The Boston Globe drew from a state inspection report to show how patients with serious medical conditions deteriorated while waiting for care at an understaffed hospital. Similarly, The New York Times used a state inspection report to recount an anesthesia error that killed a woman who was in labor.
Those stories illustrate how inspection reports — known as 2567 forms — can prove rich narrative details to stories about patient harms, Jordan Rau, a senior correspondent at KFF Health News, said during a skill-building workshop at Health Journalism ’24.
The session,“Hospital quality: Getting past the hype with public records,” covered how to read, analyze and find stories in reports generated by inspections performed in response to a complaint.
Information from the forms, also known as deficiency reports, is easily searchable on AHCJ’s hospitalinspections.org website. A database of reports is also on a spreadsheet that you can download from the CMS website. Both resources are updated quarterly.
About a quarter of Medicare patients experienced some type of harm during a hospital stay in 2018, according to a report by HHS Office of the Inspector General. Rao said that serious patient safety breaches such as falls, wrong-site surgeries and assaults, known as “never events,” are worth covering. “All of these things are still happening,” he said.
He advised checking for any 2567 forms if you are investigating a hospital.
Some of Rao’s advice:
Think like an inspector. State inspectors are charged with documenting violations of Medicare’s Conditions of Participation. Reports can be long because information is repeated in order to document multiple violations. “It is going to be repetitive,” Rao said. “That’s just the way that they work.”
Ask the hospital for its plan of correction. Reports typically contain a blank space where the hospital’s response, known as a plan of correction, goes. The plan of correction tells the hospital’s side of the story and may point to any inaccuracies in a report, Rao noted.
Pay attention to the deficiency tags. Deficiencies are described in Appendix A of Medicare’s State Operations Manual. Those with tags containing the letter A pertain to patient care. Each Condition of Participation contains multiple standards. Common categories of violations include patients’ rights and nursing services.
You might not be able to interview the patient involved in the incident. Reports de-identify all people, which makes finding a patient who was harmed extremely difficult, Rao said. Althoug, a reporter might try searching lawsuits and death records. The person who filed the complaint that initiated an investigation is also not disclosed.
You can request a report before the quarterly release. If you know about a specific incidence, Rao suggests requesting a report from a CMS regional office or a state survey agency. Generally, government agencies and hospitals don’t issue news releases about inspections. Reporters can also request copies of follow-up surveys to check if violations have been corrected.
Check with state agencies. In addition to Medicare violations, states may penalize a hospital for violating licensure rules. You may not learn about such state actions unless you ask.
