Accreditation versus Government Corruption

DSHS / Western State Hospital emphasizes that it is “FULLY ACCREDITED” at all of its websites as well as in each and every vacant position posting.  So what is hospital accreditation?  Wikipedia defines hospital accreditation as the following:


Hospital accreditation has been defined as “A self-assessment and external peer assessment process used by health care organizations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve”.


The Joint Commission is responsible for providing accreditation for hospitals by conducting inspections and most importantly monitoring National Hospital Quality Measures through mandatory report through a process called ORYX.  Data that is collected indicates how well a hospital is performing and adapting to changing patient populations through the use of a national standard.  Think of it as quality oversight.  If a hospital is accredited, quality oversight is constantly maintained through a reporting relationship with The Joint Commission.  


Why would DSHS and Western State Hospital want to advertise on its websites and job seeking websites that it is “FULLY ACCREDITED?"  Health professionals are licensed through the State and are held responsible for their own actions through the Uniform Disciplinary Act.  This means that if a health professional is directed to perform a procedure or process that endangers a patient, the health professional will be accountable, and not the individual or entity that issued the process or order.  In a hospital that is not accredited there are no national quality assurance measures (checks and balances) that are being routinely applied.  Without these quality assurance measures in place there is a high likelihood that a health professional will place their credentials at risk as accredited hospitals statistically have superior patient care processes, equipment, and outcomes.  See “Benefits of Joint Commission Accreditation.”  Quite simply, a health professional puts his or her credentials at risk by working in an inferior non accredited facility. 


DSHS/Western State Hospital understands the importance of accreditation for a health professional that is seeking a job, therefore in each any every position posted at its job website it states the following:


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Within Western State Hospital its employees have access to the State Intranet which is an internal website system that keeps employees informed of accreditation reports and medicare reports. This is the last Joint Commission Accreditation Report (3/17/15) that was posted. That report indicated that Western State Hospital was in the processes of making needed corrections to maintain accreditation.  The fact that corrections must be made shows that the accreditation system is working to assure that the “hospital” provides a national standard of care.  


Because of the unique situation of Western State “Hospital” not being a “hospital” under Washington law, Joint Commission accreditation is one of the ONLY oversight processes that occur at Western State.  If Western State Hospital was a “hospital” under Washington law, there would be mandatory reporting processes and oversight by the Department of Health. To fix Western State Hospital will require that Western State Hospital becomes a hospital under the law and thus must be overseen by the Department of Health as are all other hospitals within Washington.  Why is this important?  


Let me introduce you to a root cause of Western State Hospital failure…  The following document represents the way that DSHS and the current Governor view reporting and accountability relationships within Western State Hospital.  This document is so important that each of you should print a copy and truly contemplate what is being stated.  I preset to you BHA Management Bulletin H16-04-0001 dated April 14, 2016.


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Western State Hospital is currently in failure status with The Centers for Medicare and Medicaid (CMS) and is now one of five hospitals within the entire country that has implemented a Systems Improvement Agreement (SIA).  This means that DSHS has hired the consultant firm Clinical Services Management (CSM) to oversee care and changes within Western State Hospital so as to meet CMS requirements by March of 2017 or $65 million in federal funding per year will cease and WSH will no longer be CMS certified.  Thus the only direct oversight of Western State Hospital rests with The Joint Commission through accreditation.  If Western State Hospital were not accredited, there would be ZERO public oversight of Western State Hospital…  Indeed, any and all care and information pertaining to care could be covered up.  But luckily Western State Hospital operates with “deemed status per WAC 388-877-310” which requires accreditation status by The Joint Commission as the current Centers for Medicare and Medicaid status is in failure and under current SIA.  If Western State Hospital were not accredited, it would no longer meet deemed status to operate under the law. 


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As stated in the above document, State Hospitals are not licensed by the Department of Health (DOH).  There is no true reporting or oversight relationship with the Department of Health (licensing) as would be the case with all other hospitals within Washington.  It is specifically noted that DSHS may or may not choose to report anything to anyone, of course the one exception would be the ORYX reporting process with The Joint Commission as is required of an accredited hospital.  


With the recent Systems Improvement Agreement (SIA), Clinical Services Management (CSM) was tasked to complete a report which would be submitted to DSHS and The Centers of Medicare and Medicaid (CMS).  That report was submitted over a week ago and is being kept top secret by the current government administration.  Employees have not been allowed to see there results, although the CEO has stated she is required to make vast changes based on her interpretation of this secret document paid for by tax payers.  


We have now entered into a dangerous time where information pertaining to Western State Hospital will not be subject to public disclosure or any form of public oversight.  Not only are the employees excluded from the consultant reports, but so is the public, as well as the legislators.  The governor has access and is apparently doing everything in his power to prevent transparency of government.  


At least Western State Hospital must report data to The Joint Commission through the accreditation processes.  Were it not for being accredited, the governor would have actually initiated a full blackout of information to anyone regarding the care provided at Western State Hospital.


An addendum to this Blog will be forthcoming. 


Let me know what you think.



© Paul Vilja 2017