When it comes to hospital oversight, we assume the care we receive will be safe, effective and appropriate. But is this assumption fact or fiction?
Most of us like to be assured that when purchasing a product or service, we will receive the best value possible for the money we spend. To do so, we typically perform background “research” on the desired product(s) to help us become more comfortable before spending our hard-earned money. From this, we hope the purchase will at least meet our desired expectations.
To save us time, or at least help augment our individual sleuthing methods, we often rely on employing outside research organizations that have extensively researched thousands of products on our behalf. Consumer Reports is one excellent example. Another is the Good Housekeeping Seal of Approval.
Good Housekeeping Seal of Approval
The Good Housekeeping “stamp of approval” assures the general public that, once approved, a product will meet consumer expectations, as intended. In fact, the Seal includes a limited two-year warranty to financially protect the consumer should the product be “defective.” To earn the seal of approval, organizations must request a review of their product(s) from the Good Housekeeping Institute, which will then have their own scientists and engineers rigorously evaluate the product in their labs. If approved, a product is allowed to advertise the coveted seal on its package. Good Housekeeping serves as an independent, third-party that protects the public from inferior products, promoting a marketplace place built on trust.
Comparing Hospitals
How do you know a particular hospital delivers appropriate quality care that is safe when you or a loved one need it? Hospitals, through various national organizations and publications, are ranked annually to assist patients and their doctors to make informed decisions on where to seek the most appropriate care. For the period 2018-19, U.S. News & World Report performed their 29th annual Best Hospitals rankings. The rankings are made for 16 different specialties. Three other prominent hospital rankings are:
It is important to note that each ranking applies different methodologies when comparing hospitals. Because of this, a hospital may perform well in one ranking, but look considerably less favorably in another ranking – during that same year. Consequently, such disparate results can be very confusing (and frustrating), both for the general public and for hospitals. Additionally, some ratings organizations won’t disclose their methodology on the grounds that it is proprietary. If the methodology isn’t completely transparent, then one should be skeptical of its rankings.Hospital Accreditation
The public generally assumes that, beyond rankings, the quality and safety of each hospital is appropriately inspected, monitored and highly regulated by a government agency and/or independent organization that is sanctioned by the government to perform this oversight. For the most part, this is true. The Centers of Medicare and Medicaid Services (CMS) grant accreditation authority to CMS-approved accrediting organizations to identify deficiencies in healthcare delivery and help providers correct those deficiencies. For each hospital, accreditation serves as a fundamental process to assure a high baseline level of healthcare quality is provided to patients. For hospitals that serve Medicare patients and are eligible to receive Medicare payments, each hospital must take a great deal of preparation time (and pay accrediting organizations) to obtain this accreditation every three years (or pass state inspections).
On the surface, this all sounds reassuring to the public. However, it appears, thanks largely to a 2017 Wall Street Journal (WSJ) article, in addition to a recent study by Lam, Figueroa, et al., in BMJ, that accreditation may not be as rigid and transparent as we would assume (or hope). Like the Good Housekeeping Seal of Approval, accreditation should signify a stamp of approval that a hospital provides safe, effective care. Recent evidence suggests that accreditation is not accomplishing that goal.
The Joint Commission
The Joint Commission, a nonprofit organization that provides hospital accreditation, is responsible for about 88 percent of U.S. hospitals becoming accredited. Many Iowa hospitals and providers utilize the services of The Joint Commission. The other 12 percent of hospitals obtain accreditation by other CMS-approved accrediting organizations or are state reviewed only (with no independent accreditation). The Gold Seal is awarded by The Joint Commission to hospitals that receive accreditation.
The 2017 WSJ article found, through analysis of hundreds of inspection reports from 2014 through 2016, that The Joint Commission “typically takes no action to revoke or modify accreditation when state inspectors find serious safety violations.” In fact, in 2014, “not only did 350 hospitals have accreditation while in violation of Medicare safety requirements, but 60 percent of them also had such violations in the preceding three years.” Hospitals are allowed to keep their full accreditation despite being ousted from the Medicaid program for safety violations.
Pay-to-Play?
In addition to indirect costs of time spent preparing for the accreditation process, hospitals pay the Joint Commission an annual fee (based on hospital size) from $1,500 to $37,000. Additionally, hospitals must pay The Joint Commission to inspect them (every three years) for an average fee of $18,000. Finally, Joint Commission Resources, a subsidiary, can be hired by hospitals to help them attain and keep the accreditation. This relationship between hospitals and The Joint Commission provides the appearance of a ‘pay-to-play’ arrangement – a game that is not in the best interest of patients. The WSJ article quotes a former hospital-accreditation director at The Joint Commission citing this payment process as a “conflict of interest.” The evidence has become so compelling that last month the Trump Administration has announced increased oversight of the accreditation process.
Until recently, there has been little research that investigates whether accreditation affects patient outcomes. Much of the research performed reveals that accreditors focus largely on structural factors and processes, rather than achieving good patient outcomes. The recent study by Lam, Figueroa, et al. revealed that “…we did not find an association between accreditation status and patient outcomes…the data did not consistently support our hypothesis that hospitals accredited by The Joint Commission would have better outcomes.” Through many findings, this study concludes that “we found that hospitals accredited by private organizations did not have better patient outcomes than hospitals reviewed by a state survey agency…The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than the other lesser known, independent accrediting agencies.”
Why Should This Matter?
The Iowa Patient Safety Study© reveals that one-in-five patients in Iowa experienced a medical error within the past five years – with about 60 percent occurring in Iowa hospitals.
Every patient wants to know if a particular hospital is safe, effective and appropriate before receiving care. This also applies to clinics and other venues of care. After all, this is part of the transparency movement that calls for patients to become more informed while being an active participant in the care process. To do so, the healthcare system must provide credible (and honest) outcomes documentation that will instill confidence and trust. Unfortunately, there are large variations in complications and mortality rates across hospitals – putting the patient at great risk.
Let’s focus on what is most important, such as patient outcomes, and come clean with how this accreditation process is determined and ultimately revealed to the general public. Only then will we have the Good Housekeeping Seal of Approval on the most important ‘product’ we purchase.
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