Hospital accreditation is a process that assesses a hospital’s performance against a set of standards. This process is done differently across provinces and countries.
In Canada, most hospitals go through an accreditation process conducted by Accreditation Canada.
The accreditation process could be more transparent and provide more information to the public about the quality of care provided by hospitals
In September 2011, the American Joint Commission on Accreditation released a report identifying by name the top performing 405 medical centers in the United States across key quality measures. These measures included compliance with guidelines pertaining to a specific group of conditions, ranging from heart attack to pediatric asthma care.
In addition to reporting on individual organizations, the Joint Commission suggested that overall hospital quality has improved in the United States, some of which can be attributed to quality improvement efforts. In fact, many insurers and health plans in the United States are starting to tie hospital reimbursement with their performance on quality measures like infection and readmission rates.
The recent report by the Joint Commission received a great deal of press, as many of the hospitals with the most recognizable names – Columbia Presbyterian Hospital, Massachusetts General Hospital and Ronald Reagan UCLA Medical Center for example – were not on the list of top performing hospitals. The commissions’ president, Mark Chassin was quoted in the New York Times as saying “reputation and performance on important measures of quality do not always correlate”.
Would the same be true in Ontario?
Jack Tu, an internist at Sunnybrook Health Sciences Centre and scientist at the Institute for Clinical and Evaluative Sciences says that while “we have made progress in Canada, we lag behind the US around the quality of public reporting and the amount of information available” to measure health care system performance.
Accreditation and measuring quality in Ontario’s hospitals
While not mandatory, almost all of Ontario’s hospitals and many of the community-based health care provider organizations in the province (such as nursing homes) opt to go through regular accreditation reviews which are conducted by a national non-profit independent organization called Accreditation Canada. The accreditation process is intended to ensure that health care provider organizations are meeting a shared set of standards. Accreditation occurs on a three-year cycle, with a full, on-site survey every three years. Accreditation includes extensive measurement of performance – using over 2000 different criteria to measure various aspects of organizational performance – including patient safety and quality of care, infection prevention and control, medication management, organizational culture and effective governance.
However, the results of Canadian accreditation surveys and reviews are not released publicly. Why isn’t this information public?
Accreditation Canada reports are confidentially provided to the CEOs of the health care organizations that participated in the process. However Wendy Nicklin, CEO of Accreditation Canada, notes that “on the first page of the report there is a statement that Accreditation Canada encourages organizations to be transparent”. Nicklin also notes that among the provinces, Quebec has taken the lead in mandating that these reports are publicly released, and some other provinces have indicated they may do the same. However, Nicklin cautions that “it is important to make sure that if this information is made public it is communicated and conveyed in a way that is appropriate and useful to a public audience so as to avoid misinterpretation”. Murray Martin, CEO of Hamilton Health Sciences notes that “what nobody wants is for accreditation results to be misinterpreted … the accreditation process should be that the public has faith in their health care system, not a process that will leave them in doubt”.
Should patients and the public know the accreditation and quality status of their hospitals?
There is some evidence suggesting that publicly reporting on hospital performance can constructively influence the quality of patient care. Tu describes the United States as “being far more aggressive about reporting data such as heart attack survival rates and outcomes after cardiac surgery, where all that information is available on the web by hospital” and that in contrast “for the most part we are still in the dark about what goes on inside hospitals in Canada”.
While releasing performance information is often perceived as risky by hospitals, evidence suggests that they may have much to gain. There is little evidence that suggests members of the public use publicly-reported performance information to avoid poorly performing organizations. The evidence suggests, however, that making this information public has a motivating effect on hospital management and clinical leaders to improve quality of care and performance. Tu suggests that “public reporting is an effective mechanism to encourage hospitals and providers to improve quality of care” if “the right indicators are reported, and the information is actionable and credible”.
However, some argue that the performance information assessed in accreditation is not the right kind of performance information to share with the public. Stephen Duckett, former CEO of Alberta Health Services argues that “an accreditation system should be one that forces improvement – releasing the accreditation reports might end up making them more punitive” of poorly performing health care organizations. Duckett also notes that hospitals in Alberta, similar to Ontario hospitals, are mandated to publish quarterly information on infection rates, and emergency department wait times every three months. He suggests that “some of the accreditation measures are only measured once a year, and this information can be outdated”.
The future of public reporting of performance in Ontario and Canada
Recently Ontario introduced the Excellent Care for All Act which requires hospitals to publicly release performance improvement plans within their own organizations. Hospital CEO compensation will be tied to progress in these measures.
