The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Board of Commissioners approved a transition to unannounced surveys for all accredited health care organizations at their March 28-29 meeting. JCAHO believes that the unannounced survey is a natural progression to the new Shared Visions-New Pathways accreditation process that will begin in January 2004. According to Dennis S. O’Leary, President JCAHO, “Shared Visions-New Pathways creates the expectation that each accredited organization will be in compliance with 100 percent of the Joint Commission’s standards 100 percent of the time. Organization leaders whom we talked to not only agreed with this expectations, but further suggested that the next logical step would be the introduction of unannounced surveys.”

During 2004, the Joint Commission expects to initiate pilot testing of the unannounced survey process in up to 100 volunteer hospitals. Children’s Memorial Hospital, Chicago will be the first hospital in the country to receive the unannounced full survey. In 2005, JCAHO will conduct voluntary unannounced surveys on all types of accredited organizations as they complete the transition to the unannounced survey program slatted to begin in January 2006.

JCAHO plans to provide details about the unannounced triennial surveys through educational programs, newsletters and other outreach activities over the next several months. To learn more about the Shared Visions-New Pathways accreditation process, plan to attend WHA’s seminar “JCAHO Survey Preparation Trends” on Friday, May 2, 2003. A brochure and registration form are available at http://www.wha.org/ or contact Bridget Gifford at 608-274-1820.

Those observations were briefly cited in last week’s President’s Message and deserve further attention. The author, long-time (and hardly conservative) Washington Post columnist, David Broder, included the observations within a column that focused on SSM Health Care’s recent winning of the Malcolm Baldrige National Quality Award. In fact, Broder suggested that achievement “may well be the most promising development in health care reform in many years.

It truly is the conceit of at least some within government that the private sector must be forced to do certain things well and prodded to do other things even better. But it wasn’t a government mandate that precipitated SSM Health Care’s decision to compete for the Baldrige Award. It wasn’t government regulation that precipitated the recently announced Wisconsin Collaborative for Health Care. And, it certainly wasn’t state legislation that was the genesis for WHA’s Quality Initiative, which will begin reporting hospital-specific, evidence-based quality measurements in 2004.

The private sector generally can do things better than can bureaucracy. Especially, if “better” is defined as timelier, less costly and more prone to innovation. That’s why WHA is seeking to privatize certain aspects of the Bureau of Health Information. Our proposal presents an opportunity to deliver inpatient (and outpatient) hospital claims data to purchasers, payers, interested state agencies and our members in a cost effective and timely manner while being accountable to our various publics.

Finally, getting back to David Broder’s recent observations, we may well be at a historic period in time where provider-led organizations like SSM Health Care and WHA are stepping forward to demonstrate that “the search for internal improvements” can indeed lead to significant systemic improvement and real health care reform.

As of Monday, April 14, hospitals and other health care providers must be in compliance with the new HIPAA Privacy Rule. The Privacy Rule requires hospitals to make numerous changes to their practices in order to protect the health care privacy of their patients. In light of the new regulation, hospitals should no longer rely on their copies of the WHA Media Guide for the release of information to the media. Included in today’s packet is a new guide outlining the release of patient information to the media and the public, taking into consideration both HIPAA and state law. The new guide also is available on the WHA Web site in the News Center and in the Legal and Regulatory section.

The guide is designed to help hospital employees who are responsible for the release of patient information to the media to understand what information can and cannot be released without patient authorization.

Additional resources on HIPAA and the release of patient information to the public are available on the Wisconsin Healthcare Public Relations and Marketing Society (WHPRMS) Web site at whprms.org.

The Wisconsin Hospital Association Board of Directors, meeting in Madison April 17, approved a proposal that would change the way providers are paid by the Medicare program. The value purchasing initiative would reward hospitals and physicians in states where providers are efficient and provide high quality based on already accepted evidence-based measurements. States where providers fail to meet quality/cost targets would not receive incentive payments, but will be motivated to move into the incentive status to capture the bonus payments. States where hospitals and physicians have the highest cumulative combined score will receive a 5% “add-on” as an incentive to retain outstanding performance.

In describing the program, which will be taken to members of the Wisconsin Congressional Delegation for support, Steve Brenton said the value-purchasing concept would significantly “reform” fee-for-service Medicare by encouraging efficiency and quality enhancing behaviors.

During his President’s Report, Brenton welcomed the new representative to the WHA Board from the Wisconsin Medical Society, George Lange, MD, board certified geriatrician and internist from Milwaukee, who replaces Raymond Zastrow, MD. Brenton thanked Zastrow for his contributions to the board.

Eric Borgerding, WHA senior vice president, introduced WHA’s new vice president of workforce development, Judy Warmuth.

WHA Chair Jerry Worrick and Brenton, along with several other Wisconsin hospital CEOs and Wisconsin Technical College presidents, participated in a trip to Washington DC to meet with the Wisconsin Congressional Delegation. Brenton and Worrick said they hope that the joint efforts lead to the technical school system receiving additional federal funds that can be used to expand health occupation training programs.

