What Price Health Accreditation? Hopefully Not the Quality of Care

When Boston’s Dana-Farber Cancer Research Institute was revealed to have mismanaged a breast cancer treatment protocol so badly that it killed one woman and crippled another, the prestigious hospital was quickly put on “probation.”

When health care providers at Tampa’s University Community Hospital amputated the wrong leg of an elderly man and, in an unrelated incident, inadvertently disconnected a critically ill patient from life support, it was stripped of its accreditation.

Probation ? Accreditation ? Who uses such polite academic vocabulary in response to such medical tragedies? The Joint Commission on Accreditation of Healthcare Organizations does. The JCAHO is one of those acronymically obscure, private organizations that wield enormous influence in the medical community. It is the Moody’s, Standard & Poor’s and Good Housekeeping of hospital ratings.

Hospitals lacking JCAHO accreditation are ineligible to receive Medicare funds. Hospitals placed on probation are generally seen as disgraced in the eyes of the health care community. In an increasingly competitive medical marketplace, the details of JCAHO accreditation surveys are being used by corporate health care purchasers, insurance companies and even consumers to determine whether their hospitals are capable of delivering top-quality care.

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Sadly and perversely, however, tragic events such as those at Dana-Farber and University Community are the easy calls. Those problems are unsubtle and unambiguous. Who would argue that their systems failed? The more difficult challenge is redefining health care standards in an era when cost management is granted parity to quality care and when new technologies offer hopeful patients many risky treatment possibilities.

Inevitably, accreditation becomes a crucial battleground to define what constitutes appropriate health care. The ongoing restructuring of the health care industry is reflected in the ongoing restructuring of accreditation standards, where accrediting institutions such as the National Committee for Quality Assurance are now accrediting managed-care plans much as the joint commission now accredits hospitals.

“As we move more towards a health care system that’s dominated by managed care, the less ability many consumers will have to vote with their feet,” says Dr. Lewis G. Sandy, a vice president of the Robert Wood Johnson Foundation who has worked with accreditation organizations. “The more that you have choice constrained, the more you need quality assurance done in a rigorous way. As that kind of accreditation becomes more important, it also becomes more political.”

For example, should companies be allowed to put their employees in unaccredited health plans? What happens when hospital accreditations clash with health plan accreditations? Health care providers with poor evaluations might lose both patients and payments from health insurers. To that extent, the accreditors can accelerate the multibillion-dollar restructuring and consolidation of the health care industry. The accreditation issues clearly mirror the tensions and conflicts that are already rife throughout the industry.

“The process of accreditation has moved from being the minimum set of acceptable standards for a hospital to ‘Here is an optimum standard--how close can you get to it?’ ” insists Dr. Nancy W. Dickey, a vice chair of the American Medical Assn.’s board of trustees who also serves on the board of the JCAHO. “Accreditation in the last decade has gone from minimal standards to pushing the boundaries.”

But during that same time, she acknowledges, the incentive structures for health care providers have radically changed.

“To accredit someone today unaware of the cost motivations that are impacting decision making would be blind. . . .” Dickey agrees. “It’s going to be terribly important that the incentives provided do not negatively impact the quality of care. Patients today need to understand the incentives of their health care providers--and the accreditation process now has to address that explicitly.”

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But when does reasonable cost management blur into the sort of corner cutting that places patients at risk? After a hospital downsizes, what are the appropriate staffing ratios for prompt and proper patient care? Just how long should it take a hospital to provide an important new medical procedure to its patients?

Because these are almost impossible questions to answer fairly and objectively, tomorrow’s accreditation will be more a product of generating measurable results rather than just following certification procedures.

“We are shifting the focus from structure and process to outcomes,” says Dr. Dennis S. O’Leary, president of the JCAHO. “We expect hospitals to show how they are taking outcomes data to monitor and improve their performance.” The same concern for “outcomes research” holds true for the National Committee for Quality Assurance as well, says its president, Margaret E. O’Kane. Both managed health plans and hospitals are now being told that they have to track the results of their treatments and interventions.

In other words, it will no longer be enough for hospitals and health plans to take care of their patients by following procedures. They will have to provide data that demonstrates, over time, the efficacy of those procedures. Successes and failures must be documented or accreditation will be withheld.

What this means is that accreditation is going to transform the medical marketplace into an information marketplace. Quality information will determine quality health care. Accreditation will increasingly become the standard by which health care providers and health plans are measured--and rewarded by patronage.

That, of course, begs the question: Who accredits the accreditors? As marketplace competition intensifies, look for that question to become one of the most controversial issues in health care.

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