints and adverse events involving psychiatric care:\n HCFA rarely deploys its contracted surveyors to respond to complaints and adverse\n events, relying instead on the State agencies as its frontline responders. The contracted\n surveyors\xe2\x80\x99 special expertise should be available to enhance the States\xe2\x80\x99 ability to respond\n appropriately to complaints and events.\n\n Surveying in both psychiatric hospitals and psychiatric units of acute care\n hospitals: Inpatient psychiatric units in acute care hospitals provide the majority of the\n psychiatric care paid for by Medicare. We suggest that the contracted surveyors\xe2\x80\x99\n\n\nThe External Quality Review of Psychiatric Hospitals 22 OEI-01-99-00160\n\x0c expertise would be valuable to these units, which typically receive just a fraction of\n surveyors\xe2\x80\x99 time during an accreditation survey.\n\n We are aware of the resource implications of this recommendation. HCFA currently\n estimates the costs of each contracted survey at $8,300. HCFA could use its estimates to\n seek additional funding or seek authority to establish a survey user fee to help defray the\n costs.\n\n\n\nHCFA should hold its contracted surveyors more fully\naccountable for their performance.\n The contracted surveyors provide expertise and perform an important review of\n psychiatric hospitals on HCFA\xe2\x80\x99s behalf. But they are part-time surveyors who rarely\n gather as a group and conduct as few as three or four surveys a year. Thus, HCFA should\n take steps to ensure that its contracted surveyors maintain their survey skills, are well-\n informed on trends in survey findings, and that in general, they are upholding Federal\n interests. Toward that end, HCFA should take the following steps that promote\n accountability:\n\n Conduct periodic observation surveys of the contracted survey process.\n HCFA now lacks any such oversight mechanism of the contracted survey process. By\n accompanying contracted surveyors, HCFA gets direct and immediate information on both\n the performance of the hospital and the performance of the contracted surveyors.\n\n Obtain timely and useful performance reports. HCFA\xe2\x80\x99s tracking of psychiatric\n hospitals and their survey results is not up to the task of providing a timely, relevant, and\n up-to-date picture of the external review of psychiatric hospitals, let alone which hospitals\n are currently accredited. HCFA should improve its tracking and get regular reports that\n cover, at a minimum, the contracted surveyors\xe2\x80\x99 activities, such as types of surveys\n conducted, findings, and trends.\n\n Provide feedback and guidance to the contracted surveyors. HCFA should\n provide timely feedback to the contracted surveyors on the basis of its observation\n surveys. Furthermore, given the contracted surveyors\xe2\x80\x99 part-time status and the decline in\n scheduled surveys, HCFA should consider establishing a newsletter or website to facilitate\n a network among the surveyors.\n\n Increase public disclosure. HCFA should make the results of the contracted surveys\n widely available to the public through the Internet or other appropriate mechanisms. It\n should also make available any performance reports it collects, as described above.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 23 OEI-01-99-00160\n\x0cHCFA should determine an appropriate minimum cycle for\nthe contracted survey at psychiatric hospitals.\n This recommendation parallels one we made regarding nonaccredited hospitals in our\n previous series. No mandated cycle for these contracted surveys exists. As with our\n earlier recommendation, we are aware of this recommendation\'s resource implications.\n\n In determining an appropriate minimum cycle, HCFA should take steps to strengthen its\n ability to track all participating hospitals and their survey history in such a way that allows\n HCFA to easily determine whether the surveys were conducted by the contracted\n surveyors or State agencies. It should also take steps to coordinate the survey activity\n (accreditation, validation, State agency certification, and contracted survey) among the\n external reviewers.\n\n\n\nHCFA should negotiate with the Joint Commission to\nachieve both a more patient-centered survey approach and a\nmore rigorous assessment of discharge planning.\n\n In our previous reports, we recommended HCFA negotiate a number of survey changes\n with the Joint Commission. Here, we recommend that HCFA negotiate two more changes\n that are especially relevant to psychiatric inpatients.