Some of the same approaches to quality assessment described for physicians can be applied to hospitals. A useful starting place for assessing a hospital's quality is its accreditation. Accreditations to look for include these:
- Current, unrestricted license from the state.
- Current, unrestricted, nonprobationary accreditation from the Centers for Medicare & Medicaid Services for participation in Medicare and Medicaid.
The Joint Commission on Accreditation of Healthcare Organizations has an extensive process for assessing hospital quality with an on-site survey. Beginning January 1, 1995, the Joint Commission made available summaries of the results of its new surveys. These summaries, however, are brief and offer only general information. In addition, the Joint Commission's surveys were at one time criticized by the Inspector General of the U.S. Department of Health and Human Services as "unlikely to detect patterns, systems, or incidents of substandard care." Among the improvements implemented by the Joint Commission in an effort to address these concerns are the inclusion of outcomes measures in its review process, such as acute myocardial infarction, congestive heart failure, and complications of surgery.
General information on hospital facilities, personnel, and services are published annually by the American Hospital Association. This information can sometimes be helpful in making inferences about quality for particular conditions or procedures. For example, if you are having a high-risk delivery, you may wish to choose a hospital that has an advanced level nursery, including a dedicated neonatal intensive care unit. Or if you are planning a percutaneous transluminal coronary angioplasty, you might be well-advised to choose a hospital that offers high-quality emergency coronary artery bypass graft surgery, in the event it may be required.
The Centers for Medicare & Medicaid Services makes data publicly available on hospital performance through its Medicare Provider Analysis and Review (MEDPAR) files. In some states (e.g., Pennsylvania and New York), data are publicly available on hospital performance for specific conditions and procedures. These data can include the volume of cases, outcomes (mortality and complication rates), average length of stay, and average cost per case. Whether or not such data are publicly available for the condition or procedure of interest to you, you may wish to consider approaching the hospital administration directly with the following questions:
- What is the hospital's volume of admissions for the condition/procedure of interest?
- What is the success rate for the treatment/procedure at the hospital?
- What is the average length of stay for the condition/procedure?
- What are the results of your patient satisfaction survey for the most recent period (including response rate)?
- Does the hospital participate in any managed care networks (e.g., HMO, PPO, or POS plans)?
- Has the hospital been designated as a center of excellence for the condition/procedure by a health plan?
The final question will apply to only a small number of conditions/ procedures and hospitals. Nevertheless, one can find designated regional and national centers of excellence for high-risk, high-cost conditions/ procedures, such as organ transplantation, open-heart surgery, and burns. The National Institutes of Health also designates research centers for selected conditions. One might postulate that these centers are more likely to provide quality care for these conditions because of their successful research programs.
One variable to consider in assessing hospital quality is whether it is a major teaching hospital (defined as more than 0.097 teaching residents per hospital bed set up and staffed for patient care). Such hospitals have been found to have a lower risk of death than other hospitals, when evaluated for mortality due to hip fracture, stroke, coronary heart disease, and congestive heart failure.
The question pertaining to volume of patients treated with a particular condition or procedure can be extremely useful as a surrogate measure of quality. More than 20 years of research and dozens of published studies have linked better outcomes to hospitals and doctors delivering higher volumes of particular health care services. Research has confirmed the link of high volume to better outcomes in acute myocardial infarction (hospitals with more than 6.3 Medicare patients with acute myocardial infarction per week on average), major cancer surgery (hospitals with more than one Medicare patient per year on average for a given procedure), and carotid endarterectomy, surgery removing blockages from the carotid arteries to prevent stroke, (hospitals with more than 62 Medicare patients undergoing the procedure per year).
In interpreting hospital satisfaction survey results, it is important to consider the validity of the survey instrument and response rates. Ask whether the survey is based on a standard instrument that has been evaluated for its reliability and validity. If the survey has a response rate of less than 50 percent, the results should be considered suspect. Research suggests that nonrespondents to such surveys have lower levels of satisfaction than respondents.
HealthGrades.com Inc. is an organization that provides hospital quality rating information on the world wide web (www.healthgrades.com). Much of the HealthGrades quality rating system relies on publicly available Medicare data. A study of the ability of HealthGrades ratings to discriminate between individual hospitals in the processes and outcomes of their care was published by a team of researchers at Yale University. They found that HealthGrades ratings could accurately identify groups of hospitals that performed better in quality than other hospital groups. HealthGrades ratings did poorly, however, when it came to discriminating between two individual hospitals on their processes of care or mortality performance. The Leapfrog Group is an organization of large purchasers of health care that strives to create big leaps in health care safety, quality and value. The group recognizes hospitals conforming to their standards, publishing their performance on a number of measures of safety, quality and value on their website at www.leapfroggroup.org.
Additional resources to consider when evaluating hospital quality include the following:
- American Hospital Association, Chicago. www.aha.org
- Centers for Medicare & Medicaid Services, Baltimore, MD. www.cms.hhs.gov
Assessing hospital quality, both initially and on an ongoing basis, can be a labor-intensive process. As in the case of physician quality assessment, this kind of assessment and more should be obtainable with economies of scale through a quality health plan offering a provider network
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