As more than 1,200 U.S. hospitals celebrate their designation as a “Top Performer” from the nation's leading hospital accreditation body, some critics say the recognition does not necessarily provide an accurate picture of quality among the nation's healthcare providers.
A Joint Commission report released Thursday summarized how more than 3,300 hospitals fared on about four dozen performance accountability measures. But the majority are measures of processes (such as how many heart attack patients received aspirin on arrival or were prescribed a statin at discharge) rather than clinical outcomes (such as how many patients died or had to be readmitted to the hospital within 30 days of receiving care). That's a problem, according to some consumer groups.
This year's 1,224 top performers represent nearly 37% of the hospitals accredited by the Joint Commission. That's an 11% increase over 2013, and triple the number of qualifying hospitals that made the list four years ago.
“When we reward hospitals or give them accolades, it should be based on something a little more concrete,” said Lisa McGiffert, director of the Safe Patient Project at the Consumers Union. The new Joint Commission report lists “the top checklisters,” or those organizations that have proved they regularly follow standards of care or protocols, she said. The processes are meaningful internally to hospitals as they track how efficiently they provide care, but it may be misleading to patients to give hospitals a top-performer title just for following standard procedures. “Consumers need to look at much more than this to know if their hospital is a top performer,” McGiffert said.
Part of the concern is that process measures are a lot easier to measure than outcomes, says the author of the Skeptical Scalpel blog, a retired general surgeon whose uses his popular forum to highlight concerns with the healthcare system. (He remains anonymous in his posts.) There's nothing wrong with tracking a hospital's adherence to set standards, he said. “But it really doesn't have a lot to do with how the patients actually turn out, and it's not really a true measure of the quality of a hospital,” he said.
The annual list released Nov. 13 recognized top performers on specific measures, but did not rate all aspects of the quality of care provided in hospitals, said Dr. Mark Chassin, the Joint Commission's CEO. He defended the report and the “Top Performer” recognition. The accrediting organization carefully selects process measures that evidence shows drive better outcomes and that have clear steps hospitals can follow to achieve them, Chassin said.
“If we measure an outcome but the hospital has no idea what to do to improve, then we're setting up a lose-lose situation,” he explained. “We pick the ones that are strongly evidence-based, that we know we can measure accurately, and that can't be gamed by fiddling with coding.”
The scientific and measurement aspects needed to ensure that clinical outcome measures provide meaningful data on differences between hospitals have not all been worked out, agreed Dr. Robert Wachter, a leading quality and safety expert and associate chairman of the department of medicine at UCSF Medical Center in San Francisco.
“Many outcomes are not ready for prime time,” Wachter said. Both he and Chassin note, for example, that there are persistent and widespread concerns over 30-day readmissions, an outcome measure for which hospitals face increasing Medicare penalties. Several studies suggest the measure should be adjusted for socioeconomic factors that disproportionately affect hospitals in poor communities.
“I understand the argument consumer groups are making, and moving in the direction of more outcome measures is right,” Wachter said. But until the science catches up with the demand, the right thing for the Joint Commission and others to do is use a thoughtful combination of hospital process, outcome and structural measures (such as having an electronic health record) to make assessments.
To make the Joint Commission list, hospitals had to achieve cumulative performance of 95% or above across all reported accountability measures; achieve performance of 95% or above on every individual reported accountability measure for which there were at least 30 denominator cases; and have at least one core measure set with a composite rate of 95% or above.
The Joint Commission says hospitals have been required to report on additional measures this year, including several on perinatal care. Fewer hospitals are expected to make the top performers list in 2015 as they adjust to the newly added measures.
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