\n\n The Joint Commission is the primary external reviewer for 94 percent of the psychiatric\n hospitals that participate in Medicare. As such, it has a routine presence in those hospitals\n every 3 years. But it does not currently use the patient-tracing approach employed by\n HCFA\xe2\x80\x99s contracted surveyors. Applying such an approach could reinforce a patient-\n centered approach to the Joint Commission\xe2\x80\x99s process. Likewise, the Joint Commission\n has a significant base of experience in addressing discharge planning issues in nonhospital\n settings, such as mental health centers and residential treatment centers. That experience\n could be instructive in strengthening the review of discharge planning in psychiatric\n hospitals.\n\n\n\nHCFA should consider applying special Medicare conditions\nof participation to both psychiatric hospitals and psychiatric\nunits in acute care hospitals.\n Many experts suggest that psychiatric inpatients face vulnerabilities that warrant greater\n scrutiny than most other hospital patients. But in this respect, the external review system\n\nThe External Quality Review of Psychiatric Hospitals 24 OEI-01-99-00160\n\x0c that HCFA relies upon falls short in two important ways. First, it does not apply the\n special conditions to psychiatric units of acute care hospitals, which is where the great\n majority of Medicare beneficiaries receive inpatient psychiatric care.28 Second, in\n psychiatric hospitals, the contracted surveyors are limited to assessing compliance with\n only the two special conditions (medical records and staff requirements) even though their\n patient-based review exposes a broad array of treatment issues.\n\n Given this situation, it would appear timely for HCFA to consider special conditions that it\n would use for both inpatient settings. If HCFA moved in this direction, the following are\n among the key questions it would have to address:\n\n C Do the proposed Medicare conditions of participation for hospitals and the interim\n final rule on patient rights provide sufficient authority for the external reviewers to\n apply the extra scrutiny warranted for psychiatric inpatients?\n\n C Are additional authorities needed for key patient-care issues, including discharge\n planning?\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 25 OEI-01-99-00160\n\x0c COMMENTS ON THE DRAFT REPORT\n\n Within the Department of Health and Human Services, we received comments on our\n draft report from HCFA. Outside the Department, we received comments from the Joint\n Commission, the National Association of Psychiatric Health Systems, the National\n Alliance for the Mentally Ill, and Public Citizen\xe2\x80\x99s Health Research Group. We include the\n full text of those comments in appendix D. Below we summarize the comments and, in\n italics, offer our responses.\n\nHCFA Comments\n\n HCFA concurred with all of our recommendations. It pointed to the recently expanded\n regulations on Patient Rights that affect all inpatients, and include the rights of those\n patients to be free from the inappropriate use of restraints and seclusion. It noted both its\n planned training of the contracted, regional office, and State agency surveyors on those\n regulations and its work on a new performance evaluation system for the contracted\n surveyors. HCFA also indicated its willingness to explore using its contracted surveyors\n in psychiatric units of acute care hospitals. It expects that recent funding increases to its\n psychiatric program will allow it to reduce the interval between contracted surveys and\n notes that it will explore how to further increase the funding. HCFA is committed to a\n redesign of its system to generate trend reports on psychiatric hospital surveys.\n Furthermore, HCFA noted it will continue to work with the Joint Commission to improve\n the oversight of psychiatric hospitals.\n\n Finally, HCFA pointed out that psychiatric units in acute care hospitals that are excluded\n from the prospective payment system are subject to regulations that generally parallel the\n special conditions for psychiatric hospitals. It indicated that it will develop interpretive\n guidelines for these parallel regulations as well as a plan for the contracted surveyors to\n review them.\n\n We appreciate HCFA\xe2\x80\x99s positive response to our report. In implementing the\n recommendations, HCFA will strengthen the system of external review intended to\n protect psychiatric inpatients. We also note that the progress HCFA reports making in\n working with the Joint Commission stemming from our earlier series, \xe2\x80\x9cThe External\n Review of Hospital Quality,\xe2\x80\x9d will further strengthen that system.\n\n We have added some text on funding the contracted surveys, which is relevant to both our\n call for using the contracted surveyors more strategically as well as for determining an\n appropriate minimum cycle between surveys. We hope this new text will be helpful to\n HCFA as it explores further funding increases.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 26 OEI-01-99-00160\n\x0c We are pleased with HCFA\xe2\x80\x99s commitment to an improved system for generating\n information on the psychiatric surveys, and we continue to urge HCFA to include reports\n on recent trends in survey findings in its feedback to the contracted surveyors, through a\n newsletter or website. Such feedback can enhance the effectiveness of those psychiatric\n professionals, who survey only a few hospitals each year for HCFA.