Named after the German bacteriologist who isolated the microorganisms responsible for diseases like tuberculosis and cholera, the Robert Koch Hospital  for Contagious Disease is a lost hospital in a lost city.

Located in the former city of Koch (what is now Interstate 255 east of Route 231), the hospital was officially opened in 1875, with its land being purchased by the city of St. Louis in 1854. The location was strategically isolated so the hospital could treat patients with leprosy, yellow fever, typhoid, cholera, smallpox and diphtheria. Patients that did not survive were buried on the property’s cemetery.

The hospital eventually focused on tuberculosis patients, a disease which killed 10% of the residents in St. Louis in the early 20th Century. By 1939, the hospital property consisted of 19 buildings on 105 acres of farmland. There was a post office, a railroad stop, housing, and recreational facilities. The hospital also published its own newsletter from 1925-1947.  Financing through bonds helped the hospital grow to almost 500 beds, and that still could not keep up with the needs of the community.

In the 1950s, as public health started to win the battle against tuberculosis, the city tried to sell the property. In 1961 the City tried to refocus the hospital on the indigent elderly. Eventually, the hospital closed in November 1983.

 

Aliquippa Community Hospital, in the City of Aliquippa near Pittsburgh, Pennsylvania, opened May 12, 1957. Entrenched in the city’s foundation for over 50 years, the three story, yellow brick building went through a number of owners and names until closing as Commonwealth Medical Center in December 2008. The facility had just under 100 beds.

Originally established with contributions from area steelworkers, in the late 1990’s the hospital’s name was UPMC Beaver Valley. Commonwealth Medical Center purchased the facility in 2007 for $23 million in an attempt to restructure a facility that had lost more than $12 million since 2004.

In late 2008, Pennsylvania’s Department of Health banned the hospital from admitting new patients when it discovered that the community hospital not only was in arrears on its bills, but it was lacking critical supplies to ensure patient safety.

The Department tried to work with the hospital administration to lift the ban, yet noted its commitment to patient safety.  At the time a State representative stated: “Our obligation is to ensure that the hospital is adhering to all the applicable state regulations and can operate safely. The hospital’s financial situation isn’t our primary concern — the safety of its patients is.”  According to a local resident, Walter Dorer: “They’ve been at this same issue for years now. They just can’t get the volume base to make it run.”

Even though the hospital had reduced the number of employees to 189 from 305, it was not enough. In December 2008, Commonwealth Medical Center filed for bankruptcy protection (its predecessor, Aliquippa Community Hospital, did the same in 2002).  One week later, the hospital closed, finally ending what had once symbolized pride in the community.

John O’Donnell, chief executive officer and interim president of the hospital stated at the time: “We want to express our heartfelt thanks to all steelworkers and the families of the steelworkers who unselfishly donated money to the hospital, the dedicated employees, physicians, volunteers and community members we have been privileged to serve these past 51 years.”

Although the hospital had a history of regulatory and financial problems, the residents had ample time to prepare for the closing the statement by Aliquippa Mayor Anthony Battalini best summarized the local sentiment: “It’s devastating to the city.”

Weeks after the hospital’s December 13 closing, hospital employees were in court contending that Commonwealth Medical Center failed to provide their final paychecks — in an amount of $482,900. When the hospital closed, it stated there was no longer any financing to continue operations, so it abruptly eliminated over 200 jobs just before the winter holidays.

A local resident purchased the hospital property in 2009 for $250,000.  Unable to salvage the hospital, the owner had medical equipment, furnishings and other materials removed from the location for reuse elsewhere.

Like many residents in the community, the owner’s connection included relatives (his father, uncles and cousins) who worked for J&L Steel and formed the group of steelworkers that contributed toward the creation of the hospital.

After 10 truckloads, rescued from the hospital were stretchers, waiting room furniture, medical supply cabinets, surgical supplies, light fixtures, ceiling tiles and office furnishings. The community had given up hope that the hospital would eventually reopen, but it would never forget their institution.

“There’s still the emotional factor there. Children were born there, people were living and dying there every day,” said Thomas Stoner, Aliquippa’s city administrator. “It was just like J&L in that it was part of your life growing up. But there comes a time when you have to move forward.”