George Quinn, WHA senior vice president, presented audited financial statements from both the Association and Financial Solutions. He said assets increased at both organizations over the previous year, expenses decreased, and revenue was up. Quinn indicated that these results showed a dramatic turnaround in WHA operations.

In other reports:

1. The WHA Membership survey is complete, with 73% of the members participating, topping the national participation rate of 62%. The results of the survey will form the basis for discussion at the WHA Board Retreat in July.

2. Borgerding reported that WHA is having success in advancing hospital related budget issues of concern to members. He said even without activating the grassroots network, legislators are working closely with WHA to restore funding to the Medicaid Graduate Medical Education Program and the Rural Supplement. He also said there is growing support for the WHA proposal to privatize the collection and reporting of hospital data. (See related story on page 2.)

3. Ann Lucas, vice president external relations and member advocacy, reported that the WHA Advocacy Committee set a goal for Healthy Wisconsin of $125,000 for 2003. The statewide campaign will be launched May 15. Hospital members will receive information packets on the campaign within the next month.

4. Charles Shabino, WHA chair-elect, congratulated WHA staff on recruiting the “remarkable group of people who agreed to be on the WHA Quality Initiative Steering Committee.” He noted that all WHA members who served on the initial quality task force have been asked to be “early supporters” by signing up to participate in the WHA quality reporting effort.

5. Reporting for the Council on Rural Health, Chair Bobbe Teigen said plans are nearly finalized for the Rural Health Conference and that the Council also took action on an issue relating to the lengthy delay in DHFS facility plan review and approval.

6. Quinn reported that the Council on Finance and Payment is creating a workgroup on payer issues. He said the group is also developing ideas for several health care data publications for 2003.

7. Jerry Worrick was appointed to the Coalition to Protect America’s Medicare. He said the group is regrouping to raise money for a national advertising campaign because “clouds are forming around budget issues.”

The Employee Pride Recognition program will recognize 57 health care workers at a special reception, dinner and ceremony May 8 at the Kalahari Resort in Wisconsin Dells. Here is the list of employees who will be honored that evening.

If you submitted an entry to the Pride program and your hospital is NOT listed, contact Mary Kay Grasmick, WHA, mgrasmick@wha or 608-274-1820 as soon as possible. All essays submitted to WHA will be published in a book, a copy of which will be given to the hospital and to the honoree. In addition, WHA will prepare a press release and take a photo of each winner that will be suitable for publication in their local newspaper and employee newsletter. The news release and photo will be sent to the CEO or public relations professional following the formal recognition ceremony on May 8.

The HIPAA regulations have left little untouched that is related to the release of patient information, including how hospitals will release names to members of the clergy. Mary Salm, director of pastoral care at St. Vincent Hospital, Green Bay, shared communications with WHA that she developed for use by the clergy and hospitals in the Green Bay area. All four Green Bay hospitals worked together to develop documents that would help local clergy understand the new privacy laws. Below are a few excerpts from the letter:

“The HIPAA regulations specifically state that clergy have access to the following information for patients in hospitals only when a patient gives his/her consent:

1. Patient’s Name

2. Patient’s Room Number

3. Patient’s Religious Affiliation

General condition when appropriate such as critical, stable, etc. without disclosing anything specific about the patient.” In the letter to Green Bay clergy, Salm explains that all four Green Bay hospitals will follow the same process when a patient is admitted:

1. Each patient will be asked if it is okay to notify his/her parish. If the patient gives consent, each Pastoral Care/Chaplaincy Department will notify the clergy of admissions Monday through Friday.

2. Clergy, employed staff, or elected church personnel may call the hospitals to see who is hospitalized from their parish. However, this does not extend to volunteer visitation teams/other people from your parish. Only clergy, employed staff, or elected church personnel may get this information when calling the hospital.

3. At each hospital, the list of your parish members must be given to you by an authorized employee or volunteer.

4. Clergy, employed staff, or elected church personnel who do hospital visitation have access to their patient list at all Green Bay hospitals. If the authorized hospital employee/volunteer does not know that you are clergy, employed staff, or elected church personnel, it will be necessary for clergy to wear an Identification Badge in order to obtain their list.

Salm also suggests that clergy might consider taking the following steps:

Place the following information in your church bulletin:

“Starting April 14, 2003, there is a new federal law that prohibits hospitals from informing churches of your presence unless YOU give permission for the hospital to do so. If you are going to be in the hospital, and would like us to visit, please let the hospital know each time you check into the hospital.”

Although a very important part of healing ministry, please consider the following:

a. Seek your parishioner’s permission before placing his/her name on a prayer chain.

b. Seek your parishioner’s permission before listing him/her in a church bulletin.

c. Seek your parishioner’s permission before announcing his/her name at a church service. Patients, at times, ask hospitals to notify their clergy of their admission, but at the same time, choose to restrict their name from the hospital directory at the Information Desk in order to maintain privacy. As a result of this request, the patient’s name will not appear in the directory or on the clergy list.

For more information about the Green Bay hospital communications with clergy, contact Mary Salm at St. Vincent Hospital, 920-433-0111.