\n\nJoint Commission Comments\n\n The Joint Commission identified many changes either already implemented or underway\n that enhance the accreditation process and promote a patient-centered approach to\n oversight. Among them are the discontinuation of any advance notice for random surveys,\n enhanced presurvey information for surveyors, revised survey agendas to allow surveyors\n more time to focus on patient issues, pilot testing of onsite survey activities during\n evenings and weekends, and a more random selection of medical and personnel records\n for review. It also noted its process, already underway, to strengthen its standards for\n discharge planning.\n\n The Joint Commission took issue with how we characterized the authority of the\n contracted surveyors\xe2\x80\x99 ability to hold psychiatric hospitals accountable for patient care\n issues. It also took issue with our point that Medicare bears the cost of external review\n either directly or indirectly, pointing out that while costs related to accreditation may have\n been included in base-year calculations for prospective payment, a hospital\xe2\x80\x99s decision to\n continue to be accredited or not does not affect its Medicare reimbursement.\n\n We appreciate the Joint Commission\xe2\x80\x99s continued responsiveness to our\n recommendations, both in this report and our previous series, \xe2\x80\x9cThe External Review of\n Hospital Quality.\xe2\x80\x9d The Joint Commission\xe2\x80\x99s leadership on these issues can influence\n improvements in accredited hospitals.\n\n In response to the Joint Commission\'s concerns, we clarified our discussion of the limits\n of the contracted surveyors\xe2\x80\x99 authority and the extent to which Medicare bears the cost of\n external review.\n\nComments of Other External Associations\n\n To varying degrees, the external parties supported our findings and recommendations, but\n also reflected some concerns.\n\n The National Association of Psychiatric Health Systems is opposed to \xe2\x80\x9cwidespread\n dissemination of information [about the performance of hospitals and surveyors] without\n adequate explanation and protection\xe2\x80\x9d whereas Public Citizen expressed its concern that\n without disclosure, "public discontent will grow."\n\n\n\nThe External Quality Review of Psychiatric Hospitals 27 OEI-01-99-00160\n\x0c Both the National Alliance for the Mentally Ill and Public Citizen noted their concerns\n about accreditation and called for an increase in funding for the contracted surveys.\n\n In its comments, the National Alliance for the Mentally Ill recommended its State\n organizations as a resource to the external review of psychiatric hospitals and pointed to\n other resources on discharge planning in the Center for Mental Health of the Substance\n Abuse and Mental Health Services Administration within the Department.\n\n We suggest that HCFA consider the concerns raised by the stakeholders as it works to\n improve the system of hospital oversight. They offer perspectives that can be informative\n to HCFA.\n\n On the matter of public disclosure, we emphasize our position that such disclosure\n represents an important step toward enhancing the public accountability of the\n contracted survey process and parallels recommendations we made in our earlier series,\n "The External Review of Hospital Quality."\n\n With regard to the call for increase funding made by the National Alliance and Public\n Citizen, we note the text added to our recommendation section.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 28 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n Summary of\n The External Review of Hospital Quality Series\n On July 20, 1999, the Office of Inspector General released the four reports named below.\n A summary of each report follows.\n\n The External Review of Hospital Quality: A Call for Greater Accountability\n (OEI-01-97-00050)\n\n The External Review of Hospital Quality: The Role of Accreditation (OEI-01-97-\n 00051)\n\n The External Review of Hospital Quality: The Role of Medicare Certification\n (OEI-01-97-00052)\n\n The External Review of Hospital Quality: Holding the Reviewers Accountable\n (OEI-01-97-00053)\n\nA Call for Greater Accountability\n\n This report synthesizes the three other reports and includes our recommendations to\n HCFA.\n\n Continuum of Oversight\n\n In developing this report, we found it helpful to consider external hospital oversight in\n terms of a continuum, characterized by a collegial approach on one side and a regulatory\n approach on the other. Oversight in the collegial mode emphasizes trust, professional\n accountability, and education. Oversight in the regulatory mode emphasizes\n investigations, enforcement of minimum requirements, and public accountability.