 

A recent study at the University of California, San Francisco reported that one out of every four hospital emergency departments have shut down in the past 20 years, even as ED visits have increased by 35%. The strain of regulatory pressures on today’s medical facilities is causing significant gaps, if not chasms, in the infrastructure of America’s health care.

Indeed, in the past few years the media outlets around the nation have reported on myriad stories about lost hospitals. Less frequent are the stories about new hospitals, although they do exist from time to time. The tales of relocated hospitals, however, provide an interesting perspective on health care today.

There is nothing easy about moving a hospital, especially if the transition includes the continuity of care without disruption, like the case of St. Anthony Hospital in Denver, Colorado.  Starting June 17, 2011, the new hospital just outside of Denver in the City of Lakewood will provide the highest level of care in a state-of-the-art environment consisting of eight floors and 560,000 square feet. With a price tag of about $435 million, the new St. Anthony Hospital will include:

• A Level I Trauma Center
• 222 private inpatient rooms (including 76 Intensive Care, 128 Medical/Surgical, and 18 Inpatient Rehabilitation beds)

• 36 Emergency Department rooms, including four trauma rooms
• 14 surgical suites
• 14,000 electrical outlets
• 2,400 doors
• 246 clocks, all synchronized by GPS to one-tenth of a second
• A separate orthopedic specialty hospital

The hospital’s website provided a statement about the reasons for the move:

“The current hospital is more than 100 years old, so we are faced with an aging facility that was not designed for modern technology. It wasn’t going to be efficient or cost-effective to refurbish the existing building. And since we are land locked, there is no room to expand to add much needed medical office buildings for our physicians. [¶] The leadership team looked at several sites for the relocation of the hospital. The Lakewood site was selected because it remains part of our existing service area, allowing us to continue providing care to people in west Denver and beyond. St. Anthony Hospital’s move to Lakewood will allow us the space we need to provide excellent medical services to patients from throughout the region. The new facility will be more spacious and allows us to accommodate emerging technologies of the future. And with two medical office buildings that will be walkway-attached, it will be much more convenient for our physician partners and patients to access the hospital.”

The 119 year old hospital has spent the past 30 months planning the six mile move. Timing and precision are critical, especially since state law prohibits the hospital from operating two separate emergency departments at the same time. Indeed, as the old hospital closes as of 12:00 am on June 16, 2011, the new facility will open at 12:01 am the following day (or one minute later).

Aside from ensuring that emergency services remain uninterrupted, the hospital will also move about 155 patients. Starting at 7:00 am, patients will depart the old hospital three ambulances at a time, heading for three separate entrances, carrying one ICU and two Med/Surg patients each. This will repeat ten minutes later. The ambulances will be staffed with a registered nurse and at least three other staff members. As an added measure of protection, medical helicopters will be on stand-by. Most of the hospital’s 2,000 physicians, employees and volunteers will be working that day.

According to hospital CEO Dr. Ray Mencini: “Our No. 1 priority during the move is patient safety and patient care, and after nearly 2 1/2 years of careful planning and preparation, we have thought through many scenarios and have developed contingency plans to account for any unforeseen circumstances.”

As for the economic impact of the move, the hospital provides a statement for that as well:

“In studies by the Lewin Group on behalf of the American Hospital Association, it is estimated that, for every dollar a Colorado hospital spends, it supports an additional $1.40 in business activity in the area. In our most recent fiscal year, St. Anthony spent approximately $204 million on payroll, medical supplies and other expenses. That would generate an additional $336 million in economic activity in the area. The same study shows that in Colorado, each hospital job creates an additional 1.1 jobs due to indirect business and household spending.”

 

A Recent study published in the July issue of Infection Control and Hospital Epidemiology teaches children about the importance of hand-washing hygiene, while waiting in a hospital emergency department. By using a gel that glows, children can see how effective their hand washing technique actually is, and be entertained while waiting.

According to Dr. Anna Fishbein, a physician and researcher at Northwestern University’s Children’s Memorial Hospital in Chicago (and the study’s lead author): “Waiting for the doctor is usually a tiresome and unproductive experience, but we were able to turn the waiting room into an interactive education center to help kids improve their hand hygiene.”

