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HHS Inspector General Identifies Deficiencies
In Psych Hopsital Quality Review

NAMI One of 4 Outside Organizations Which
Provided Published Comments on Draft Report

For Immediate Release, May 25, 2000
Contact: Chris Marshall

The Office of the Inspector General (OIG), Department of Health and Human Services (HHS) on Tuesday released a report, "The External Quality Review of Psychiatric Hospitals." The report identifies a number of deficiencies in existing quality review processes.

The Health Care Financing Administration (HCFA) and four outside organizations were asked to review the draft report. These four were the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Alliance for the Mentally Ill (NAMI), the National Association of Psychiatric Health Systems (NAPHS), and Public Citizen, Health Research Group. NAMI's January 13, 2000 comments are attached at the end of this report.

The OIG reached the following conclusions:

1. "Overall, we concluded that while there are strengths in this system, there are also deficiencies that call for attention."

2. "The extent to which the system of oversight is holding psychiatric hospitals accountable for patient care is questionable, especially in the key areas of discharge planning and restraints and seclusion."

3. "We also found psychiatric hospitals falling through the cracks, with fewer contracted surveys being conducted and the elapsed time between such surveys growing."

The report emphasizes the lack of coordination between HCFA's deemed status agent, JCAHO, and HCFA's hospital contracted surveyors, a panel of surveyors who follow the care of a sample of patients to specifically determine hospital compliance with record keeping and staffing requirements.

Regarding JCAHO, the IOG offered: JCAHO "has been grounded on the collegial side" of oversight. "However, while the Joint Commission's approach is still grounded in the collegial mode, it recently made some changes in its accreditation of psych hospitals that mark a shift toward the regulatory mode. During the summer of 1999, JCAHO conducted 38 completely unannounced surveys of Charter hospitals. During the surveys, the team, rather than the hospital staff, selected the records for review. JCAHO has announced more frequent use of unannounced surveys."

The OIG concluded: "HCFA's contracted surveyors, state agencies, and the Joint Commission tend to carry out their psych hospital oversight on independent tracks with little coordination."

The OIG made the following recommendations:

1. "Our recommendations call for HCFA to exert its leadership in shaping the external review of psychiatric inpatient care."

2. "We directed our recommendation to HCFA and call for it to deploy its contracted surveyors more strategically, by making them available to respond to adverse events and complaints at both psychiatric hospitals and psychiatric units in acute care hospitals."

3. "Furthermore, we recommended HCFA negotiate with the Joint Commission to achieve a more patient-centered survey approach and a more rigorous assessment of discharge planning."

4. HCFA should consider applying special Medicare conditions of participation both to psychiatric hospitals and psychiatric units of acute care hospitals.

A. The external review system that HCFA relies upon falls short in two important ways:
1. Does not apply special conditions to psych units of acute care hospitals 2. Contracted surveyors only assess compliance with two special conditions-medical records and staff requirements.

B. What's needed

1. Extra scrutiny for patients with psychiatric illness. 2. Additional authority for key-patient care issues, including discharge planning.

5. "Public disclosure plays a minimal role in holding the contracted surveyors accountable. HCFA makes little information available to the public on the performance of the psychiatric hospitals or the contracted surveyors..On the matter of public disclosure, we emphasize our position that such disclosure represents an important step toward enhancing the public accountability of the contracted survey process."

6. "HCFA should hold its contracted surveyors more fully accountable for their performance. Toward that end, it should:"

  • Conduct periodic observation surveys of the contracted survey process

  • Obtain timely and useful performance reports

  • Provide feedback and guidance to the contracted surveyors.

  • Increase public disclosure. HCFA should make more information available on the oversight and performance of psychiatric hospitals by, at a minimum, posting information on the Internet.

7. "HCFA should negotiate with the Joint Commission to achieve both a more patient-centered survey approach and a more rigorous assessment of discharge planning."

Though only four outside organizations were asked to review the draft, approaches varied:

To NAPHS: "We strongly encourage HCFA to rely on JCAHO, within the framework of its deemed status relationship." But NAMI discussed the "current inadequacies of the JCAHO deemed status" approach. Public Citizen went further and declared: "At its core, the JCAHO is riven with conflict of interest: corporate members comprise 75% of its board (they pay $20,000 for the privilege), hospitals hand-pick the medical records to be reviewed, and hospital surveys are generally announced months ahead of time."

While NAMI advocated public disclosure of hospital performance, including the use of independent, third party consumer and family monitoring groups, such as those which operate in Delaware, New Hampshire, Oklahoma, and Pennsylvania, NAPHS "opposes wide spread dissemination of information about the performance of hospitals and surveyors" whereas Public Citizen "expressed its concern that without disclosure, public discontent will grow."

The OIG concluded, "On the matter of public disclosure, we emphasize our position that such disclosure represents an important step toward enhancing the public accountability of the contracted survey process."

The OIG recommended that JCAHO should use the patient -tracing approach employed by HCFA's contracted surveyors. Further, the OIG suggested that "HCFA should negotiate with the Joint Commission to achieve both a more patient-centered survey approach and a more rigorous assessment of discharge planning."

The OIG focuses on two significant deficiencies-hospital discharge planning and the inappropriate use of restraint and seclusion.

There is hope for progress. The OIG stated: "We appreciate HCFA's positive response to our report. In implementing the recommendations HCFA will strengthen the system of external review intended to protect psychiatric inpatients."

Copies of the report, which includes the comments of HCFA and the four organizations, are available from the HHS OIG web site, or call 617-565-1050.