\n\n Strengths and Deficiencies of External Hospital Review\n\n C The Joint Commission\xe2\x80\x99s strengths are rooted in the collegial side of the continuum,\n as its surveys focus on education, fostering improvement, and reducing risks. But\n\n\n\nThe External Quality Review of Psychiatric Hospitals 29 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n these educationally oriented surveys are unlikely to detect patterns of poor care or\n individual practitioners with questionable skills.\n C The State agencies\xe2\x80\x99 strengths are more rooted in the regulatory side, as they serve\n as front-line responders to complaints and adverse events in both accredited and\n nonaccredited hospitals. But they rarely conduct routine, not-for-cause surveys of\n nonaccredited hospitals.\n\n Overall, the System Is Moving Toward the Collegial Mode of Oversight\n\n C The Joint Commission, which dominates hospital oversight, is already grounded in\n the collegial mode, and is leading the movement. HCFA is clearing the way for\n State agencies to follow with its proposed conditions of participation, which\n deliberately parallel the Joint Commission\xe2\x80\x99s approach.\n\n C The movement toward the collegial mode may undermine patient protections.\n Both the collegial and regulatory modes have value, but as the system moves too\n far toward collegial side, it leaves little attention to the investigatory and patient\n protection efforts that are the core of the regulatory mode.\n\n C The movement in hospital oversight contrasts significantly with the recent\n movement in nursing home oversight that has emphasized regulatory approaches\n such as surprise inspections, penalties, and public disclosure of survey results.\n\n Limited Accountability to HCFA for Performance of Joint Commission and\n State Agencies\n\n C HCFA obtains little information on the performance of Joint Commission or the\n State agencies. The value of validation surveys, its main vehicle to assess the Joint\n Commission, is limited. HCFA has piloted a promising new approach, observation\n surveys, but it has yet to issue any evaluation of the pilot. HCFA does not conduct\n validation surveys of State agencies and conducts few observation surveys.\n\n C HCFA provides little performance feedback to the Joint Commission and State\n agencies. In fact, HCFA is more deferential than directive to the Joint\n Commission. And while it is more directive with the State agencies, it gives them\n little feedback on how well they perform their hospital oversight work.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 30 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n C Public disclosure plays only a minimal role in holding the Joint Commission and\n State agencies accountable. The Joint Commission has been proactive in making\n hospital survey results widely available, but HCFA has makes little information on\n hospitals or State agencies available. By contrast, HCFA posts nursing home\n survey results on the Internet.\n\n Recommendations to HCFA\n\n Guiding Principle: Perform Steering Role to Achieve Balance Between the\n Collegial and Regulatory Modes\n\n C A credible system of hospital oversight must reflect a reasonable balance between\n both modes.\n\n C HCFA must recognize the inherent strengths and limits of accreditors and State\n agencies.\n\n C HCFA must revise the proposed Medicare conditions of participation to (1) affirm\n the importance of the regulatory role of State agencies, (2) recognize the vital role\n that State agencies play in investigating complaints and adverse events, and (3)\n eliminate the suggestion that fewer compliance surveys will be necessary by\n working in a partnership mode with hospitals.\n\n Recommendation: Hold the Joint Commission and State Agencies More\n Accountable for their Performance\n\n C Deemphasize validation surveys, reconsider observation surveys, and require\n performance data.\n\n C Negotiate the following with the Joint Commission to improve accountability and\n achieve more balance:\n\n < More unannounced surveys,\n < More meaningful accreditation levels,\n < More random selection of records during surveys,\n < More background information for surveyors,\n < More input into survey priorities,\n\n\nThe External Quality Review of Psychiatric Hospitals 31 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n < More rigorous assessments of hospital improvement efforts, and\n < More attention to complaints.\n\n C Assess periodically the justification for the Joint Commission\xe2\x80\x99s deemed status.\n C Increase public disclosure on the performance of hospitals, the Joint Commission,\n and State agencies.\n\n Recommendation: Determine Minimum Cycle for Certifying Nonaccredited\n Hospitals\n\n C Ensure nonaccredited hospitals are subject to routine external review.