The study relied upon 60 pediatric patients waiting for the doctor. By using Glo Germ Gel and a black light, children could see areas where direct and germs remained (the gel creates a yellow glow in these areas). After seeing the areas with a yellow glow, the children washed their hands with ordinary soap and water. After a second application of the gel under a black light, the hands of the children were cleaner, and under a four-point cleanliness scale, they went from “very dirty” to “very clean.”

“We found that using the gel alone to illustrate the areas of hands that may not be getting clean, even without verbal education, improves children’s hand hygiene,” said Dr. Mary Groll, also of Children’s Memorial and the study’s principal investigator. “Considering the importance of hand hygiene in disease prevention, the implications of this study will have lasting impact in this community’s effort to decrease the spread of illness.”

The Centers for Medicare & Medicaid Services (CMS) last week proposed regulations designed to help patients choose better-quality health care at more affordable prices. These new rules will permit the public disclosure of certain Medicare data so that it can be compiled into reports on physicians, hospitals and other health care providers. These reports will attempt to identify how good providers really are, and how much they charge.

Part of the Patient Protection and Affordable Care Act, these new regulations will promote transparency, according to CMS Administrator Donald M. Berwick, M.D. He explained: ”Making more Medicare data available can make it easier for employers and consumers to make smart decisions about their health care. Performance reports that include Medicare data will result in higher quality and more cost effective care. And making our health care system more transparent promotes competition and drives costs down.”

These new regulations will hopefully help patients and employers understand more about health care in their community as it provides the following:

• CMS would provide standardized extracts of Medicare claims data from Parts A, B, and D to entities that qualify to receive this data.  In theory, this data can only be used to evaluate performance so it can be produced in a report for the public.
• The data provided to the qualified entity will cover one or more specified geographic area(s).
• The qualified entity would pay a fee that covers the federal government’s cost connected with the enforcement of these regulations.
• To prevent mistakes, the regulations require qualified entities to share the reports confidentially with providers prior to public release.
• Publicly released reports will never contain individual patient information, but rather reports in the aggregate.

These proposed regulations are part of the Hospital Value-Based Purchasing initiative designed to reward hospitals for better quality of care and greater efficiencies with respect to Medicare. The proposed rules will also permit Medicare to pay new Accountable Care Organizations (ACOs) for improvement.

The full text of the proposed regulations can be viewed HERE.

On November 6, 1766, Sir Francis Fauquier, Governor General of His Majesty’s Colony of Virginia, gave his annual speech to the House of Burgesses. These words of the Governor General ultimately resulted in the first state psychiatric hospital:

“It is expected I should also recommend to your consideration and humanity, a poor, unhappy set of people, who are deprived o their senses and wander about the country terrifying the rest of their fellow creatures. A legal confinement and proper provision ought to be appointed for these miserable objects.”

On October 12, 1773, “The Public Hospital for Persons of Insane and Disordered Mind,” opened its doors for “idiots, lunatics and persons of unsound minds.” Later relocated to Williamsburg and renamed Eastern State Hospital, this is the oldest hospital in the United States that has exclusively treated the mentally ill. The Hospital’s first patient arrived on April 28, 1774. The patient was charged 15 pounds a year.

The institution changed names over the years, known as the “Public Hospital,” the “Lunatick Hospital,” and even the “Mad House.” The legislature officially changed the name on March 6, 1841 to Eastern Lunatic Asylum, and on February 22, 1894 to Eastern State Hospital.

On June 7, 1885, the original facility burned to the ground. Eventually rebuilt, by 1935 Eastern State Hospital has a census of 2,000 patients. Without any further space to expand, between 1937 and 1968, all patients were relocated to a new hospital inWilliamsburg. In 1985, the original hospital was rebuilt on its excavated foundations, opening to the public as a museum.

Like most mental institutions in the United States, after World War II the treatment of patients evolved as psychiatric drugs for the treatment of certain mental conditions became more available and effective. The concept of creating community-based care became known as “deinstitutionalization” in the 1960s.

In January 2011, Eastern State Hospital was criticized for what was described as “barring” its doors and turning away new patients. Since 2004, the Hospital reduced its capacity from 523 to 300 beds, with the removal of 85 beds in 2009 alone. In a report by Inspector General Douglas Bevelacqua, due to the lack of residential programs, many patients were essentially “stuck” in the hospital.  “Admissions and discharges represent the front door and the back door to a state facility, and, if either the entrance or exit is blocked, it creates pressures for the entire public sector safety net system,” Bevelacqua explained.