Accreditation Canada notes in its 2010-2013 Strategic Plan that its “role in knowledge transfer to support ongoing quality improvement and adoption of best practices needs to be defined and further developed” and that Accreditation Canada’s “role in enhancing public awareness of the role and value of accreditation should be clarified”. Martin notes that the accreditation process “has very low public recognition and that the public release of this information would help increase the stature of accreditation, as well as recognize its role and value”.
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Accreditation – lovely white wash. I don’t think accreditation as we currently see it means anything. The evaluations are superficial, things get spruced up, and two weeks later, everything is the same as it was. In fact, accreditation doesn’t really produce a change in behaviour, just a change in appearance.
The solution – make the hospitals compete for patients and funding based on short and long term outcomes and publish as much information as possible.
The patient in me says, ” Does it really matter? In most cases someone else decides which hospital I will end up in – usually my GP or the ambulance dispatcher.” The taxpayer in me says, “Absolutely! We should all be able to access and assess this information.”
I have only once in my life given explicit orders not to go to a specific hospital because of a bad prior experience. If you think that that is a declaration about that specific hospital, you would be wrong. I go there usually but avoid specific departments, in this case, the emergency room. And that has less to do with the medical staff than it has to do with the patients in emergency who do not have emergencies but they also do not have their own family doctor so go there for sniffles, the flu and other non emergency type issues. Sadly, this seems to be a problem in all Ontario hospitals, perhaps in all Canadian hospitals. I don’t know. What it says to me however, is that something isn’t working according to Hoyle in our hospitals and needs to be fixed. Perhaps if the taxpayer knew how much time and money are wasted, they would be more likely to demand the required changes. So make it public knowledge. It will not only push the medical community within the hospital to perform to their best, it will push the administrators to do their best also and it will push the politicians to dole out money and write the medical laws and regulations based on facts and not on whoever is the best at marketing.
One of the best practices for a highly performing health care system to adopt is for health care provider institutions to publicly publish their performance indicator rates. Published rates drive performance
As long as measures are valid and well selected, they should be published for the public. Transparency changes behavior, and drives performance
The NACQ (The de facto accreditation institution in the US similar to Accreditation Canada) initially faced a lot of resistance similar to the current fear and resistance in Canada – to publish measures publicly. Several questions were raised about the validity of their measures, and their measurement system. However, because of the public’s pressure to have hospitals accountable and transparent, the organization slowly became the seal of approval for a lot of consumers and corporations. This forced more hospitals, on their own accord, to publicly publish their indicators, in order to gain the seal of approval by the public. This resulted in changes in behaviour for most hospitals, and as the years went by more hospitals published, and those who had published before, continually strived to improve their publicly displayed performance measures.
Despite taking everything else cited as a negative for public display of performance measures, ( e.g misintepretation of data by public ) in account , transparency has been shown to change behaviour , which means published rates drive performance.
For a healthcare system to adopt to best practices, like the rest of the world ( US, Britain) publicly published performance indicator rates will drive performance ( re : Bending The Cost Curve Report )
In general, I am all in favor of greater transparency in any process. I think what I would want to know before deciding whether accreditation reports ought to be publicly available is how clearly the reports capture hospital quality, as opposed to characteristics of the patient populations they serve. I can think of at least two areas when this could be an issue.
The first would be tertiary care facilities that take on patients with extremely complicated medical histories. Sick Kids, for example, often admits children for procedures that could be performed at community hospitals, but are done at Sick Kids due to some added complexity or greater severity . We would want to be careful to make sure that in measuring something like readmission rates, the readmissions were due in some measurable way to the quality of care provided, rather than the fact that many of their patients are more complex.
The second would be community hospitals who serve particularly complex populations, such as inner city hospitals and those serving Aboriginal populations. In both cases, high proportions of patients have chronic conditions that may drive up readmission rates through no fault of the hospital. Again, we would want to be sure that the measurements we are employing are sensitive enough to be able to distinguish between readmissions due to quality problems vs. readmissions due to patient complexity.
One way to address this challenge might be to classify hospitals according to their primary patient populations, in order to ensure fair comparisons – such that Sick Kids would only be compared to other children’s hospitals, and St. Michael’s would only be compared to other inner-city hospitals. If we can be sure that the measurement process is fair and accurate, then I would be happy to see the results made public.