\n\n\nThe Role of Accreditation\n\n Announced Surveys\n\n C Announced Joint Commission accreditation surveys are wider than they are deep.\n They are carried out in a collegial and tightly structured manner, leaving little time\n to pursue leads or respond to complaints. They serve as a means of reducing risk\n and fostering improvement. They are unlikely to surface substandard care or to\n identify individual practitioners whose judgement or skills are questionable.\n\n C Although accreditation results matter enormously to hospitals, the results fail to\n make meaningful distinctions across hospitals.\n\n C Despite having 6 levels of accreditation, 99 percent of the hospitals surveyed by\n the Joint Commission between May 1995 and June 1998 clustered in just 2 of\n those levels: accredited with commendation (16 percent) and accredited with\n recommendations for improvement (83 percent).\n\n Unannounced Surveys\n\n C The Joint Commission\xe2\x80\x99s reliance on unannounced surveys is limited. It conducts\n 1-day, random unannounced surveys to ensure continued compliance with\n accreditation standards between triennial surveys. From June 1995 through May\n\n\n\nThe External Quality Review of Psychiatric Hospitals 32 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n 1998, it conducted such surveys, providing 24 to 48 hours notice, on about 5\n percent of its accredited hospitals.\n\n\n\n\n Responses to Major Adverse Events and Complaints\n\n C The Joint Commission treats major adverse events as opportunities for\n improvement. Accordingly, it emphasizes education, prevention, and\n confidentiality but limits public disclosure on the causes, consequences, and\n responses to such events.\n\n C The Joint Commission devotes little emphasis to complaints. Although it has\n mechanisms for receiving complaints both within and outside the survey, its survey\n process is not particularly geared to dealing with them.\n\n Use of Standardized Performance Measures\n\n C Despite the Joint Commission\xe2\x80\x99s early plans to incorporate standardized hospital\n performance data into its accreditation program, such data remain of limited value\n to external assessments of hospital quality.\n\n\nRole of Certification\n\n Announced Surveys\n\n C Routine State agency surveys of nonaccredited hospital are a low priority. The\n State agencies\xe2\x80\x99 limited budget goes to nursing home and home health agency\n surveys first. Thus the backlog of Medicare certification surveys at nonaccredited\n hospitals is growing: 50 percent of nonaccredited hospitals had not been surveyed\n within 3.5 years as of late 1997, up from 28 percent in 1995. Elapsed time\n between surveys has grown from 1.5 years to 3.3 years.\n\n C HCFA\xe2\x80\x99s certification surveys fail to make meaningful distinctions among\n nonaccredited hospitals, simply resulting in a status of certified or not certified.\n\nThe External Quality Review of Psychiatric Hospitals 33 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n From January 1996 to June 1998, HCFA terminated just one hospital based on its\n certification survey results.\n\n Responses to Major Adverse Events and Complaints\n\n C Complaints and sentinel events drive HCFA\xe2\x80\x99s hospital oversight and precede\n routine surveys in budget priority.\n Use of Standardized Performance Measures\n\n C HCFA has not sought to collect or disseminate standardized performance data for\n nonaccredited hospitals.\n\n\nHolding the Reviewers Accountable\n\n C The HCFA holds the Joint Commission and the State agencies only minimally\n accountable for their performance in reviewing hospitals.\n\n Joint Commission\n\n C HCFA\xe2\x80\x99s main tools for overseeing the Joint Commission are validation surveys,\n but these surveys are fundamentally limited because they are based on different\n standards that are applied at different points in time. They are also expensive to\n implement and based on a sample that is flawed. HCFA has piloted an observation\n survey that has promise but remains undeveloped.\n\n C HCFA obtains few reports about the Joint Commission\xe2\x80\x99s performance.\n\n C HCFA\xe2\x80\x99s own feedback to the Joint Commission is of limited value. In fact, its\n guidance on policy and procedural matters to the Joint Commission is negligible.\n\n C The Joint Commission has been proactive in making hospital survey results widely\n available on the Internet and through other means. HCFA, on the other hand,\n makes little available on the performance of the Joint Commission.\n\n State Agencies\n\n\n\nThe External Quality Review of Psychiatric Hospitals 34 OEI-01-99-00160\n\x0c APPENDIX A\n\n\n\n\n C HCFA conducts no validation surveys and few observation surveys at\n nonaccredited hospitals to oversee State agencies\xe2\x80\x99 performance.\n\n C While it varies by region, nationally HCFA obtains little that reflects on the States\xe2\x80\x99\n performance specific to hospitals--indeed, it largely relies on States to assess their\n own performance.