Although Eastern State Hospital has taken great efforts to improve the care for its patients, without a proper infrastructure to transition patients from the hospital into the community, there will always be a struggle to treat the mentally ill.

 

On November 6, 1766, Sir Francis Fauquier, Governor General of His Majesty’s Colony of Virginia, gave his annual speech to the House of Burgesses. These words of the Governor General ultimately resulted in the first state psychiatric hospital:

“It is expected I should also recommend to your consideration and humanity, a poor, unhappy set of people, who are deprived o their senses and wander about the country terrifying the rest of their fellow creatures. A legal confinement and proper provision ought to be appointed for these miserable objects.”

On October 12, 1773, “The Public Hospital for Persons of Insane and Disordered Mind,” opened its doors for “idiots, lunatics and persons of unsound minds.” Later relocated to Williamsburg and renamed Eastern State Hospital, this is the oldest hospital in the United States that has exclusively treated the mentally ill. The Hospital’s first patient arrived on April 28, 1774. The patient was charged 15 pounds a year.

The institution changed names over the years, known as the “Public Hospital,” the “Lunatick Hospital,” and even the “Mad House.” The legislature officially changed the name on March 6, 1841 to Eastern Lunatic Asylum, and on February 22, 1894 to Eastern State Hospital.

On June 7, 1885, the original facility burned to the ground. Eventually rebuilt, by 1935 Eastern State Hospital has a census of 2,000 patients. Without any further space to expand, between 1937 and 1968, all patients were relocated to a new hospital in Williamsburg. In 1985, the original hospital was rebuilt on its excavated foundations, opening to the public as a museum.

Like most mental institutions in the United States, after World War II the treatment of patients evolved as psychiatric drugs for the treatment of certain mental conditions became more available and effective. The concept of creating community-based care became known as “deinstitutionalization” in the 1960s.

In January 2011, Eastern State Hospital was criticized for what was described as “barring” its doors and turning away new patients. Since 2004, the Hospital reduced its capacity from 523 to 300 beds, with the removal of 85 beds in 2009 alone. In a report by Inspector General Douglas Bevelacqua, due to the lack of residential programs, many patients were essentially “stuck” in the hospital.  “Admissions and discharges represent the front door and the back door to a state facility, and, if either the entrance or exit is blocked, it creates pressures for the entire public sector safety net system,” Bevelacqua explained.

Although Eastern State Hospital has taken great efforts to improve the care for its patients, without a proper infrastructure to transition patients from the hospital into the community, there will always be a struggle to treat the mentally ill.

As part of its continued effort to improve patient safety and contain health care expenditures, in August 2007 the Centers for Medicare & Medicaid Services (CMS) announced it would no longer reimburse providers for “conditions that could reasonably have been prevented.” In shifting this burden to hospitals and physicians, CMS focused on a list of specific complications called “never events,” meaning they should never occur in the hospital.

Since then, CMS’s program has been adopted by private insurance companies as well, hoping to save money inside the Federal Government’s shadow. This week, CMS announced that the same rules would apply for Medicaid patients, and that hospitals and other health care providers will no longer be reimbursed for illnesses, injuries, or readmissions that should have been prevented, or in this particular instance under the Patient Protection and Affordable Care Act (PPACA), are ”reasonably preventable.”

The Medicaid list is similar to that of Medicare, including:

• transfusing the wrong blood type
• certain falls that result in injury
• fractures, or head injuries
• burns and electric shocks
• catheter-associated urinary tract infections
• surgical site infections after certain procedures, such as bariatric surgery or coronary artery bypass

Medicaid will also follow Medicare’s lead not pay for “never events,” such as performing the wrong procedure, conducting surgery on the wrong part of the patient, or even conducting the correct procedure, but on the wrong patient. CMS Administrator Donald Berwick, MD, stated in a press release. ”These steps will encourage health professionals and hospitals to reduce preventable infections and eliminate serious medical errors. As we reduce the frequency of these conditions, we will improve care for patients and bring down costs at the same time.”

The final rule is effective July 1, 2011, but CMS will permit states the option to implement between July 1, 2011 and July 1, 2012.

