The national health care group that has moved to revoke its accreditation of Shady Grove Adventist Hospital because of patient care errors is under increasing pressure to get tougher with the thousands of hospitals it inspects for federal and state governments.

For years, consumers and government officials have complained that the Joint Commission on Accreditation of Healthcare Organizations--which reviews 4,800 hospitals and helps governments decide whether the facilities should receive Medicare funds--has not done enough to crack down on hospitals that provide poor care.

Now, officials say, the commission finally is strengthening its inspection program. It's an approach being met skeptically by Shady Grove officials, who say the commission is dealing with reports of patient care problems at the 263-bed hospital more harshly than it otherwise would have because it wants to show it is serious about stricter enforcement.

"Congress has been very hard on the joint commission and the way they survey hospitals," Shady Grove's interim president, Terry W. White, told the Montgomery County Council last week, during a session in which he said Shady Grove is a well-run hospital that simply has made a few mistakes. "We believe the joint commission has heard Congress. They all live here and read the same newspapers."

The economic consequences of losing accreditation could be severe for the Rockville hospital. Health plans could stop admitting patients, the government could halt Medicare funding and the hospital's parent company--controlled by the Seventh-day Adventist church--could find it difficult to raise capital.

Joint commission President Dennis S. O'Leary dismissed the notion that the agency is sacrificing fair, objective evaluations to political grandstanding.

"The fact is that [Shady Grove officials] have serious standards-and-compliance problems," O'Leary said. "I hope they're working on them. . . . We did not single them out as an example; they are not the only organization that has lost or is at risk of losing their accreditation this year."

The joint commission has long drawn criticism from patient advocates and government officials who believe its relationship with the hospitals it inspects has been too cozy.

A typical hospital pays the agency $21,000 for a scheduled inspection every three years. Rarely are hospitals publicly taken to task for poor performance--and even then the public is given no details.

At the same time, the joint commission each year sells $25 million worth of books, seminars and videotapes to hospitals that want to learn the best ways to comply with the commission's standards. It's part of a lively marketplace for consultants--some of whom work part time as joint commission surveyors.

People unhappy with the nation's hospital regulation system said that instead of cracking the whip, the commission has been too forgiving.

In July, the commission was bruised by a critique from the U.S. Department of Health and Human Services's inspector general that said commission inspectors were too "collegial" with the hospitals. Last month, a report by the Institute of Medicine, part of the National Academy of Sciences, estimated 98,000 Americans die each year from the types of medical mistakes that inspections are supposed to prevent.

Such reports have intensified the pressure on the Chicago-based commission, which says it is making its inspections more stringent and increasing the number of surprise visits. But the agency has a long way to go before overcoming the hospital industry's view of the evaluation process.

Doctors, nurses and hospital administrators say hospitals typically spend a year making cosmetic preparations for scheduled inspections that focus more on theoretical issues and hospital processes than checking actual performance.

Julia Ann LaJoie, a pediatric emergency physician at Shady Grove, said her hospital is being singled out.

"These kinds of mistakes happen in every single hospital all over the country all the time," she said.

The joint commission lowered Shady Grove's rating last month after verifying complaints by several doctors and patients about mistakes, poor supervision and inadequate staffing. After The Washington Post reported that Shady Grove medical staff leaders complained that the administration was ignoring their concerns, inspectors from the joint commission and Maryland's office of health care quality converged on the hospital.

Both found serious problems, including the death of an intensive care unit patient who was left unattended in a hallway and an operation performed on the wrong hip of an 81-year-old woman. They also cited the hospital for committing medication errors, repeatedly failing to report mistakes and incidents and allowing a highly contagious tuberculosis patient to wander around the hospital.

Moreover, records showed the hospital's board of directors showed little interest in the quality of care, officials said.

Although it would not mean an immediate shutdown, loss of accreditation subjects a hospital to heightened scrutiny from state officials and could cause the U.S. Health Care Financing Administration to disqualify it from receiving Medicare or Medicaid funds. Few hospitals can operate without funds from those programs.

Shady Grove is appealing the joint commission's action at a hearing tomorrow in Chicago, arguing that the two surveyors who visited the hospital for one day in October did not have a complete picture of the incidents. Those surveyors persuaded the joint commission to drop the hospital's accreditation from the highest rank, accreditation with commendation and a 99 percent rating, to the second lowest, preliminary non-accreditation.

"The fact they got a 99 percent is as much a farce as the low rating they're getting now," LaJoie said.

But deputy inspector general George F. Grob praised the commission's new policies. "We're very happy that the joint commission has taken a stronger stance," Grob said. "We think it's long overdue . . . but there's a lot more to be done."

Hospital industry leaders have mixed feelings about the joint commission--the only private enterprise assigned by federal law to oversee an entire industry.

"Our members look and say, 'This thing is supposed to be helping us, not regulating us,' and the government is saying, 'No, it's supposed to be regulating you, not helping you,' " said American Hospital Association spokesman Rick Wade. "The joint commission is trying to be both."