\n C HCFA gives State agencies limited feedback on how well they perform their\n hospital oversight activities. However, it does give them considerable guidance,\n often on a case-by-case basis.\n\n C HCFA makes little information available to the public on the performance of\n wither hospitals or the States. By contrast, it posts nursing home survey findings\n on the Internet and Federal law requires nursing homes to post their findings as\n well.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 35 OEI-01-99-00160\n\x0c APPENDIX B\n\n\n Methodology\n We collected information presented in this report from the following sources:\n\nHCFA\n\n We obtained data on the number of contracted surveys from HCFA\xe2\x80\x99s consultant that\n handles logistical support for the contracted surveyors. These data included the date, type\n (recertification, follow-up, initial, and complaint), and results of surveys conducted by the\n contracted surveyors.\n\n We also obtained data from HCFA\xe2\x80\x99s Online Survey Certification and Reporting System\n (OSCAR). These data included surveys based on complaints at psychiatric hospitals and\n the number of nonaccredited psychiatric hospitals. For the latter, we extracted the identity\n of nonaccredited psychiatric hospitals and confirmed their accreditation status by visiting\n the Joint Commission\xe2\x80\x99s website.\n\n We also interviewed staff and managers at HCFA\xe2\x80\x99s central and regional offices. We\n reviewed a variety of HCFA documents, including contracts and HCFA\xe2\x80\x99s interpretive\n guidelines for surveys, among others.\n\nJoint Commission on Accreditation of Healthcare Organizations\n\n We interviewed officials from the Joint Commission on Accreditation of Healthcare\n Organizations. We also reviewed documents from the Joint Commission, including\n accreditation manuals, policies, the briefing book for members of the Restraint Use Task\n Force, and hospital survey protocols. We requested and received aggregate data from the\n Joint Commission on sentinel events involving restraints and seclusion and on survey\n activity in psychiatric hospitals.\n\nSurvey Observations\n\n Based on schedules of upcoming Joint Commission surveys and HCFA\xe2\x80\x99s contracted\n surveys, we were able to observe two Joint Commission surveys and two HCFA\n recertification surveys. The psychiatric hospitals we observed were located in both urban\n and suburban locations, with bed sizes ranging from under 50 to over 400. The Joint\n Commission surveys we observed were an announced triennial survey and a special\n unannounced survey.\n\n\n\nThe External Quality Review of Psychiatric Hospitals 36 OEI-01-99-00160\n\x0c APPENDIX B\n\n\nExpert Interviews\n\n We interviewed various stakeholders from around the country. They included mental\n health officials from various States, practicing psychiatrists, experts in restraints and\n seclusion, and discussions with surveyors from both the Joint Commission and HCFA.\n\nOther Documents\n\n In addition to the documents referenced above, we reviewed statutes, regulations,\n legislative history, and a variety of articles from newspapers, journals, and websites.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 37 OEI-01-99-00160\n\x0c APPENDIX C\n\n\n\n A Framework for Considering the\n External Review of Hospitals\n The following five components present a framework for considering the external quality\n review of hospitals. They are intended to complement the internal quality assurance and\n improvement efforts that hospitals undertake themselves. They are approaches that health\n care purchasers, such as Medicare and Medicaid, can rely upon to ensure that their\n beneficiaries receive quality services from hospitals. They can also be of use to\n beneficiaries and other consumers concerned about the quality of their hospital care.\n\n We present the components to facilitate analysis of the extent and type of external review\n that is desirable, whether carried out by accreditation bodies, certification agencies,\n Medicare Peer Review Organizations, HCFA, or others. Each component has strengths\n and limitations. Moreover, each can be used in support of a review philosophy based on\n continuous quality improvement, more traditional compliance enforcement, or some\n combination thereof.\n\n We omitted a sixth component: the retrospective review of medical records to determine\n appropriateness of care. Formerly a role of the Medicare Peer Review Organizations,\n such medical record review is no longer carried out on such a large scale. However, some\n medical record review does occur as part of the components described below.