NAMI's January 13 comments on the OIG draft follows:

NAMI - National Alliance for the Mentally Ill
Colonial Place Three
2107 Wilson Blvd, Suite 300
Arlington, VA 22201-3042

January 13, 2000

June Gibbs Brown
Inspector General
U.S. Department of Health and Human Services
5250 COHEN
330 Independence Avenue, SW
Washington, DC 20201

Dear Ms. Gibbs:

NAMI - the National Alliance for the Mentally Ill - appreciates the opportunity to review your draft report, "The External Quality Review of Psychiatric Hospitals" (OEI-01-99-00160). Your report should be very helpful in improving the quality of care in psychiatric hospitals.

Our comments emphasize the current inadequacies of deemed status through JCAHO, recommend your consideration of another form of external quality review, and refer you to a resource within HHS (not cited in your report) on discharge planning problems.

Current Inadequacies of JCAHO Deemed Status

Previous OIG reports issued July 20, 1999, particularly OEI-01-97-00050 and OEI-01-97-00051, cite the overall problems with deemed status.

Attached is our August 11 letter to JCAHO President Dennis O'Leary. JCAHO devoted several years to developing a Comprehensive Accreditation Manual for Behavioral Health but no psychiatric hospital in the nation is evaluated through these standards. All psychiatric hospitals are surveyed through the Comprehensive Manual for Hospitals. This is false advertising. JCAHO declares that they have specialty behavioral healthcare standards yet they do not use them. The "general" hospital standards are just that - "general." Trade press coverage of this letter is also attached. Psychiatric hospitals prefer the less rigorous general standards.

Attached is our August/September 1999 NAMI Advocate article summarizing an open forum with JCAHO officials at the NAMI annual convention. Though JCAHO requires that facilities inform the public when JCAHO surveyors arrive for a survey and though JCAHO requires a public meeting as part of the survey process, usually the facility runs a short announcement in the classified advertising section of the local paper to meet this requirement. JCAHO does not require facilities to outreach to known advocate, consumer, family, and patient groups within the community. This is another example of a JCAHO less than rigorous effort to have facilities meet JCAHO requirements.

The OIG report cites the Hartford Courant series and observes that JCAHO surveys often miss important events within a facility. Attached is the October 13, 1998 Courant article on Gloria Huntley of Central State Hospital in Virginia. JCAHO commended Central State with its highest ranking. The day after the award of this highest ranking, Gloria Huntley, in restraints for 558 hours during her last two months of life, died in restraints. This example just affirms the OIG observation.

Attached is NAMI's December 2, 1998 letter to JCAHO President Dennis O'Leary objecting to their reversal of their announced sentinel event policy. Here is an example of the Commission announcing a very constructive policy, only to change it when hospitals, which dominate the JCAHO governing board, complain.

Attached are the November 22 comments submitted to JCAHO by the Advocates Coalition for the Appropriate Use of Restraints, reacting to their draft revised standards on the use of restraints and seclusion. The advocates coalition, chaired by NAMI, is alarmed that HCFA's legal agent - JCAHO through deemed status - would develop standards which contradict and undermine HCFA final interim regulations. If JCAHO has deemed status under the law, how can they develop standards which contradict and undermine HCFA regulations? Obviously, the hospitals are using their dominance on the JCAHO governing board to use the Commission to undermine national HCFA standards. Attached is a January 3, 2000 trade press article on this dynamic. JCAHO is quoted as saying that HCFA and JCAHO are basically equal partners who discuss how to resolve differences. It seems an interesting attitude by the legal agent of a governmental agency, particularly an agent controlled by the regulated industry.

Last I attach NAMI's January 4, 1999 letter to HHS Secretary Donna Shalala which cites Section 1875 (b) of the Social Security Act. This is the section of the act authorizing deemed status. Section 1875 calls for the Secretary to continually study the validation of JCAHO processes. NAMI doubts whether HCFA is performing this obligation.

Another Form of External Quality Review

Four state mental health agencies - Delaware, New Hampshire, Oklahoma, and Pennsylvania - use NAMI state organizations as independent and external consumer and family facility monitoring teams. Consumer and family volunteers who are trained in monitoring review, who are authorized access to facilities (24 hours a day, 7 days a week, some unannounced, some without facility companions), and who sign confidentiality agreements, are used in state psychiatric hospitals. In September 1999 NAMI conducted a briefing at HCFA headquarters on how these teams operate. Information is available from me at NAMI, from the four state NAMI organizations, and the four state mental health authorities. We would like the OIG report to acknowledge the potential role such consumer and family monitoring teams can play in enhancing both quality and accountability in psychiatric hospitals.

HHS Discharge Planning Resource

Dr. Larry Rickards at the Center for Mental Health Services/SAMHSA/HHS has convened and authored two reports on problems with psychiatric hospital discharge planning. Internal CMHS reports were prepared in 1992 and 1997. Little positive accomplishment occurred in the nation between 1992 and 1997. The reports provide detailed information on problems as well as suggest possible policy solutions to identified problems. Information is available from Dr. Rickards at 301-443-3706.

NAMI hopes that these reactions are helpful as you proceed to finalize the report. We appreciate your seeking our comments.

We would also like to share these comments with colleagues within both HCFA and CMHS. May we do so now? Please advise.


E. Clarke Ross, D.P.A.
Deputy Executive Director for Public Policy

c.c. George Grob, Deputy Inspector General for Evaluations and Inspections
Elise Stein, Office of the Inspector General