Measuring Researching and Monitoring the Quality of Health Care - Accreditation

Accreditation of health care providers—facilities and organizations—provides consumers, payers, and other stakeholders with the assurance that accredited facilities and organizations have been certified as meeting or exceeding predetermined standards. Accreditation refers to both the process during which the quality of care delivered is measured and the resulting official endorsement that quality standards have been met. In addition to promoting accreditation to health care consumers and other purchasers of care such as employer groups, accreditation assists health care facilities and organizations to recruit and retain qualified staff, increase organizational efficiencies in order to reduce costs, identify ways to improve service delivery, and reduce liability insurance premiums.

Joint Commission on Accreditation of Healthcare Organizations

As of 2004 the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) surveys and accredits more than sixteen thousand health care organizations and programs throughout the United States. JCAHO is a not-for-profit organization, headquartered in Oakbrook Terrace, Illinois, with a satellite office in Washington, D.C. JCAHO has more than one thousand surveyors—physicians, nurses, pharmacists, hospital and health care organization administrators, and other health professionals—who are qualified and trained to evaluate specific aspects of health care quality.

Working closely with medical and other professional societies, purchasers of health care services, and management experts as well as other accrediting organizations, JCAHO develops the standards that health care organizations are expected to meet. In addition to developing benchmarks and standards of organizational quality, JCAHO is credited with promoting improvement in infection control, safety, and patients' rights.

JCAHO GROWS TO BECOME THE PREEMINENT ACCREDITING BODY. Early efforts to standardize and evaluate care delivered in hospitals began in 1910 by the American College of Surgeons, a group that forty years later would start the present-day Joint Commission on Accreditation of Healthcare Organizations, originally dubbed the Joint Commission on Accreditation of Hospitals (JCAH) in 1953. In 1965 JCAH began to offer long-term care facilities accreditation as well as hospitals, and in 1972 the Social Security Act was amended to require the secretary of HHS to validate JCAH findings and include them in the HHS annual report to the U.S. Congress.

In 1975 JCAH expanded its scope to include accreditation of ambulatory health care facilities, and in 1978 it began to evaluate and offer accreditation to hospital laboratories. In 1983 accreditation of hospice care organizations began and the accreditation schedule was changed from a two-year cycle to three years for hospitals, psychiatric facilities, substance abuse programs, community mental health centers, and long-term care organizations. In 1987 JCAH was renamed the Joint Commission on Accreditation of Healthcare Organizations to reflect its greatly expanded scope of accreditation services.

In 1990 hospice accreditation was integrated into home health care accreditation processes, and accreditation for managed care organizations was initiated within the ambulatory care accreditation program. During the 1990s JCAHO moved to emphasize performance-improvement standards, required accredited hospitals to prohibit smoking in the hospital, and began performing random, "surprise" surveys—unannounced site visits to accredited organizations. JCAHO also offered accreditation to health care networks, preferred provider organizations (PPOs), and managed behavioral health care organizations.

On April 1, 1998, in a move intended to stem the rising tide of medical errors, JCAHO revised its sentinel event policy, the requirement that accredited organizations immediately report and investigate the causes of medical errors and institute preventive and corrective measures. In 1999 JCAHO launched a toll-free telephone complaint hotline to encourage patients, families, care-givers, and other concerned citizens to report concerns about quality of care at accredited organizations.

During 2000 JCAHO established standards and survey requirements for agencies that provide foster care services and developed cooperative agreements with professional organizations that certify and accredit blood banks, cancer centers, and hospital rehabilitation programs. JCAHO also added standards for assisted-living facilities, pain assessment and management programs, and office-based surgery programs. In 2001, following the terrorist attacks of September 11, JCAHO set up a command center to provide round-the-clock advice and counsel to accredited hospitals and health care organizations.

On July 1, 2002, JCAHO required hospitals to begin collecting and reporting data about the care they provide for four specific diagnoses—acute myocardial infarction (heart attack), heart failure, community-acquired pneumonia, and pregnancy and related medical conditions. JCAHO has termed these "core measure data" and will use them to compare facilities and assess the quality of service delivered. In 2002 JCAHO also moved to make its recommendations more easily understood by consumers so they could make informed choices about health care providers.

In June 2004 JCAHO began to identify a set of performance measures for its new Health Care Staffing Services Certification Program. Staffing firms certified by the Joint Commission will be required to use the standardized set of measures, which will allow for national comparisons among agencies that provide temporary nurses and other professional personnel to health care organizations. The certification program was designed to meet quality oversight needs that have arisen in recent years as a result of significant, ongoing shortages of nurses and other professional personnel. These shortages have forced health care organizations to fill vacant positions with temporary personnel provided by staffing firms, which are not themselves subject to any quality oversight mechanism. The Joint Commission certification program will provide an independent, comprehensive evaluation of an agency's ability to provide competent staffing services.