\n\n 1. Announced, On-Site Surveys of Hospitals\n\n These involve some combination of observations of facility and equipment; reviews of\n medical credentials, and other records and documents; and interviews. They result in a\n pass/fail or some kind of score intended to distinguish level of performance. They can also\n involve follow-up to correct or improve.\n\n 2. Unannounced, On-Site Surveys of Hospitals\n\n The approach is basically the same as above except that the hospital has not had time to\n prepare. The intent is to gain a clear assessment of the facility as it typically functions and\n to trigger any necessary follow-up.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 38 OEI-01-99-00160\n\x0c APPENDIX C\n\n\n\n 3. Response to Complaints Concerning Hospitals\n\n These involve complaints of a particular instance of care or more encompassing matters\n concerning a hospital\xe2\x80\x99s performance. The response to complaints can range from a\n minimal distant review to a thorough on-site review. The process can trigger corrective\n actions and system improvements.\n\n 4. Response to Major Adverse Events in Hospitals\n\n These involve cases where substantial patient harm resulted from what may be poor\n performance on the part of the hospital and/or its practitioners. Here, too, the response\n can range from minimal to thorough and can trigger corrective actions and system\n improvements.\n\n 5. Collection and Dissemination of Standardized Performance Measures\n\n The aim here is to establish the standardized use of measures in ways that enable\n purchasers, consumers, accrediting bodies, and others to compare hospital performance.\n The comparisons can focus on a hospital\xe2\x80\x99s own performance over time and/or on how its\n performance compares to other hospitals. The data can be drawn from surveys of patients\n or providers, billing claims, and the hospitals\xe2\x80\x99 own records.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 39 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n Comments on the Draft Report\n\nIn this appendix we present the text of comments of all parties that responded to our draft report.\nThey are:\n\nCHealth Care Financing Administration, U.S. Department of Health and human Services\n\nCJoint Commission on Accreditation of Healthcare Organizations\n\nCPublic Citizen, Health Research Group\n\nCNational Association of Psychiatric Health Systems\n\nCNational Alliance for the Mentally Ill\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 40 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 41 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 42 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 43 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 44 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 45 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 46 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 47 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 48 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 49 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 50 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 51 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 52 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 53 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 54 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 55 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 56 OEI-01-99-00160\n\x0c APPENDIX D\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 57 OEI-01-99-00160\n\x0c APPENDIX E\n\n\n\n Endnotes\n1. U.S. General Accounting Office, Mental Health: Improper Restraints and Seclusion Use\nPlaces People at Risk, GAO/HEHS-99-176, September 1999.\n\n2. According to HCFA\xe2\x80\x99s Online Survey and Certification Reporting System (OSCAR), 65\npsychiatric hospitals are nonaccredited as of August, 1999. However, we determined that 26 of\nthose hospitals are, in fact, accredited.\n\n3. These data are based on the four most common psychiatric DRGs in Medicare according to\nthe 1997 HCFA Customer Information Set: DRG 430 (psychosis), DRG 429 (dementia), DRG\n426 (depressive neurosis), DRG 427 (neurosis except depressive), and DRG 428 (disorders of\npersonality and impulse control).\n\n4. P.L. 89-97.\n\n5. Psychiatric units in acute care hospitals are not subject to these extra conditions.\n\n6. 42 C.F.R. 482.60-62.\n\n7. United States Code, Congressional and Administrative News: Legislative History, First\nSession 1965, p. 1970.\n\n8. HCFA published its proposed hospital conditions of participation on December 19, 1997 (62\nFed. Reg. 66,726).\n\n9. 64 Fed. Reg. 36,070, July 2, 1999.\n\n10. Ibid., 36,089.\n\n11. Congress also provided that hospitals accredited by the American Osteopathic Association\ncould be considered in compliance, but only to the extent that the Secretary deemed appropriate.\n(Social Security Act, sec. 1865, 42 U.S.C 1395bb.)