The Coastal Post - May, 1997

Marin General Accreditation Report Finally Revealed; Showed Serious Deficiencies

By Georgia Sears

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has released the 1995 compliance with JCAHO standards showing Marin General Hospital (MGH) with an overall score of 72. This score placed MGH in the lowest 5% nationally. No hospital in the country received an overall score below 70.

To maintain its accreditation, JCAHO regulations have required MGH to resolve the numerous problem areas identified. According to the JCAHO report, MGH now has been accredited.

MGH Performance Report

The site visit for the current accreditation was conducted in January 1995. JCAHO returned in July 1995 to conduct a focused visit, which it rarely does and only for hospitals receiving the lowest scores. MGH had additional follow-ups in November, 1995 and February 1996, at which time the facility appears finally to have qualified for accredited status. JCAHO released the accreditation report in April, 1997. The accreditation cycle will begin again with a site visit in January 1998.

JCAHO evaluates hospitals on compliance with 500 standards of care in 45 areas. The following summarizes the 24 areas in which MGH scored less than a 1 (Substantial Compliance with the standard, the highest score possible). The number in parentheses indicates the percentage of hospitals nationally that received a score equal to or lower than MGH during the initial visit. MGH received recommendations for improvement in 16 of these areas.

Patient Rights and Organization Ethics:

Patient Rights (12%). Put another way, this means, for example, that JCAHO determined at the time of the initial survey visit that 88% of all hospitals nationally met standards for Patient Rights, better than MGH.

Assessment of Patients:

Initial Assessment Procedures (14%), Pathology and Clinical Lab Services (9%), Reassessment Procedures (7%), Processes for Patient Care Decisions (10%), Needs Assessment for Specific Patient Populations (17%).

Care of Patients:

Planning and Providing Care (17%), Anesthesia Care (15%), Medication Use (10%), Nutrition Care (10%), Operative Procedures (2%), Special Treatment Procedures (53%).


Patient and Family Education (3%).


Strategic Planning (11%), Departmental Leadership (9%).

Management of the Environment of Care:

Design of the Environment (34%), Implementation of Safety Plans (3%), Monitoring Safety Plans (6%).

Management of Human Resources:

Orienting, Training and Educating Staff (11%), Assessing Staff Competence (8%).

Management of Information:

Information Management Planning (2%); Availability of Patient-Specific Information (51%).

Medical Staff:

Organization, Bylaws, Rules, and Regulations (36%), Credentialling (37%). MGH was in substantial compliance with 21 of the 45 areas JCAHO evaluates. During initial site visits, scores of 1 were received by 90% to 98% of hospitals nationally in 14 of these areas, by 80% to 89% in 5 of these areas, and by 70 to 79% in the remaining 2 areas.

With the exception of rehabilitation care, areas in which JCAHO considered MGH to be in substantial compliance address management issues rather than direct patient care. For example, MGH was ranked as being in substantial compliance for having relevant policies to assess patients (95% of hospitals had the same score), while in all other patient assessment performance areas summarized above, they were among the lowest in the nation.

Updated Performance Scores

Hospitals must correct the deficiencies noted by JCAHO within a specified period of time to remain accredited. The main method hospitals use to upgrade their ratings is to prepare written documents describing changes in procedures in those areas JCAHO found to be wanting, and by asserting that the changes have been implemented.

JCAHO calculates an updated overall evaluation score after follow-up and other monitoring. Hospitals must have a score of at least 90 to be accredited. If a facility was accredited with recommendations, the maximum updated overall evaluation score that can be given is 94. With their updated score of 93, MGH claims to have corrected enough deficiencies identified by JCAHO to be accredited.

The JCAHO has minimal procedures for verifying hospital compliance between accreditation cycles. Further, according to JCAHO, "The updated score assumes (JCAHO emphasis) the hospital remains in continued compliance in those performance areas which were in compliance at the time of the original full survey."