National Committee for Quality Assurance

The National Committee for Quality Assurance (NCQA) is another well-respected accrediting organization that focuses its attention on the managed care industry. NCQA began surveying and accrediting managed care organizations in 1991. By 2004 the majority of all health maintenance organizations (HMOs) in the United States had been reviewed by NCQA, and about half of the states accepted NCQA accreditation in place of state review since accreditation indicated that the managed care plans met specific regulatory requirements.

When a managed care organization undergoes a NCQA survey, it is assessed using more than sixty different standards, each focusing on a specific aspect of health plan operations. The standards address access and service, the qualifications of providers, the organization's commitment to prevention programs and health maintenance, the quality of care delivered to members when they are ill or injured, and the organization's approaches for helping members manage chronic diseases such as diabetes, heart disease, and asthma.

To ensure fair comparisons between managed health care plans and to track their progress and improvement over time, NCQA uses a tool called the Health Plan Employer Data and Information Set (HEDIS). The more than sixty HEDIS measures look at health care delivery issues such as:

• Management of asthma and effective use of medication
• Controlling hypertension (high blood pressure)
• Effective and appropriate use of antidepressant medications
• The frequency and consistency with which smokers are counseled to quit
• Rates of breast cancer screening
• The frequency and consistency with which beta blocker (drug treatment) is used following heart attack
• Rates of immunization among children and teens

NCQA combines HEDIS data with national and regional benchmarks of quality in a national database called Quality Compass. This national database enables employers and health care consumers to compare health plans to one another and make choices about coverage based on quality and value rather than simply price and participating providers (physicians, hospitals, and other providers that offer services to the managed care plan members).

NCQA issues health plan "report cards," rating HMOs and other managed care organizations (MCOs) that health care consumers and other stakeholders can access at the NCQA Web site. After NCQA review, MCOs may be granted NCQA's full accreditation for three years, indicating a level of excellence that exceeds NCQA standards. Those that need some improvement are granted one-year accreditation with recommendations about areas that need improvement, and those MCOs that meet some but not all NCQA standards may be denied accreditation or granted provisional accreditation.

In 2003 NCQA reported that managed care quality had improved dramatically for the fourth consecutive year. In 2003 participating health plans' performance on every measure was better than the previous year's results.

The 2003 NCQA State of Health Care Quality report was not nearly as positive as the report about the managed care. The NCQA found the nation's health care system plagued with "quality gaps" that prevent millions of Americans from receiving "best practice" care. These gaps result from factors such as poor use of technology and unreasonable payment systems, and they are responsible for more than fifty-seven thousand avoidable deaths each year. The report also documented the huge financial toll of commonplace failures to deliver appropriate care—nearly forty-one million sick days and more than $11 billion in lost productivity could be avoided annually if evidence-based "best practices" were more widely adopted. The "quality gaps" were not equally distributed throughout the system—health plans that measured and reported their performances were found to demonstrate higher levels of clinical quality.

Accreditation Association for Ambulatory Health Care, Inc.

Another accrediting organization, the Accreditation Association for Ambulatory Health Care, Inc. (AAAHC), was incorporated in 1979 and focuses exclusively on ambulatory (outpatient) facilities and programs. Outpatient clinics, group practices, college health services, occupational medicine clinics, and ambulatory surgery centers are among the organizations that are evaluated by AAAHC. The AAAHC accreditation process involves a self-assessment by the organization seeking accreditation and a survey conducted by AAAHC surveyors who are all practicing professionals. AAAHC grants accreditation for periods ranging from six months to three years.

In April 2002 the AAAHC and JCAHO signed a collaborative accreditation agreement that permits ambulatory health care organizations to use their AAAHC accreditation to satisfy JCAHO requirements. In June 2002 the Centers for Medicare & Medicaid Services (CMS) granted AAAHC authority to review health plans that provide coverage for Medicare beneficiaries. HMOs, PPOs, and ambulatory surgery centers are now considered Medicare-certified upon their receipt of accreditation from the AAAHC.

During 2003 and 2004 several states, including Florida, California, and Ohio, approved the AAAHC to conduct accreditation of office-based surgical centers, primary care practices, and freestanding radiology centers such as magnetic resonance imaging (MRI) services.