Hospital Impact—Why hospitals should rethink the accreditation process

Hospital entance
Hospitals and health systems should strive to have a proactive relationship with their accrediting body. (Getty/monkeybusinessimages)
Patrick Horine

These days, healthcare organizations are under tremendous pressure to improve every facet of care delivery.

The need to improve is often a consequence of the Medicare Conditions of Participation, which requires hospitals to be accredited by an outside agency. If condition-level deficiencies are found, hospitals can be barred from receiving Medicare revenue if they are not corrected within a short period of time.

Traditionally, hospitals and their accreditation agencies have often had adversarial relationships. This can begin from the moment an accreditation surveyor enters the premises. John Cooke, a longtime surveyor, calls it the “gotcha game.”

It can mean a surveyor clandestinely picks up a piece of patient information from a nursing station and presents it to the hospital accreditation liaison at the end of the workday as “proof” the hospital is not safeguarding sensitive data. Or he or she might focus on an obvious but easily corrected flaw in care delivery and present it as a significant finding.

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But there are also opportunities for hospitals to improve their quality processes as part of qualifying for accreditation.

A prime example of this is Charleston Area Medical Center in West Virginia. Concern was growing among clinical staff about the patients it served being vulnerable to strokes. This was borne out by the data: The stroke rate among West Virginians is about a third higher than the national average, with the state ranking 48th out of the 50 states in stroke prevalence. A West Virginian is nearly 2.4 times more likely to suffer a stroke than a Coloradan and more than twice as likely as a Minnesotan.

Charleston Area Medical Center staff attended a multiday educational session on implementing the ISO 9001 quality management system within the facility, a quality process originally developed for the manufacturing sector but adapted for use in hospitals. That led to the creation of more timely interventions for stroke patients brought into the hospital’s emergency room, particularly those suffering from ischemic strokes.

The hospital placed a particular focus on the delivery of a clot-busting medicine called tissue plasminogen activator, or tPA. If the medicine is not received within a few hours of the onset of a stroke, it will have little to no effect.

To speed the treatment process, an additional radiologist was hired to provide more timely interpretation of brain scans. The existing team of eight neurologists met to discuss more timely interventions.

As a result of this protocol, a total of 140 patients received tPA within an hour of their stroke between April 2016 and April 2017, compared to about 30 in the same period in 2015-2016. The hospital also created a telestroke program, guaranteeing patients immediate care from a neurologist even if they are not at the CAMC facility. In addition, patients swiftly receive antithrombotics and anticoagulation therapy.

After discharge, patients were prescribed cholesterol-reducing drugs and smoking cessation counseling if needed. Hospital officials said ISO 9001 served as a roadmap for revamping stroke care.

Peg Palmer, a longtime nurse practitioner who had recently retired from Charleston Area Medical Center, was admitted last year after suffering a stroke. She walked out of the facility three days later, according to an article (PDF) in InFlight magazine.  

“Everyone collaborated quickly to determine the most appropriate treatment,” she told the publication.

Charleston Area Medical Center received the Malcom Baldrige National Quality Award for quality of care in 2015.

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Another example is CoxHealth, a five-hospital system in Southwest Missouri. It used ISO 9001 to make changes to its electronic health records system in order to better monitor patients who were being admitted multiple times through its emergency departments. It decided to provide an outpatient care program to focus on these patients, with particular focus on dental pain, mental health and social issues. Much of this care was delivered in collaboration with federally qualified health centers within the hospitals’ service areas.

As a result, the readmission rates among that specific patient population dropped 16%. More than 10,000 care hours opened up in the individual CoxHealth emergency departments, which allowed increased access for 3,400 acute emergent patients.

All of these advancements came after Charleston Area Medical Center entered into a more proactive relationship with its accrediting body in 2013, and CoxHealth did the same in 2015.

What constitutes a proactive relationship? It is not preparing for a survey every three years, but working with the accrediting body on an ongoing basis to spot issues that can be addressed. It is not being dictated to by the accrediting body, but instead is the result of collaborating so the hospital and its staff are in continuous improvement mode.

However, making that change after years, if not decades, of treating the accreditation process as a dreaded chore that crops up every once in a while is not easy. It often requires challenging the status quo. It requires resolve and courage. It requires taking a long hard look at the way an individual hospital is operated and managed and having everyone on the same page devoted to make a change.

It’s not easy, but it can be done. The result—for both patients and staff—is usually worth it.

Patrick Horine is the CEO of DNV GL Healthcare, which accredits some 500 hospitals in 49 states to participate in the Medicare program.