The JCAHO Survey

JCAHO is the leading health care accrediting body in the world. It evaluates and accredits more than 15,000 US healthcare organizations, including about 5,000 hospitals. Almost every large healthcare organization in America voluntarily seeks JCAHO accreditation. Hospitals are required to be accredited by JCAHO in order to be reimbursed for treating Medicare patients. About 97% of all inpatient medical treatment is provided in JCAHO-accredited facilities.

The accreditation process involves site visits by JCAHO representatives every three years. Hospitals are evaluated as to how well they comply with 500 standards of care in 45 areas. Each standard has a possible score from 1 to 5. A score of 1 indicates the hospital substantially complied with the standard and is the highest possible score. A score of two indicates significant compliance, 3 partial compliance, 4 minimal compliance, and 5 noncompliance.

JCAHO calculates an overall score with a possible range from 0 to 100, with 100 representing the highest possible score. According to JCAHO, "The scoring does not indicate a hospital's ranking in relation to others. It indicates how well a hospital measures up against an absolute standard which reflects the level of performance that every hospital would wish to meet."

On the initial full survey, scores between 90 to 100 were achieved by 59% of hospitals nationally, and scores from 80 to 89 were achieved by 36%. Only 5% of hospitals, including MGH, scored in the 70 to 79 range. Nationally, no hospital received an overall score below 70. According to JCAHO, there may be no real difference between a hospital that scores 72 and a hospital that scores 78. However, "the greater the difference in scores, the more likely there is a difference in patient care."

Based on the initial survey, JCAHO initially awards seven levels of accreditation. The highest level is Accreditation with Commendation, awarded to about 12% of hospitals with scores of 94 or higher. This is followed by Accreditation, which is awarded to about 10% of hospitals based on the initial survey with scores of 90 or above.

Accreditation with Recommendations for Improvement is given when organizations demonstrate inadequate compliance with specific JCAHO standards during the initial visit. About 80% of hospitals are accredited initially with one or more recommendations for improvement. To be fully accredited, JCAHO regulations require hospitals to correct observed deficiencies.

The JCAHO report for every accredited health care facility in the country can be obtained free of charge by writing the organization at One Reiaissance Boulevard, Oakbrook Terrace, IL 60181. Their phone number is (630) 792-5000.

The Responsibilities of the Marin Health Care District

The Health Care District law charges our elected Directors to do everything a reasonable person might do to promote the health and welfare of communities served by the District. Marin General Hospital is owned by the Marin Health Care District and by extension all residents of the District. In building Marin General Hospital, the voters, the District, and the District's elected Board of Directors demonstrated a strong commitment to the health of the community, without regard for income or insurance status, consistent with the intent of District Health Care Law.

The 1985 lease of the District's hospital to MGH Corporation caused a controversy which has never abated. In 1995, MGH Corporation joined the Sutter Healthcare System, creating one of the largest healthcare entities in California. Despite strong public opposition, the merger was sanctioned by the affirmative votes of District Directors Suzanna Coxhead and Valerie Bergmann, forming a questionable quorum with Director Larry Bedard. The voters subsequently recalled Director Bedard and Director Paul Lofholm in the 1996 election for conflicts of interest.

Maintaining JCAHO accreditation is a key requirement of the lease between the Health Care District and MGH Corporation. Indeed, it is one of the only requirements in an unusually tenant-friendly lease which suggests that MGH Corporation is required to guarantee minimal standards of care for its patients. The JCAHO accreditation report has shown District residents that MGH Corporation has not managed the District's assets in a manner that promotes the health and welfare of those who reside in the communities served by the District.

Since the last JCAHO update in November, 1995, numerous patients and family members have spoken out at District Board meetings about the quality of care they or their loved ones have received at MGH. Issues expressed in that public forum parallel exactly the concerns reflected by JCAHO and suggest the Corporation has failed to correct despite its claims to the contrary.

Unlike all District Boards of Directors since 1985, the current Board has a majority of members who are not controlled by MGH Corporation. Voters created this board majority by recalling Directors Lofholm and Bedard. The District Board must take strong affirmative action to promote quality health care at Marin General Hospital. Indeed, the law requires that they do everything a reasonable person might do to protect the quality of health care services at our District-owned hospital. The voters demand that they meet their obligation.