A way to be cop and coach
In his editorial "An invitation to a `blowback' " (June 17, p. 52), Neil McLaughlin takes the American Hospital Association to task for suggesting that volunteer hospital experts work as surveyors to improve the Joint Commission accreditation process. However, this notion should not be rejected out of hand. Hospitals, and therefore the public, could benefit a great deal from increased attention by fellow experts, rather than just by surveyors who focus on adherence to the rules. The question is how best to do it.
McLaughlin's commentary highlights the inherent conflict in the JCAHO's attempt to be both accreditor and quality-improvement resource, to be both cop and coach. While the JCAHO steadfastly asserts that accreditation is not the same as regulation, neither the public nor hospitals are persuaded. Nor, perhaps, should they be. After all, as McLaughlin observes, "All institutions entrusted with people's lives, including hospitals, need some rigorous supervision by an outside agency." In the U.S., that standard-setting and supervising agency for most hospitals is the JCAHO. For example, only 15 states require reporting of serious adverse events; the rest leave it to the JCAHO's sentinel events reporting program. Like it or not, the JCAHO is the primary hospital oversight agency in America.
Hardly the tame organization that McLaughlin portrays, the JCAHO is simplifying the accreditation process while making it tougher. New safety standards, announced a year ago will, if they are enforced, have real bite: Those include meaningful safety programs and full disclosure to patients. Moving to unannounced site visits will also enhance the credibility and efficiency of the accreditation function.
Although they are unlikely to do so, hospitals should welcome these changes. The public widely perceives that hospitals are not serious about safety. Hospitals that demonstrate that they are meeting the JCAHO standards-and even exceeding them-will begin to overcome that skepticism. It is very much in their interest to do so. Enforcement of tougher standards is a triple win. It improves safety while enhancing the credibility of both hospitals and the JCAHO.
But what about quality improvement? The JCAHO could enhance its credibility in that role by distancing its accreditation process from improvement coaching. Here is where AHA President Richard Davidson's clever idea for tapping the expertise of hospital leadership comes in. Instead of part of the accreditation process, it could be part of the response. When the accrediting process uncovers serious deficiencies, hospitals could be encouraged-or even required-to seek peer consultation such as Davidson recommends. For when there are serious problems, what hospital CEOs really need is a critical look from their successful peers, those who really know. The AHA could orchestrate this kind of service.
There is precedent for this kind of approach in New York state's oversight of cardiac surgery and procedures. When hospitals are found to have serious deficiencies by the state health department's monitoring program, a cardiac advisory committee of local and national expert cardiologists and cardiac surgeons conducts site visits and makes recommendations to chiefs of services. Improvements are often both rapid and dramatic.
There is also precedent for the AHA to take on such a role. From early in the safety movement, the AHA has been out in front in providing its member hospitals with specific and useful tools for improving patient safety. Creative collaboration between these two organizations entrusted with ensuring the safety and quality of care in our hospitals should be encouraged, not denigrated.
Lucian Leape, M.D.
Harvard School of Public Health
The value of tiers
Your editorial "These tiers must fall" (June 10, p. 24) incorrectly assumes that when health plans group hospitals into tiers based on cost they are compromising members' access to high-quality care.
It has been our experience at MVP Health Care that most of the hospitals in our network that score highest on quality-of-care indicators also perform especially well at controlling their costs. To assume that high cost equals high quality ignores the reality of the healthcare marketplace, where quality and cost are inexorably linked.
Further, offering members a choice of hospitals through a tiered hospital network continues the positive trend, begun with prescription-drug formularies and other forms of tiering, that directly connects the cost of care to the consumers' healthcare decision.
Assigning a higher consumer cost to higher-cost hospitals, as is the case in tiered networks, is an important first step. The second step must be giving consumers access to more detailed hospital quality information through initiatives such as those supported by the Leapfrog Group. When health plan members are empowered to assess both the cost and quality of hospital care, they will be able to make educated healthcare decisions. At that point, tiered hospital benefits will demonstrate their real value in controlling hospital costs and promoting quality of care.
President, chief executive officer
MVP Health Care
I was delighted to read Laura Benko's article "Routine maintenance" detailing the current state of disease management (July 1, p. 30). Her article underscores the potential of disease management for containing skyrocketing healthcare costs and improving preventive care.
Benko has appropriately identified the need for patient compliance as a significant factor in the overall success of a self-care regimen. However, in the study conducted by LifeMasters, referenced in the article, the percentage of patients actively engaged, monitoring and reporting data was 42%-almost half of those targeted-and not 10% as reported.
Significant savings are achieved at this compliance rate, even though 100% of the identified eligible members do not participate. We in this field are continually developing new ways to engage and interact with more members.
Chief executive officer
LifeMasters Supported SelfCare