It seems intuitive and driven by common sense to have a set of standards for a hospital to meet to ensure patient safety. This baseline effort to guarantee “quality” is met through accreditation metrics set forth by organizations that have fueled the process becoming big business.
The U.S. Centers for Medicare and Medicaid (CMS), for example, insist for hospitals to be eligible for Medicare payments they be evaluated by a CMS-approved accrediting agency or review by state survey. To do so is labor-intensive and costly, but the perceived price of not doing so has resulted in about 75% of hospital systems paying these accrediting bodies to get accredited. One body, The Joint Commission, is the behemoth responsible for 80% of the market. Lately, the value of such evaluations in terms of improving patient outcomes has become central to the discussion of their greater utility.
With a focus on the processes of care and structural factors, there is limited data on the association between these accreditation efforts and actual clinical outcomes. A new study published in BMJ sought to clarify the picture.
Their objective was to answer these three questions (paraphrased from here)
Is accreditation associated with better patient outcomes in U.S. hospitals?
Do outcomes vary between those hospitals accredited by The Joint Commission compared to those accredited by independent organizations?
How does patient experience differ between hospitals accredited by an accrediting organization as opposed to those undergoing a state survey, as well as those by The Joint Commission or an independent agency?
Basically, the authors attempted to get a glimpse into the effectiveness of oversight via oversight and shed light on aspects not traditionally studied like understanding the association of accreditation with hospital mortality and readmission rates (e.g. patient outcomes).
“US hospital accreditation by independent organizations is not associated with lower mortality, and is only slightly associated with reduced readmission rates for the 15 common medical conditions selected in this study. There was no evidence in this study to indicate that patients choosing a hospital accredited by The Joint Commission confer any healthcare benefits over choosing a hospital accredited by another independent accrediting organization.”
Among the study flaws affirmed by the research team
This was an observational study by design, which means it doesn’t prove cause and effect nor can it eliminate for a likely host of confounders that weren’t included or measured in the consideration. Another limitation, the data excluded those outside of the Medicare insured population so extrapolating beyond that is not possible. In terms of patient experience, low response rates and the subjective nature of the surveys could easily influence negative or false assumptions.
The take home message
It is evident that the tale of the benefits of accreditation with respect to available data on patient outcomes is a limited, mixed one. That said, despite the imperfect state of what this work can inform on the subject, the effort was very important given how much investment (e.g. financial, diverted attention away from clinical responsibilities) is made in these accreditation endeavors, nationally and worldwide. Although processes can lead to improved patient outcomes, the emphasis when assessing high quality care and where to make refinements should be more directed to and centrally-focused on reducing mortality, readmission and minimizing preventable complications.
The purpose of hospitals is to treat, manage and, hopefully, cure patients - assuage suffering. Accreditation procedures should support optimizing this fundamental tenet. If they don’t, then obtaining more data on the topic is a necessity to making them more efficient and effective in facilitating the delivery of the highest quality care. Tacit acceptance of the current strategy of accreditation puts a premium on status quo, unless patient outcomes are positively linked to current evaluations we should constantly be challenging it for the better. This study is a good start.
Lam Miranda B, Figueroa Jose F, Feyman Yevgeniy, Reimold Kimberly E, Orav E John, Jha Ashish K et al. Association between patient outcomes and accreditation in US hospitals: observational study BMJ 2018; 363 :k4011 (see here).