INTRODUCTION

Scope of hospital services is a structural measure that reflects whether a hospital has the resources-facilities, staff, and equipment-to provide care for the medical conditions it professes to treat or to care for the medical conditions affecting potential patients. There are several potential sources of information on the scope of a hospital's services, including hospital advertising, media reports about the existence of special equipment or specially trained staff, consumer guidelines for selecting medical providers, and organizations that accredit or certify hospitals.1 Identifying whether a hospital complies with external standards such as those used for accreditation or certification by an external body, however, is likely to be the most valid means of ascertaining a hospital's scope of services. Accreditations and cer

'Hospital certification typically refers to approval by governmental bodies; accreditation usually indicates approval by a private organization, most often a professional organization of peers. The term "guidelines" refers to standards proposed by professional organizations and voluntarily applied by providers.

tifications for scope of hospital services are distinct from some of the other indicators evaluated in this report in at least one sense. As currently constructed, they measure only the capability of a hospital to deliver good quality care, not the quality of care actually delivered or its outcome.

This chapter briefly describes two national methods of overall accreditation/certification of hospitals, that of the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) and that of the Health Care Financing Administration (HCFA). It then describes external standards and guidelines for neonatal intensive care units, cancer care, and hospital-based emergency and trauma services. The next sections of the chapter analyze the reliability, validity, and feasibility of using external standards and guidelines related to the scope of hospital services as indicators of the potential of a hospital to deliver good quality care. The final section draws conclusions and discusses policy implications.

JCAHO Accreditation

The most well-known and widely applied hospital accreditation standards are those of JCAHO. Of the approximately 6,800 hospitals of all types in the United States, about 5,000 (70 percent) are surveyed by JCAHO. Submitting to JCAHO evaluation is voluntary, but not all hospitals are eligible for JCAHO surveys (325). One reason that JCAHO accreditation is important is that such ac

creditation, along with certain additional criteria, is a condition of participation in the Medicare and Medicaid programs (Section 1865 of the Social Security Act). Medicare and Medicaid pay for

'In addition to being accredited by JCAHO, hospitals must meet requirements for utilization review (Section 1861(e)(6) of the Social Security Act (42 CFR Subpart S, 405.1901(d)(1) and 482.30) ) and discharge planning (Public Law 99-190). In practice, the require(continued on next page)

about 38 percent of the hospital care provided in this country (715). JCAHO accreditation is also woven through the hospital licensure requirements of 41 States (323) and is a condition of participation for an unknown number of insurance companies (48).

JCAHO conducts a complete survey of each eligible hospital once every 3 years and assesses each hospital's compliance with over 2,000 standards. The purpose of the JCAHO hospital accreditation process is to evaluate each hospital's overall capability of providing medical care. Thus, particular attention is paid to functions affecting the entire hospital, such as the governing body, the medical staff, nursing services, infection control, and quality assurance, and the way these and other functions are integrated across the hospital. Throughout this chapter, and for purposes of evaluating JCAHO accreditation as a potential indicator of the quality of care, it is important to keep in mind that it is not JCAHO's purpose to separately accredit individual hospital departments such as those that provide emergency services or neonatal intensive care. Because JCAHO does survey and evaluate those services as part of its overall accreditation process, however, JCAHO standards for these separate departments are discussed in this chapter as having the potential to evaluate whether hospital scope of services is appropriate.

JCAHO standards are developed by panels of experts, sometimes with the aid of scientific literature, and are evaluated by interested hospitals and other experts before their adoption. JCAHO standards and required characteristics focus on

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ments for utilization review are met by the existence of utilization and quality control peer review organizations.

In general, to meet the Medicare and Medicaid conditions of participation, hospitals must meet "any requirement under section 1861(e) of the [Social Security] Act and implementing regulations which the Secretary [of Health and Human Services], after consulting with [the Joint Commission] and [the American Osteopathic Association], identifies as being higher or more precise than the requirements for accreditation (section 1865(a)(4) of the Act)" (42 CFR Subpart S, 405.1901(d)(3)). Psychiatric hospitals must meet "the additional special staffing requirements that are considered necessary for the provision of active treatment in psychiatric hospitals (section 1861(f) of the Act) and implementing regulations" (42 CFR Subpart S, 405.1901(d)(2)).

certain key functions across the hospital: quality assurance, privilege delineation, existence of policies and procedures, and infection control.

A hospital's failure to comply with key JCAHO standards sometimes results in "accreditation with contingencies." JCAHO gives each hospital a contingency score (which may be zero) that determines in part whether the hospital is accredited. The actual accreditation decision is made by JCAHO's Accreditation Committee, following a recommendation by JCAHO staff, using a set of weighting procedures and objective rules to ensure consistency across hospitals. If a hospital receives a contingency, it must satisfy JCAHO within a specified period of time that it is in compliance with the problem standards. Depending on the nature of the contingencies, hospitals may have to submit to a focused resurvey, usually within 6 to 9 months from the date they receive the report. From 1982, when the current JCAHO accreditation procedure was implemented, until 1987, the percentage of surveyed hospitals with JCAHO contingencies of any type increased from about 65 percent to 90 percent (387,388,524).

About 75 hospitals (5 percent of JCAHO-surveyed hospitals) each year receive enough contingencies of a serious nature that a formal nonaccreditation decision from JCAHO looks probable; the hospitals are informed of this possibility by JCAHO staff before the staff recommendation goes to the JCAHO Accreditation Committee. Among the 5 percent, 3 to 4 percent of the JCAHO-surveyed hospitals correct their deficiencies to the satisfaction of JCAHO and avoid a formal nonaccreditation decision. Each year, about 1 to 2 percent of all JCAHO hospitals surveyed, or 15 to 30 hospitals, are formally judged by JCAHO to be nonaccredited. Some of the 1 to 2 percent of hospitals that are formally nonaccredited work on correcting deficiencies while they are appealing the JCAHO decision and then request a resurvey; others drop their quest for JCAHO accreditation, sometimes permanently. Some hospitals do, however, request HCFA inspection following nonaccreditation by JCAHO.

