Call it an extreme accreditation makeover. Starting next month, hospitals and other healthcare organizations will have to answer to the public as well as to the Joint Commission on Accreditation of Healthcare Organizations for their track records on bolstering patient safety and nailing key measures of quality care.
That's when the JCAHO unveils the next generation of a report to consumers it has issued for the past 10 years, summarizing accreditation results and rating provider organizations on their performance. Among other significant differences, the new format relegates the traditional detail on standards compliance to the background in favor of data directly measuring clinical quality.
In addition, a new rating scheme resurrects a once-reviled method of representing performance in symbols. But unlike an attempt a decade ago to introduce a five-star rating system-which was aborted and replaced with numerical scores-the incoming approach employs field-tested markers to grade and differentiate at a glance: a check mark, a red minus, a green plus and even a shiny gold star.
Accredited organizations late last week got their first chance to peek at the Web-accessible reports compiled on them through a secure JCAHO Internet connection and could request last-minute changes before the postings are revealed to the public July 15.
"There will be no surprises," said Jerod Loeb, executive vice president of research at the Oakbrook Terrace, Ill.-based accrediting agency. "They have seen their data. They just haven't seen it as we have portrayed it."
In the makeover of what had been a drab public face on the accreditation process, the JCAHO's new reporting format will thrust into full view its information on the clinical quality and skill of individual provider organizations-data that were collected and kept for years to evaluate provider progress but never posted publicly.
Most prominent is a listing of more than a dozen practices required of hospitals to meet the commission's National Patient Safety Goals, along with a check or minus after each one denoting implementation successes or shortcomings.
Next are results detailing how often a hospital adhered to clinical quality indicators reported to the JCAHO in connection with its Oryx performance measurement program, one of many factors that figure into a final determination of accreditation.
Until this year accredited hospitals had to choose two sets of measures on which to report data from among four disease conditions: heart attack, heart failure, pneumonia, and pregnancy and related conditions. A fifth set of Oryx measures covering surgical-infection prevention was added for 2004, and hospitals in January had to add a third measure set from among the five choices.
Quality efforts multiply
The commission's planned revamp of its reporting tool drew no opposition from the American Hospital Association, but the timing of its release may be catching the industry unaware, said AHA spokesman Richard Wade. "With everything else going on, this might not be as front and center as it ought to be," he said.
The AHA and its affiliated state associations have been apprised of and provided feedback on the impending launch of the new quality reports during the past several months, Wade said. But he added that hospitals have been preoccupied lately with a different project co-sponsored by the CMS and the healthcare industry called the National Voluntary Hospital Reporting Initiative, and consequently the JCAHO effort has "probably less of a presence in our members' minds" than the public-private initiative.
Under the Medicare modernization act, only hospitals enrolling in the "voluntary" program will be eligible in fiscal 2005 for the full rate of healthcare inflation in their Medicare payments. Among other things, that meant registering for Web-based data transmission by June 1 to become eligible.
The two initiatives ask for many common data elements on heart attack, heart failure and pneumonia, a result of coordination between the federal government and other quality monitoring agencies. That's a plus for hospitals concerned about collecting different data for multiple quality-improvement efforts, but it could confuse hospital executives trying to keep the various initiatives straight, Wade said. He called on the JCAHO to make the distinctions clear between the two programs.
Loeb said the commission has given all providers instructions to preview their data on the site and will be keeping track of access. "We will be able to tell if they've seen it," he said. If a hospital hasn't logged on with the July debut approaching, "We will automatically push a hard copy out to them," he said.
The AHA, which has issued a "quality advisory" to its members on the JCAHO project, also wants the commission to share its media materials as the deadline nears, Wade said. That will give hospitals a chance to prepare answers to questions likely to be posed by local press.
Satisfying providers, consumers
The industry mood was decidedly less agreeable when the JCAHO hatched its first plan to disclose accreditation information to the public nearly 10 years ago. The plan attempted to adapt scores in each of 28 survey performance areas to a rating of one to five stars, but critics complained that it oversimplified complex accreditation to the point of being useless to consumers while trivializing quality data by using a rating system often applied to restaurants and movies.
As a compromise, the rating system was changed to a numerical summary with an overall score on a 100-point scale and separate scores in each performance area on a grid format.
But since then, resistance to publication of quality information has dissipated at the insistence of consumers, employer groups and the government, while research has shed more light on how to effectively represent quality data, Loeb said. "The world has changed in this 10-year period," he said.
The new format abandons the idea of converting detailed accreditation results to a consumer-focused report. Instead, it lists only an organization's accreditation status-accreditation, provisional accreditation or conditional accreditation-and the programs for which the organization is accredited such as hospitals, laboratories and home care.
The commission also gives prominent billing to its budding certification program for disease-specific care, touting in a shaded box on the first page any "demonstrated special competency" in areas such as diabetes or stroke care.
The first page also uses symbols as overall ratings on implementing patient safety practices and meeting quality-improvement goals compared with all other similar organizations nationally and statewide. The different elements in each of those areas are scored in more detail on subsequent pages, using both comparative symbols and numerical percentages of compliance with interventions such as giving aspirin at arrival or beta-blocker prescriptions at discharge for heart attack patients.
Applying easily understood comparative symbols for consumers was an important focus for the quality reports, Loeb said. "Just giving them a raw number doesn't tell them a lot," he said.
For example, hospitals offering aspirin at arrival 90% of the time for patients showing heart attack symptoms might seem like they're doing a good job, but those hospitals will get a minus on their reports. That's because the national average for the measure is 93%. "We don't want you to be satisfied at 91 (percent) if the rest of the industry can achieve 95 (percent)," said Evelyn Woods, the JCAHO's executive vice president of support operations and chief information officer.
The overall average for the nine Oryx measures of heart attack care is 91%, which will saddle hospitals with a minus grade on the opening page of their reports for percentage scores in the high 80s.
On the opposite extreme, the star symbol rewards providers that performed an appropriate intervention 100% of the time. Those measures already are adjusted to eliminate occasional situations in which the intervention is not the right move for certain patients, Loeb said.
The star symbol was added late in the formative process in response to feedback from researchers and other groups such as employer coalitions recommending additional incentives for well-performing providers to go beyond being above average, said Woods, who directed the revamp.
In general, provider performance rose significantly during the past year, some indicators reaching exemplary levels "because of the laser focus on some of these measures" in the Oryx program, the CMS-sponsored initiative and others, Loeb said. "Organizational improvements occur when the data get moved into the public domain."