by Marianna Kern Grachek, MSN, CNHA, FACHCA The high cost and limited availability of liability insurance present a significant challenge for long-term care organizations. For insurers, rising litigation rates in long-term care mean that identifying significant risks in the provision of this care is increasingly important. Accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is one way organizations can demonstrate to insurers a commitment to doing the right things and doing them well. Risk management in long-term care has evolved beyond managing liability and avoiding lawsuits. It means understanding the entire continuum of care and focusing on performance improvement, all the while maintaining a focus on outcomes of care. LTCQ, Inc., an independent long-term care information services company, recently completed an empirical study demonstrating that JCAHO-accredited long-term care facilities have better outcomes and fewer high-risk events.
The LTCQ study examined how accredited and nonaccredited facilities fared in surveys conducted by the Centers for Medicare and Medicaid Services (CMS). LTCQ analyzed both routine triennial surveys and special surveys triggered by resident or family complaints. All surveys were conducted from November 2000 through October 2001. Facilities were included in the sample if they had a triennial survey during that year; complaint surveys were included in the analysis if they took place during that year.
In all there were 13,654 facilities in the study sample. Of those, 1,538 were accredited; 617 were first accredited during the year of the study. The other 921 had been accredited before the start of the year in which the study was performed.
LTCQ's study found that JCAHO- accredited facilities had fewer healthcare deficiencies and fewer life-safety code deficiencies than nonaccredited facilities. In addition, facilities accredited prior to the study year had fewer healthcare deficiencies than those first accredited within the study year, suggesting that there is a cumulative benefit from the JCAHO accreditation process. All differences were statistically significant.
JCAHO-accredited nursing facilities had significantly fewer health-related deficiencies in categories, or levels, H and higher-deficiencies involving actual harm to more than an isolated number of residents, up to immediate jeopardy to any resident. Of nonaccredited facilities, 4.6% were found to have such deficiencies; only 2.2% of accredited facilities were cited for such deficiencies (Figure 1). Deficiencies involving immediate jeopardy were reported for 2.6% of nonaccredited facilities, but only 1.0% of accredited ones.
CMS reports on complaint surveys include the specific allegations made by the complainant (there might be several), whether the allegations were substantiated on the complaint survey and whether new health-related deficiencies were encountered. JCAHO-accredited facilities had fewer complaints, total allegations, substantiated allegations, abuse allegations and substantiated abuse allegations (Figure 2).
Quality Indicators and Accreditation Status
The Nursing Home Compare database reports several prevalence-based quality indicators (QIs), including the prevalence rates for pressure ulcers, restraints and contractures; there are also statistics for recent weight loss. The full survey database (aka OSCAR [Online Survey and Certification Reporting]) contains prevalence rates for the same conditions on admission to the facility, thus permitting the estimation of incidence rates. It also includes the rate of administration errors per 100 medication passes.
Accredited facilities had:
- An 18% lower prevalence of restraint use
- A 13% lower incidence of restraint use
- An 8% lower prevalence of contractures
- A 25% lower incidence of contractures
- A 5% lower rate of recent weight loss
- A 13% lower rate of medication administration errors
Raw rates of pressure ulcers were higher in accredited facilities, but risk-adjusted rates were not. Other differences in favor of accredited facilities all remained so after risk adjustment.
Figure 1. The relationship between accreditation status and survey deficiencies was greatest for facilities belonging to for-profit chains. Those facilities accredited for more than a year averaged 1.5 fewer survey deficiencies than did the nonaccredited facilities. Differences in rates of severe deficiencies were dramatic (Figure 3): For example, 4% of nonaccredited facilities had deficiencies of level H or higher. Only 2% of accredited facilities had such deficiencies.
Adjustments for Location, Staffing and Size