Moffett ML (Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VAMC and Baylor College of Medicine)
Morgan RO (Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VAMC and Baylor College of Medicine)
All VAMCs offering inpatient services use the JCAHO accreditation process. Compliance with JCAHO standards and preparation for the triennial survey is time consuming and costly, however, the effects on quality of care have never been investigated. The goal of this study is to assess the role of JCAHO surveys as a measure of process quality.
VA administrative inpatient databases were used to extract hospital characteristics, patient characteristics and treatment outcomes for all admissions for Heart Failure (DRG 127) from the first quarter 1996 to the fourth quarter 2003. Patient outcomes were death during stay, death within 30 days of discharge, 90-day readmission, and patient misadventures. These data were combined with JCAHO survey data and include the full survey score, 45 performance area scores, and date of inspection. Performance area scores were grouped into Patient Focused Functions (PFF- e.g. assessment and treatment procedures and medication use), Organizational Functions (OF – e.g. leadership, and human resource management), and Structures with Functions (SF – e.g. credentialing and governance). Adjusting for time trends, hospital size, specialty in heart failure, age, gender, income, admission, and co-morbidities, we examined how variation in PFF, OF and SF explained variation in patient outcomes.
Variation in Full Survey scores showed no significant associations with outcomes of care. Better PFF scores were associated with reduced patient mortality within 30 days of discharge (p=0.01), reduced 90-day readmission rates (p=0.05), and fewer patient misadventures (p=0.004). In contrast, better OF scores were associated with worse patient outcomes; including higher 30-day mortality (p=0.001), more 90-day readmissions (p<0.001) and more patient misadventures (p=0.04). Better SF scores were associated with worse 30-day mortality (p=0.09) but fewer patient misadventures (p=0.05).
Patient-focused performance area scores are indicators of process quality. However, the inverse relationships between OF scores and patient outcomes are disturbing. If these performance areas measure aspects of organizational efficiency, our findings may demonstrate a tradeoff between efficiency and care quality.
Full Survey scores from JCAHO hospital inspections do not predict quality of care. Improvements in overall scores depend on improvements in both PFF and OF scores which appear to have opposing associations with patient outcomes.