HCFA Certification

Hospitals that desire Medicare and Medicaid reimbursement but choose not to be surveyed by

JCAHO or cannot meet JCAHO's eligibility or accreditation criteria may opt to be certified by HCFA. About 1,400 hospitals per year routinely choose to be surveyed by HCFA. Because tor every day that a hospital is not certified by HCFA, it loses Medicare and Medicaid reimbursement, not being accredited by JCAHO or certified by HCFA is very costly for a hospital.3

Most HCFA-certified hospitals are small, rural community hospitals (438). Texas has the largest number of HCFA-certified hospitals (157 hospitals), followed by Kansas (83), Minnesota (63), Georgia (59), Nebraska (56), Mississippi (55), California (53), Oklahoma (51), Louisiana (50), Florida (48), and Iowa (46) (438). Those 11 States have half the non-JCAHO-accredited, HCFA-certified hospitals in the United States and its possessions.

'Accreditation by the American Osteopathic Association enjoys the same status with respect to Medicare and Medicaid payment as JCAHO accreditation.

HCFA uses survey methods that are somewhat different from JCAHO's. HCFA's hospital surveys are conducted annually, whereas JCAHO's are conducted every 3 years. HCFA/State surveyors have the force of law and the threat of noncertification to ensure compliance, while the JCAHO organization does not. HCFA surveyors are State personnel, and although the teams receive some training from HCFA, their composition is determined by the States (399). JCAHO surveyors are hired and trained by JCAHO. JCAHO provides 2 weeks of didactic training, a 3- to 4-week preceptorship, and an annual 3-day conference for surveyors.

JCAHO has stricter criteria for surveyors than does HCFA. JCAHO requires each survey team to include one physician, one nurse, and one hospital administrator. In addition, JCAHO requires the nurse and hospital administrator surveyors to have had administrative experience in a hospital. The qualifications of HCFA/State surveyors are more diverse, and many of these surveyors are not as highly trained as JCAHO surveyors. Of

the 2,786 surveyors (of a total of about 3,400) who responded to a HCFA questionnaire, for example, only 10 (less than one-half of 1 percent) were medical doctors (646). Finally, HCFA has substantially fewer standards than does JCAHO, and HCFA's conditions of participation are much less detailed than JCAHO's standards. Generally, 1 percent or less of the hospitals surveyed by HCFA each year are terminated from the program involuntarily (249).*

Overall Hospital Accreditation/Certification and Scope of Services

Neither JCAHO accreditation nor HCFA certification is designed to assess whether particular hospital departments are capable of providing specific services. Nevertheless, JCAHO accreditation or HCFA certification does ensure that a certain scope of services exists in a hospital. In order to qualify for the survey on which JCAHO accreditation is based, a hospital must meet certain eligibility criteria. The hospital must maintain facilities, beds, and services that are available over a continuous 24-hour period, 7 days a week. Unless a hospital is a psychiatric or substance abuse facility, it must also provide diagnostic radiology, dietetic, emergency, rehabilitation, and respiratory care services, among others. In addition, it must provide at least one of the following acutecare clinical services: medical, obstetric-gynecological, pediatric, surgical, psychiatric, or alcoholor drug-abuse services. If the hospital provides obstetric-gynecological or surgical services, it must also provide anesthesia services.

A hospital is also required to supply far fewer hospital services for HCFA certification than for JCAHO accreditation. Services required by JCAHO that are not required by HCFA include emergency services, nuclear medicine services, some type of special care services, professional library services, and social work services. For both JCAHO accreditation and HCFA certification, surgical services are optional. Although both

*In fiscal year 1987, 9 hospitals were terminated involuntarily, in fiscal year 1986, 20 hospitals were terminated involuntarily, and in fiscal year 1985, 8 hospitals were terminated involuntarily for not meeting HCFA's conditions of participation.

"The reason surgical services are optional for JCAHO is to make it possible for psychiatric hospitals to be accredited. In most other

HCFA and JCAHO rate a number of specific departments or services (e.g., diagnostic radiologic services, outpatient services, surgical and anesthesia services), for the most part, neither rates condition-specific services such as heart disease or cancer services.

Standards and Guidelines for Specific Services

Neonatal Intensive Care Services

In 1976, in the face of a proliferation of neonatal intensive care units, the Committee on Perinatal Health' proposed guidelines for the regionalization of U.S. maternal and perinatal health services (142). Underlying the concept of regionalization of these services is the idea that high-risk mothers and infants will be screened and referred or transported to the appropriate level of care. The Committee on Perinatal Health proposed three levels of hospital care for perinatal services. Hospitals that served as regional centers and provided the most sophisticated neonatal intensive care were to be designated Level III facilities. Hospitals that provided neonatal intensive care but lacked some services provided in Level III facilities were to be called Level II facilities; and hospitals that provided normal newborn care with no special units for the care of seriously ill infants were to be called Level I facilities.

In 1983, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists more fully explicated the responsibilities and requirements of the three levels of hospitals in the regional system of maternal and perinatal services. A document issued by these organizations specified guidelines for minimum number of beds, square footage per bed, personnel, hospital structure, equipment, ancillary support, and educational services for parents (15).

A recent analysis by OTA concluded that neonatal intensive care has been in large part responsible for the remarkable decline in U.S. neonatal

respects, psychiatric hospitals are held to the same standards as all other accredited hospitals.

"The Committee on Perinatal Health was a joint effort by the American Medical Association, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the American Academy of Pediatrics.