It takes a lot to deny a facility's accreditation outright: Only after a facility demonstrates inability or unwillingness to correct non-compliant areas of its practice within a reasonable period of time will the major accreditation bodies - JCAHO, AAAHC or AAAASF - censure the facility by refusing accreditation.

The good news is that accreditation denial needn't permanently mar a facility. It is possible to rehabilitate your facility and restore its accreditation - and more importantly, the morale of personnel and the faith of the community you serve. Here's how one troubled urban hospital recently began to fight to recover JCAHO accreditation.

Fall from grace
On Feb. 5, 2001, Greater Southeast Community Hospital in Washington, D.C., aced its JCAHO accreditation with "full standards compliance," according to the hospital's accreditation history on JCAHO's Quality Check Web site. This was no small feat: Financially troubled for many years, Greater Southeast had been purchased out of bankruptcy in 1999 by Scottsdale, Ariz.-based, Doctors Community Healthcare, Inc.

But within a year, Greater Southeast had slipped and fallen. In 2002, the hospital, its parent company and other Doctors Community subsidiaries filed for Chapter 11 bankruptcy protection after the collapse of Ohio-based National Century Financial Enterprises. An inner-city hospital, Greater Southeast leaned on the firm to meet daily cash needs, particularly to sustain an overburdened ER and maintain core staffing levels.

When JCAHO surveyors returned for Greater Southeast's February 2002 accreditation review, they discovered varying degrees of non-compliance in crucial practice areas, including fire- and patient-safety protocols, infection control standards, staffing, patient record keeping, quality improvement programs and executive clinical leadership.

Strikes two and three
JCAHO issued conditional re-accreditation on Feb. 23, 2002, and sent surveyors back in November to check on the hospital's compliance progress. Once again, the accreditation body found substantial non-compliance. JCAHO temporarily sustained Greater Southeast's conditional accreditation until it could conduct a special, thorough on-site evaluation.

According to a statement released by JCAHO, the Joint Commission conducted the evaluation Jan. 30 and followed up with unannounced visits Feb. 11 and 12. The evaluators failed the hospital in infection control, anesthesia, staffing and clinical leadership. The next day, JCAHO issued a preliminary denial of the hospital's accreditation.

"The purpose of recommending something less than full accreditation is not to punish facilities," says AAAHC surveyor Beth Darby, RN, MBA. "It's to get facilities to look critically at their own practice and im-prove flaws in their standards."

Denied again
Greater Southeast appealed the ruling and, shortly thereafter, assembled a new management team to begin the arduous process of rehabilitating the hospital. But the damage was already done. On Aug. 12, the District of Columbia's Depart-ment of Health (DoH) gave the facility 60 days to demonstrate across-the-board practice improvements or lose licensure. The hospital pledged to do so at an Aug. 14 press conference.

On Aug. 18, JCAHO's Board Appeal Review committee, composed of four members of JCAHO's board of commissioners, met to review Greater Southeast's appeal. According to JCAHO's statement, per policy, the committee did let hospital representatives attend the meeting but did let Greater Southeast submit written materials in its defense. The committee considered only information about the hospital's activities and performance at the time of the on-site survey relevant to the appeal review.

The verdict: JCAHO denied Greater Southeast's accreditation, effective immediately, for "failure to correct individual standards compliance deficiencies or otherwise meet the conditions imposed under a Con-ditional Accreditation status."

Road to recovery
The new management team immediately set to work to secure re-licensure from the DoH and re-accreditation from JCAHO. The stakes were - and remain - as high as the time was short to implement a plan.

The first task: district licensure. The hospital continues to receive Medicare and Medicaid payments without JCAHO accreditation while operating under conditional DoH licensure. If Greater Southeast fails to gain re-licensure from the DoH, it will be doomed. Medicare and Medicaid account for more than half of Greater Southeast's reimbursements, according to a hospital spokesperson.

Heading the hospital's rehabilitation team is Joan Phillips, the vice president of Brent-wood, Tenn.-based Cambio Health Solutions, which specializes in rehabilitating hospitals. The hospital also coaxed Ana Raley, Greater Southeast's former chairman and president, out of retirement to serve as a special advisor on the project.

"As a vital first step ? we have successfully garnered support from [the DoH] to ensure we have met standards for patient safety and operational improvement without fail," says Ms. Raley in a statement.

The hospital also announced it would file a survey request with JCAHO immediately after securing DoH re-licensure.

The big plan
Outpatient Surgery obtained a copy of the work plan crafted by Cambio and Greater South-east to regain licensure and accreditation. Some key points:

• Medical executive committee. The hospital assembled an executive clinical department, headed by Edgar Potter, MD, who previously served as the chief medical officer at several facilities. In addition, Robert Williams, MD, became director of the ER department and Dell Harvell, RN, became the head nurse for clinical management of the ICU.
• Quality improvement. The bolstered clinical leadership outlined a quality improvement program including anesthesia, surgical services (including wrong-site-surgery prevention protocols) and infection-control standards (including instrument reprocessing and personnel hand hygiene).
• Staffing. The hospital pledged to meet core staffing requirements for nurses and that, to promote greater continuity of care, no more than 80 percent of the nursing staff will be comprised of PRN agency nurses. The plan also includes an initiative to increase anesthesia staffing and ER coverage.
• Fire and safety. The hospital will immediately improve fire-safety compliance, specifically the functioning of emergency generators as a secondary power source.

Road to recovery
DoH announced that it would let the hospital, which had been operating under probation since August, retain its operating license but at a lessened capacity after the hospital corrected deficiencies in emergency care, fire safety, physician supervision, quality assurance and staffing. (Health inspectors earlier had determined that at least six preventable deaths had occurred at the facility.) DoH limited the 303-bed hospital's inpatient capacity to 150 and said it would continue to monitor the quality of care at the hospital.

The hospital recently re-applied to JCAHO for accreditation, according to a Joint Commission spokesperson. The hospital will be surveyed Dec. 15 to 17. "They will be surveyed against the full scope of standards we consider under our initial survey policy and will have to demonstrate a four-month compliance track record," says the spokesperson. JCAHO usually renders accreditation decisions 30 to 45 days after a survey.

Cambio officials express "confidence and cautious optimism" that they've steered the hospital onto the right track to regain conditional accreditation from JCAHO in fairly short order. Beyond that, Greater Southeast has set its sights on attaining more substantial compliance with JCAHO standards, as the quality improvement programs further strengthen clinical and safety processes.