It's no surprise that hospital chiefs would be stunned and nervous—and some perhaps downright angry—in learning suddenly this week about an electronic database showing 8,000 serious quality and safety violations in about 1,000 hospitals, many in gritty detail, with a few keyboard clicks.
No longer do journalists and members of the public need to file Freedom of Information Act Requests, and wait weeks or months for a government response for many of these documents. Now they can go directly to HospitalInspections.org
Providers may also be a bit chagrined because the new tool was not created by the Centers for Medicare & Medicaid Services, which authorized the complaint investigations that resulted in these reports, but by persistent leaders of the nearly 1,500-member Association of Health Care Journalists. The AHCJ has perseverated with requests for this database for more than three years.
Now journalists from Coronado, CA to Danbury, CT are busily breaking stories of which hospitals in their regions got into trouble, sparing no details. And healthcare providers' media reps and their bosses are scrambling to explain how they've revised their procedures so such events never happen again.
See Also: CMS Unveils Hospital Violations Database
"Everybody benefits from this information because for far too long we've operated under a culture that was more paternalistic about healthcare information, that certain people were entitled to have it and certain people were not, and if you wanted it, you had to jump through hoops to get it," said Charles Ornstein, AHCJ president who fought hard to get CMS to focus on a collaboration.
This new transparency is a long time coming, indicative of a new culture of disclosure that I, a member of AHCJ, am delighted to see.
Though still incomplete, with major gaps, the keyword-searchable site helps payers and patients know which hospitals persistently fail Medicare's "conditions of participation," and caused or came close to causing patient harm or death.
And it can help all healthcare organizations know more about the circumstances and frequency with which these harmful events occur so work can be done to prevent them.
Providers React
"We're concerned that this new tool, while well-intentioned, provides information without context and creates more confusion than clarity," said Bruce Siegel, president and CEO of the 250-member National Association of Public Hospitals and Health Systems. "Worse, it tells patients only half the story by failing to include hospital responses and plans of correction."
Joanne Conroy, MD, chief health care officer for the Association of American Medical Colleges and a former hospital CEO, said, "What they've done is a huge data dump… And it will be a challenge for this website to give real information that will drive real change….to figure out within groups of similar episodes what might be a common thread."
Nancy Foster, vice president of quality and patient safety for the American Hospital Association, said it's "hard for even a seasoned healthcare policymaker to understand the CMS documents or thoughtfully apply them to make informed decisions."
For example, state survey teams usually write these reports on behalf of CMS, and these teams "vary considerably in size, experience, expertise and training" resulting in differences in the number and types of citations. Notably, Foster said, because in some areas such as fire safety, CMS requirements are more than a decade out of date, a hospital may have modernized, and be non-complaint with an obsolete rule.
Yes, hospitals are nervous. They weren't told about this project in advance, so they couldn't stop it.
Though they may protest too much, I think hospitals want to see this all laid out, and if they don't, they should. True, the database is far from perfect, but as Ornstein said, "The perfect shouldn't be the enemy of the good… [this is] a first step to bringing transparency to hospital inspections."
To Conroy's point, the keyword search function allows anyone to filter violations that involved certain types of violations such as "falsified" reports, equipment malfunction, fires, infections, sponges, transfusion, abuse, restraints, and so forth. That might not be a deep dive analysis, but it's something.
Ornstein, now senior reporter for ProPublica in New York City, told me it wasn't easy getting CMS to turn over these electronic files, known as "2567" statements of deficiency. "It represented a fundamental shift in how they release information. And so there was a lot of explaining and a lot of work that went into showing them why this was needed, necessary, and do-able," he said.
He adds that these deficiencies were not relatively minor, but were serious enough that CMS "set a date for Medicare termination" if they weren't fixed.
In other words, serious enough that the hospital could go broke, although most will fix their problems before that happens.
While a reporter for The Los Angeles Times covering the massive failures that closed Martin Luther King Jr./Drew Medical Center in 2007 and the Kaiser Permanente kidney transplant debacle of 2006, Ornstein realized "special reports were integral to understanding the depths of the problems at those facilities."
He and members of the AHCJ board wanted the public to see common problems at multiple hospitals, which required getting access to a searchable database that until now, only CMS had been able to see.
The effort began with his March, 2010 letter to CMS Acting Administrator Charlene Frizzera, in which he proposed "An AHCJ-led initiative" that would "put online CMS 2567s" dating to 2005, starting with 340 hospitals with two or more violations of Medicare's conditions of participation.
But there was a delay. The administration was then focused on implementing the newly passed Patient Protection and Affordable Care Act. "It took time to get their attention and show them how this fit with the administration's promise and pledge of transparency." It took time to get attention from the right people, he said.
In March of 2011, after many e-mails and calls, Ornstein met with acting CMS administrator Don Berwick. Later he met with Berwick's successor, acting CMS administrator Marilyn Tavenner.
Top level CMS officials gave excuses why they couldn't move forward. One was that investigations of complaints about many hospitals are performed not by CMS or its designated state agencies, but by accreditation organizations such as The Joint Commission, whose resulting survey documents CMS does not have. Ornstein says he is working on getting those documents.
Another problem: the hospitals' plans of correction—required in each survey document—aren't yet in an electronic database.
The tipping point came in October, 2012, when Tavenner and CMS chief medical officer Patrick Conway, MD, "made it clear they had crossed the hurdle," Ornstein said. AHCJ would get the electronic database with reports dating to January, 2011, without the plans of corrections and of course, without any violation reports performed by accrediting organizations like TJC.
The journalism group used funds from the Ethics and Excellence in Journalism Foundation, and hired an application developer to build a user interface that allows users to search by state, city, or by keyword.
Troubleshooting begins
Ornstein noticed that some reports weren't uploaded. In fact, several of CMS' 10 regions weren't uploading some reports into CMS' central computer system at all. "It took time to identify" the problem, and still several thousand narrative reports that detail violations are missing. Large numbers of reports from key states like California weren't there.
So the database launched on Saturday with 5,251 deficiencies that have narrative reports, but another 2,895 are missing narratives, Ornstein says. Also missing are reports on psychiatric, rehab, and long-term hospitals, and reports on general surveys done at random, not in response to complaints.
The site is imperfect and incomplete, but it is live.
Jeff Selberg, executive vice president and COO of the Institute for Healthcare Improvement in Cambridge, MA says he understands hospital executives' concerns, which he said "are borne out of fear." But that shouldn't really affect whether the reports are made more accessible, he said.
"I'm an outlier in terms of my approach to how the industry feels," Selberg continued. "I believe you have to start from where you are, that you perfect the data by putting it out in whatever form you have it, and perfect it over time. I would hope that the association (AHCJ) continues to push to improve to the degree it stimulates a better and more readable format."
"Across industries, public accountability results in more diligence toward improvement."
Ornstein sees this period in the process as just the beginning of "a major paradigm shift for (CMS) to be putting these reports on line. I hope they will expand the information and make it even more robust and useful."
Let's hope he's right.