SC Hospital Executive Update, November 16, 2011

On October 24, 2011, CMS issued a proposed new regulation that modernizes some of the Medicare Conditions of Participation for Hospitals. These changes were the direct result of consistent pressure from The Joint Commission, and it’s critical that hospitals in our state (and across the nation) understand not only the substance of the changes, but also the process that produced them.

From the day Dr. Mark Chassin took over as President of The Joint Commission, he has heard numerous complaints from hospitals about Conditions of Participation (COPs) that are no longer relevant to modern hospital care. In recent years Dr. Chassin has heard increasing examples of how some Medicare COPs actually impede quality improvement efforts in hospitals.

At Dr. Chassin’s direction, The Joint Commission inventoried approximately 30 ways in which the COPs impeded hospitals’ efforts to improve the safety and quality of care they provide. The list was presented to CMS, along with a request to modernize the COPs in question.

Once Don Berwick was installed as Director of CMS, Dr. Chassin began advocating for CMS action on the outdated Conditions of Participation. Last month’s issuance of modernized COPs is the end product.

Those of us in the business of advocacy recognize how difficult it is to persuade CMS to change its standards. Kudos are due to Dr. Chassin and his team at The Joint Commission, not just for convincing CMS to modernize the COPs, but for listening to our nation’s hospitals and taking action on their behalf.

The Joint Commission is an enterprise that has several distinct lines of business. Most of you are very familiar with The Joint Commission as the accrediting body for hospitals in America. The Joint Commission is led by a board of directors that includes one state hospital association executive, and that seat is currently held by my colleague Craig Jones from Oklahoma.

Two other lines of business in The Joint Commission enterprise are governed by a separate board of directors: domestic consulting and international accreditation. I currently serve on the board that oversees these two businesses (Joint Commission Resources/Joint Commission International). As members of these two boards, Craig Jones and I have already commended Dr. Chassin and his team for their sustained efforts to modernize the Medicare COPs. We have also asked him to prepare a summary of changes to the COPs so we can disseminate it to our colleagues across the country and to our own hospitals, and you may access that summary by clicking here.

We hope you find this information helpful. We’re not trying to sell Joint Commission accreditation or consulting; we simply believe the organization deserves credit for listening to hospital leaders and providing national leadership for change.