\n\n12. Costs associated with accreditation may or may not have been included in the base-year\ncalculations under the prospective payment system, depending on the hospital\xe2\x80\x99s accreditation\nstatus at that time. Accreditation is voluntary, and whether or not a hospital elects to be\naccredited does not change its reimbursement from Medicare.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 58 OEI-01-99-00160\n\x0c APPENDIX E\n\n\n\n13. As of May 2000, the Joint Commission reported that of the 38 Charter hospitals subject to an\nunannounced survey, it accredited 2 with commendation, 29 with type 1 recommendations, 3\nwith conditional accreditation. Another four were not accredited. Since the unannounced\nsurveys, 17 of the 38 hospitals have closed and 3 were sold.\n\n14. Current HCFA policy, as outlined in the State Operations Manual \xc2\xa72042, is to announce\nsurveys at psychiatric hospitals. However, practices vary across HCFA regions, with some\nregional offices announcing and some not announcing upcoming surveys. In some cases, then, the\nhospitals have no advance knowledge that the contracted surveyors are coming and thus are\nunlikely to have presentations prepared for the contracted surveyors. HCFA is in the process of\nclarifying its policy on announcing such surveys.\n\n15. We recognize that current Medicare conditions of participation require discharge planning\nbut spell out no requirements for the execution of that plan, thus hospitals cannot be held directly\naccountable for that process. However, inadequacy of the discharge plan\xe2\x80\x99s execution could be\nrelated to inadequacies in its planning.\n\n16. According to the American Hospital Association, the length of stay in psychiatric hospitals\ndropped 80 percent: from 204 days in 1974 to 41 days in 1997.\n\n17. On July 2, 1999, HCFA issued an interim final rule on patient rights, which covers the use of\nrestraints. That interim final rule is outside the purview of the contracted surveyors.\n\n18. Joint Commission on Accreditation of Healthcare Organizations, Restraint Use Task Force\nMeeting: Agenda and Materials, May 26, 1999.\n\n19. The Joint Commission held these hearings in early 1999: March 29 in San Francisco, April 6\nin Atlanta, and April 13 in Washington, D.C..\n\n20. In 1997, Joint Commission surveyors found the standard for time-limited orders for restraints\nout of compliance in 16 percent of the psychiatric hospitals surveyed that year. In 1998, they\nfound that same standard out of compliance 10 percent of the time. (Data as reported by the Joint\nCommission).\n\n21. We based this analysis on the recertification surveys of the two special conditions, which\nrepresent the majority of the surveys conducted by the contracted surveyors. Our analysis\nexcluded follow-up, initial, and complaint investigation surveys conducted by the contracted\nsurveyors.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 59 OEI-01-99-00160\n\x0c APPENDIX E\n\n\n\n22. According to HCFA, the FY 1993 amount of $3,000,000 funded the contracted surveys for 7\nmonths, from September 19, 1992 through March 1993. In April 1993, HCFA modified the\ncontract and budgeted an additional $1,187,370 for the next 12 months, taking the contract\nthrough the remainder of FY 1993 and into FY 1994.\n\n23. Validation surveys are on-site reviews of hospitals that are conducted some time after the\naccreditors\xe2\x80\x99 or State agencies\xe2\x80\x99 own visits.\n\n24. HCFA did observe the contracted surveyors at a psychiatric hospital in late summer, 1999.\nThat observation resulted in no written report nor formal performance assessment.\n\n25. HCFA has a contract with Romain Consulting to provide logistical support for the contracted\nsurveyors. Romain schedules surveys at psychiatric hospitals, assigns surveyors, arranges travel,\nand tracks the survey activity. HCFA\xe2\x80\x99s contract with Romain calls for the following major\nroutine reports: (1) monthly progress reports, (2) monthly summary of meetings with HCFA,\n(3) quarterly expenditure reports, and (4) draft and final year-end reports. During the course of\nour inquiry, we asked to review samples of the monthly reports as well as the year-end reports.\nHCFA responded that no such reports existed, referring us instead to Romain. Romain likewise\nkept no such reports.\n\n26. In FY 1997, 54 percent of the contracted surveyors conducted 3 or fewer surveys; In FY\n1998, 42 percent. To date in FY 1999, 58 percent of the contracted surveyors conducted 3 or\nfewer surveys (based on data reported by Romain Consulting).\n\n27. According to HCFA, it trained all the contracted surveyors in January 1992, June 1995, and\nApril 1998. It provided training for newly recruited surveyors in both November 1992 and March\n1999.\n\n28. According to 1997 HCFA Customer Information Set data, 66 percent of the 497,159\npsychiatric discharges were from psychiatric units in acute care hospitals and 27 percent were\nfrom free-standing psychiatric hospitals.\n\n\n\n\nThe External Quality Review of Psychiatric Hospitals 60 OEI-01-99-00160\n\x0c'