To see the regulations, click HERE.

 

The Department of Health and Human Services (HHS) issued today its intended regulations to modify the Privacy Rules under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The new standards relate to how these Privacy Rules account for disclosures of protected health information (PHI). HHS would like to require covered entities and business associates to account for disclosures of protected health information as it relates to treatment, payment, or even health care operations in general, provided such disclosures occur in connection with the patient’s electronic record.

An extension of the Health Information Technology for Economic and Clinical Health Act (HITECH) and HIPAA, these proposed regulations would entitle individuals to an access report identifying exactly who accessed the electronic protected health information in the particular context.   Present requirements under the Privacy Rule (45 C.F.R. § 164.528) require covered entities to make available (at an individual’s request) certain disclosures of health information.  A disclosure is defined at Section 160.103 as “the release, transfer, provision of access to, or divulging in any other manner of information outside the entity holding the information.”

For each disclosure, the accounting must include:

• The date of the disclosure
• The name (and address, if known) of the entity or person who received the protected health information
• A brief description of the information disclosed
• A brief statement of the purpose of the disclosure

Existing law, however, provides for a number of exceptions from the disclosure requirements, including:

• To carry out treatment, payment and health care operations
• Pursuant to an authorization
• For the facility’s directory or to persons involved in the individual’s care

Section 13405(c) of the Health Information Technology for Economic and Clinical Health (HITECH) Act, Title XIII of Division A and Title IV of Division B of the American Recovery and Reinvestment Act of 2009 (ARRA) provides that the exemption of the Privacy Rule for disclosures to carry out treatment, payment, and health care operations no longer applies to disclosures “through an electronic health record.” Section 13400 of the HITECH Act defines an electronic health record (“EHR”) as “an electronic record of health-related information on an individual that is created, gathered, managed, and consulted by authorized health care clinicians and staff.”

If enacted without further modifications, an individual will have a right to receive an accounting of such disclosures made during the three years prior to the request.  HHS has proposed that these new requirements take effect January 1, 2013 (for EHR systems acquired after January 1, 2009) and January 1, 2014 (for EHR systems acquired before January 1, 2009).

Additional information about these changes in patient privacy rights can be found at the Federal Register Website.

In a country of more than 311,000,000, the burdens placed on the health care system are both enormous and complex as Americans expect a fundamental right to first rate health care without much regard for its cost. The Federal Government, however, is mindful of this expense, and since 1964 the United States Department of Health and Human Services (HHS) has published an annual series of data presenting total health expenditures in the United States.

Health Care Spending

Identified as National Health Expenditure Accounts (NHEA), these estimates attempt to measure the total annual dollar amount of our nation’s health care consumption. The information also tries to identify the amount invested in the future of health care (such as medical structures, equipment, research, etc.). Some of the more significant expense categories monitored by the NHEA include:

• Hospital Care: This includes all services provided by hospitals to patients (room and board, ancillary charges, resident physicians, pharmacy, etc.), measured by total net revenue.
• Physician and Clinical Services: This includes services provided by Doctors of Medicine (M.D.) and Doctors of Osteopathy (D.O.), outpatient care, and some laboratory expenses. It also includes the professional component of hospital charges if these charges are usually billed separately.
• Other Professional Services: This includes professional services by private nurses, chiropractors, podiatrists, optometrists, and physical/occupational/speech therapists.
• Dental Services: This includes Doctors of Dental Medicine (D.M.D.), Doctors of Dental Surgery (D.D.S.), or Doctors of Dental Science (D.D.Sc.).
• Other Health, Residential, and Personal Care: This includes care provided in residential care facilities, ambulance services, and workplace health care services, among others.
• Home Health Care: This includes health care provided in freestanding home health agencies (HHAs).
• Nursing Care Facilities: This includes freestanding nursing home facilities that provide both nursing and rehabilitative services.
• Prescription Drugs: This includes the retail side of medication.
• Durable Medical Equipment: This includes in part the retail side of certain items such as surgical and orthopedic products, wheelchairs, eyeglasses, and hearing aids.
• Other Non-Durable Medical Products: This includes the retail side of non-prescription drugs and medical supplies.
• Population: The NHEA uses a modification of U.S. Census figures.
• Out-of-Pocket Payments: This includes direct spending by consumers for all health care goods and services, including any amounts not covered by insurance (such as co-payments and deductibles, but not insurance premiums).
• Health Insurance: This includes private health insurance, Medicare, Medicaid, and other such public payers.
• Private Health Insurance: This includes premiums paid to insurance companies, as well as the costs for advertising, sales commissions, rate credits, taxes, profits, etc.

