Study: Poor performers have best improvement

Significant improvement for 15 of 18 measures

Joint Commission’s 18 Quality-of-Care Indicators

ACUTE MYOCARDIAL INFARCTION

  • Aspirin within 24 hours after admission
  • Aspirin prescribed at discharge
  • ACE inhibitors prescribed at discharge for patients with left ventricular systolic dysfunction
  • Smoking-cessation counseling or advice
  • Beta-blocker within 24 hours after admission
  • Beta-blocker prescribed at discharge
  • Mean time from arrival to thrombolysis
  • Mean time from arrival to PCI
  • Inpatient death

HEART FAILURE

  • Discharge instructions regarding medications, diet, weight, worsening of symptoms, follow-up, and activity
  • Assessment of left ventricular function
  • ACE inhibitor prescribed at discharge for patients with left ventricular systolic dysfunction
  • Smoking-cessation counseling or advice

PNEUMONIA

  • Oxygenation assessment within 24 hours after admission
  • Pneumococcal screening, vaccination, or both by discharge
  • Blood cultures collected before initiation of antibiotic therapy
  • Smoking-cessation counseling or advice
  • Mean time from arrival to initial antibiotic administration

Source: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL.

A new study by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) on hospital performance between 2002 and 2004 showed that hospitals with a low level of performance at baseline had greater improvements over the two-year period than hospitals with a high level of performance at baseline in 16 of 17 process-of-care measures.1

In addition, the study, which examined hospitals’ performance on 18 standardized indicators of the quality of care for acute myocardial infarction, heart failure, and pneumonia, found significant improvement in performance on 15 of the 18 measures. (See box, right.)

Among those measures, the greatest improvement was seen in the three measures of counseling for smoking cessation. In addition, a 19%, 32%, and 33% absolute difference from the first quarter to the last quarter was seen for acute myocardial infarction, heart failure, and pneumonia, respectively.

"We were very encouraged by the results," says Scott C. Williams, PsyD, Director of JCAHO’s Center for Public Policy Research.

"I’m not sure what we expected, but this is what we hoped for; 15 of 18 measures really did show significant improvement, and the others did not show a downturn," he adds.

One of the things Williams says he found most interesting was that hospitals with a lower level of performance at baseline had greater improvements. "I’m not sure we’ve seen similar findings to this previously, but our initial reaction was that this was kind of intuitive," he asserts.

"But the more we thought about it, it shouldn’t be intuitive. Here these folks had been performing at a lower level, and for whatever reason, they were improving. There’s no reason to expect that they would look at their data and just improve. That’s an impressive thing and a good thing," Williams explains.

That’s not to say that high performers stood still, however. "High performers, where there was room to improve, still continued to improve," he notes.

The researchers recognized that increased documentation, in response to JCAHO requirements, may have helped boost the performance numbers, as more improvements might now be recorded than in the past.

"One of the things we expected was as we shined the light on these processes, documentation would improve — which we did see," says Williams. "All you can really say about what happened before is you didn’t know, because it was not documented."

The other key finding in the JCAHO paper was that despite the improvement, things certainly could get better. For example: 91% of heart attack victims got beta-blockers, and only 55% of heart failure patients received the necessary discharge instructions. "Those discharge instructions, smoking cessation, pneumococcal vaccination measures all saw good improvement but were still nowhere near where they need to be," he states.

As for the number of patients receiving beta-blockers, "I’d be happy if I saw 98% to 99% compliance on all the measures," Williams explains.

As for the future, he has this message for quality managers: "We will look to continue expanding measures and measure sets, so they have greater choices in what to focus on.

"We’d also like to see, whether from the federal government or from some other source, a real push towards electronic medical records. This will absolutely contribute to better outcomes," adds Williams.

Reference

  1. Williams SC, Schmaltz SP, Morton DJ, et al. Quality of care in U.S. hospitals as reflected by standardized measures, 2002-2004. N Engl J Med 2005; 353(3):255-264.

Need More Information? 

For more information, contact:

  • Scott C. Williams, PsyD, Director, Center for Public Policy Research, Joint Commission on Accreditation of Healthcare Organizations, Division of Research, 1 Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5166. E-mail: swilliams@jcaho.org.