Hospitals that are part of multihospital healthcare systems are more likely to be accredited with commendation by the Joint Commission on Accreditation of Healthcare Organizations than freestanding hospitals, according to a review of JCAHO data by MODERN HEALTHCARE.
The JCAHO said only 4.7% of the 5,300 hospitals it accredits receive its highest recognition-accreditation with commendation. But system-owned hospitals accounted for 55% of the 250 hospitals accredited with commendation as of April 1995, according to the JCAHO's most recent data.
Accreditation with commendation "recognizes a hospital's exemplary performance in areas such as quality improvement, patient rights, medication use, practitioner credentialing, safety and organization management," the JCAHO says.
High JCAHO scores haven't been used yet in marketing to the public, but it's believed they can give hospitals an important advantage in managed-care contracting.
The proportion of system hospitals receiving commendation exceeds their ratio within the healthcare industry. Overall, 2,864 of the nation's 6,467 hospitals, or 44%, were owned, leased or managed by multihospital healthcare systems in 1993, according to the American Hospital Association's latest available statistics.
As recently as 1993 only 43% of 275 hospitals accredited with commendation were system-owned, JCAHO data show (See chart).
Observers believe that systems increased their number of hospitals in 1994 through acquisitions and mergers. MODERN HEALTHCARE's 1995 Multi-unit Providers Survey indicated a 7% increase in system-operated hospitals in 1994. If the 7% increase is applied to the 1993 AHA data through extrapolation, then an estimated 47% of the nation's hospitals were part of systems in 1994.
"System hospitals do better (than freestanding hospitals)," said Charles Bair, the JCAHO's executive vice president of accreditation operations. "They have dedicated quality professionals who help their hospitals share information and benchmark data."
Miami Heart Institute is an example of a system hospital that scored well enough on its last survey to be accredited with commendation in August 1994. It's owned by Columbia/HCA Healthcare Corp.
Columbia has one of the industry's highest rates of system hospitals accredited with commendation, primarily because of its merger with Galen Health Care in 1993, which brought in more than two dozen hospitals accredited with commendation, the MODERN HEALTHCARE review found.
Including its recently acquired Healthtrust facilities, 46 of Columbia's 318 hospitals, or 14.5%, are accredited with commendation, compared with 4.7% of all hospitals. Kaiser Permanente has a higher rate, with 18%, or six of 33, of its hospitals accredited with commendation.
Like Kaiser and other systems, Columbia has a corporate quality staff to assist its hospitals with JCAHO surveys, said Carolyn Lipp, vice president of quality and resource management for Columbia's 56-hospital Florida Group.
"If we have to write a new type of plan for the JCAHO, we don't have to invent the wheel. We use our best hospitals as role models," Lipp said.
For example, 258-bed Miami Heart's job descriptions were so good that the JCAHO said it would use them as a nationwide model, said Steve Fuller, Miami Heart's vice president of human resources.
Miami Heart has low mortality rates, which it touts when marketing the hospital to patients and insurers. Based on 1991 HCFA data, Miami Heart executives said the hospital has the third-lowest mortality rate in the nation.
Miami Heart's goal is to exceed the requirements of the JCAHO's 700 standards, said Linda Combs, Miami Heart's vice president of physician services. For example, the hospital conducts at least 25% more training exercises, such as fire drills, than the JCAHO requires.
System and JCAHO officials cited several other reasons why a higher proportion of system hospitals are accredited with commendation.
For one, a system benefits from having a single JCAHO team survey its hospitals. The single team system is believed to reduce inconsistencies and enable surveyors to become accustomed to each system's quality plans.
For another, JCAHO surveyors brief system executives on survey results and suggest areas of improvement or offer praise. As a result, system hospitals compete among themselves to achieve higher quality recognition. Some systems, such as Columbia, also have tied JCAHO scoring to compensation.
Freestanding hospitals also use outside organizations and employ tactics similar to those used by system hospitals to help them through the JCAHO process.
For example, stand-alone hospitals hire consultants to conduct mock surveys. Hospital quality improvement personnel also attend JCAHO seminars and consult hospital associations or alliances for guidance on JCAHO policy changes.
But system executives believe the closer relationships developed among JCAHO surveyors, corporate staff and hospital quality teams give system hospitals an edge.
"Systems have more structure and have developed (departments) to deal with all the various regulations at the state and federal levels," said Jack Lord, the AHA's senior adviser for clinical affairs. "It doesn't surprise me that system hospitals score better."
Scores don't equate quality.
Still, higher scores or accreditation with commendation doesn't necessarily mean system hospitals have higher quality than freestanding hospitals, Lord and Bair agreed.
"The survey doesn't speak to individual patient outcomes," Bair said. "When a hospital scores well in all areas, it is expected that (good) outcomes will follow."
Although JCAHO officials are hesitant to make the connection between good outcomes and high survey scores, several executives of hospitals accredited with commendation believe their facilities have increased quality in clinical and patient-satisfaction areas because of their more rigorous, self-imposed accreditation process.
"We believe (accreditation with commendation) is an indicator of higher quality," said Ora Douglass, vice president for quality improvement at Northside Hospital, a 460-bed freestanding facility in Atlanta.
In 1992, Northside developed a 10-member department under Douglass to oversee the hospital's quality program and JCAHO surveys. It became accredited with commendation in March 1994.
"Historically, hospitals have placed oversight (of the JCAHO survey) at a lower level," Douglass said. "We take this very seriously and give it high priority. We view accreditation as an ongoing process, not just something to get ready for every three years."
Northside also uses outside groups for training and assistance in meeting JCAHO standards and preparing for surveys, Douglass said.
For example, each year the hospital conducts a mock survey with the help of Quality Healthcare Resources, a JCAHO consulting subsidiary. To compare best practices, Northside officials also meet with other hospitals through its membership in VHA, an Irving, Texas-based hospital alliance.
Before its 1994 survey, Douglass said she asked the JCAHO to identify the hospital's survey team.
"We found out which hospitals were surveyed by the team coming in for our inspection," Douglass said. "We visited those three hospitals and found out the personalities of the surveyors, what they liked and didn't like. It was very helpful in our preparation."
`IT DOESN'T SURPRISE ME THAT SYSTEM HOSPITALS SCORE BETTER.' -Jack Lord; "WE BELIEVE )ACCREDITATION WITH COMMENDATION) IS AN INDICATOR OF HIGHER QUALITY.' -Ora Douglas
Systems increase numbers of hospitals
accredited with commendation 1994 1993
Number of hospitals accredited with commendation
by the JCAHO: 250 275
Percent system-operated 55% 43%
Percent freestanding 45% 57%
Total percentage of hospitals that are system-operated 47% 44%
Total percentage of hospitals that are freestanding 53% 56%
Sources: Joint Commission on Accreditation of Healthcare â– Organizations, American Hospital Association, Modern Healthcare's 1995 Multi-unit Providers Survey