Growth in U.S. National Health Expenditures (NHE)  over the next ten years is expected to be slightly higher due to the Patient Protection and Affordable Care Act (PPACA), as well as other issues. Average annual growth in NHE for 2009 through 2019 is expected to be 6.3 percent (0.2 percentage point faster than pre-reform estimates).  NHE as a portion of the nation’s Gross Domestic Product (GDP) is expected to be 19.6 percent by 2019 (or 0.3 percentage point higher than projected before reform). Incidentally, PPACA is expected to result in a lower average annual Medicare spending growth rate for 2012 through 2019 (6.2 percent). This is 1.3 percentage points lower than pre-reform estimates.

For comparison purposes, the following information was compiled for 2009:

• NHE grew 4.0% to $2.5 trillion, or $8,086 per person, and accounted for 17.6% of GDP.
• Medicare spending grew 7.9% to $502.3 billion, or 20 percent of total NHE.
• Medicaid spending grew 9.0% to $373.9 billion, or 15 percent of total NHE.
• Private health insurance spending grew 1.3% to $801.2 billion, or 32 percent of total NHE.
• Out of pocket spending grew 0.4% to $299.3 billion, or 12 percent of total NHE.
• Hospital expenditures grew 5.1% in 2009.
• Physician and clinical services expenditures grew 4.0%.
• Prescription drug spending increased 5.3%.

Health Care Oversight

To understand the scope of issues health care must face on any given day, it is important to become familiar with the building blocks that make up today’s health care hierarchy.Who is responsible for oversight?  At the top of the health care pyramid is the nation’s President, Barack Obama.  Underneath the President lies a complex organization of individuals and agencies at both the federal and state level, who make up the gargantuan structure commonly referred to as health care.  The President directly oversees the Office of the Secretary, HHS.  HHS has multiple operating divisions, including:

• Administration for Children and Families (ACF) (and the accompanying Administration for Children, Youth and Families (ACYF))
• Administration on Aging (AoA)
• Agency for Healthcare Research and Quality (AHRQ)
• Agency for Toxic Substances and Disease Registry (ATSDR)
• Centers for Disease Control and Prevention (CDC)
• Centers for Medicare & Medicaid Services (CMS)
• Food and Drug Administration (FDA)
• Health Resources and Services Administration (HRSA)
• Indian Health Service (IHS)
• National Institutes of Health (NIH) and the National Cancer Institute (NCI)
  
• Substance Abuse and Mental Health Services Administration (SAMHSA)

HHS staff divisions include:

• Assistant Secretary for Administration (ASA)
• Assistant Secretary for Financial Resources (ASFR)
• Assistant Secretary for Legislation (ASL)
• Assistant Secretary for Public Affairs (ASPA)
• Assistant Secretary for Planning and Evaluation (ASPE)
• Assistant Secretary for Preparedness and Response (ASPR)
• Center for Faith Based and Neighborhood Partnerships (CFBNP)
• Departmental Appeals Board (DAB)
• Office of Intergovernmental Affairs (IGA)
• Office of Civil Rights (OCR)
• Office on Disability (OD)
• Office of the General Counsel (OGC)
• Office of Global Health Affairs (OGHA)
• Office of the Inspector General (OIG)
• Office of Medicare Hearing and Appeals (OMHA)
• Office of National Coordinator of Health Information Technology (ONC)
• Office of the Assistant Secretary for Health (ASH)
• The Surgeon General

The Food and Drug Administration is another important agency under HHS. Protecting and promoting public health, the FDA consists of nine centers/offices, including:

• Center for Biologics Evaluation and Research (CBER) (with eight additional offices contained therein);
• Center for Devices and Radiological Health (CDRH) (with eight additional offices contained therein);
• Center for Drug Evaluation and Research (CDER) (with over twenty offices contained therein, including six offices under the Office of New Drugs);
• Center for Food Safety and Applied Nutrition (CFSAN) (with three additional main offices and nine sub-offices contained therein);
• Center for Tobacco Products Organization (CFTBO) (with seven additional offices contained therein)
• Center for Veterinary Medicine (CVM) (with six additional offices contained therein);
• National Center for Toxicological Research (NCTR) (with five additional offices contained therein);
• Office of the Commissioner (OC) (with over forty offices and sub-offices contained therein); and
• Office of Regulatory Affairs (ORA) (with nine additional offices contained therein).

Accreditation and Certification

Due to the sensitive nature of their services, hospitals must exist in a heavily regulated industry, and the Federal government is only part of the overall health care regulatory equation.  Accreditation, certification and periodic review come from a variety of both public and private sources, though the goal is generally consistent:  develop uniform standards to ensure that hospitals in the United States all operate at an acceptable safety level and deliver quality patient care in an appropriate and effective manner.

Any one healthcare institution can be subject to accreditation review at any time from entities such as the Joint Commission, Healthcare Facilities Accreditation Program (HFAP), Community Health Accreditation Program, Accreditation Commission for Health Care, The Compliance Team, or Healthcare Quality Association on Accreditation (HQAA). In October 2008, CMS approved DNV Healthcare as a third national accreditation program for hospitals seeking to participate in the Medicare program. Recently, hospitals accredited through DNV Healthcare have been added to the American Hospital Association (AHA) Guide, listing these facilities as well as those accredited by the Joint Commission and HFAP.

Each program or department is governed by its own set of rules.  For example, Joint Commission surveys hospitals by following more than 276 standards, reviewing 1,612 elements of performance.  HFAP does largely the same thing, pursuant to its 1,100 or more individual standards.  Focusing on durable medical equipment (DME), HQAA has developed its own review process, and “vows to continuously strive to set standards of the highest quality on behalf of the DME industry and business owners.”  Indeed, HQAA “listen[s] . . . act[s] . . . [and] stand[s] together and in unison to bring the whole of DME service and provision to the next level.”

There are numerous other entities participating in the certification/accreditation process, and virtually every facet of the health care system is governed and reviewed by multiple organizations.  Take the American Hospital Association, which designs and administers Certification Programs to recognize mastery of well-defined bodies of knowledge within health care management disciplines.  The Certification Commission for Healthcare Information Technology is a recognized certification body for electronic health records and their networks.  Even educational programs, general education or specialty education (such as podiatric medicine) must receive proper accreditation in a hospital setting.

California

In addition to the list above, every hospital is subject to special regulations from its own state.  Health care facilities in California are licensed, regulated, inspected, and/or certified by a number of public and private agencies at both the state and federal level, including the California Department of Public Health (CDPH).

State and federal agencies have separate jurisdictions, but there is overlap.  For example, CDPH’s License and Certification Division (“L&C”) is responsible for ensuring that hospitals comply with state law, but it also cooperates with CMS to verify that facilities accepting Medicare and Medi-Cal (Medi-Cal is California’s version of Medicaid) payments meet federal requirements.  California’s Office of Statewide Health Planning and Development (OSHPD) regulates hospital construction and administers programs which endeavor to implement the vision of “Equitable Healthcare Accessibility for California.”

These two examples serve to emphasize as well as outline the complexities of state regulations that often accompany their federal counterparts.  CDPH is divided into eight separate programs, including:

• Office of the Director, or State Public Health Officer;
• External Affairs;
• Policy and Programs;
• Center for Chronic Disease and Health Promotion;
• Center for Environmental Health;
• Center for Family Health;
• Center for Health Care Quality; and
• Center for Infectious Disease.

Like CDPH, OSHPD is one of 13 departments within California’s Health and Human Services Agency.  Made up of six separate boards and commissions, OSHPD’s mission is “to promote healthcare accessibility through leadership in analyzing California’s healthcare infrastructure, promoting a diverse and competent healthcare workforce, providing information about healthcare outcomes, assuring the safety of buildings used in providing healthcare, insuring loans to encourage the development of healthcare facilities, and facilitating development of sustained capacity for communities to address local healthcare issues.”

In the present climate of health care reform, things do change fast. The foundation that makes up the nation’s health care hierarchy, however, may take some time to understand.