Reducing Risk and Enhancing Value Through Accreditation

by Marianna Kern Grachek, MSN, CNHA, FACHCA

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).

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.

Adjustments for Location, Staffing and Size
JCAHO-accredited nursing facilities are more likely than nonaccredited ones to be found in urban areas in the eastern United States, and they tend to be larger. While they do not have more nursing staff per resident than nonaccredited facilities, they tend to have more permanent employees and fewer contract staff. To confirm that the differences between accredited and nonaccredited facilities were not merely the result of these other factors, LTCQ calculated statistical models that incorporated factors other than accreditation as independent predictors of deficiencies, complaints and QI problems.

In the analysis of the entire national sample, chain membership and for-profit status were considered, as well. These additional analyses confirmed the positive effect of accreditation and, in some cases, showed even stronger effects than a simple comparison of overall rates.

In this group of facilities:

• JCAHO-accredited facilities are 21% less likely to have a deficiency involving actual harm or immediate jeopardy (i.e., the odds ratio for deficiencies of level G or higher was 79%).
• JCAHO-accredited facilities are 39% less likely to have a deficiency involving harm to more than an isolated number of residents, or immediate jeopardy (odds ratio for deficiencies of level H or higher was 61%).
• JCAHO-accredited facilities are 33% less likely to have a deficiency involving immediate jeopardy (odds ratio for deficiencies of level J or higher was 67%).

• Odds ratio for deficiencies of level H or higher: 40%
• Odds ratio for deficiencies of level J or higher: 48%

Why the Differences?
JCAHO-accredited organizations fare better for a variety of reasons. JCAHO’s framework of key organizational and resident-focused functions provides long-term care organizations with a tool with which to proactively manage organ-izational risk. This framework helps the provider to create systems and processes to enhance positive outcomes and reduce clinical, financial and compliance-related risks.

Accreditation demands that facility (and, if applicable, chain) management continually monitor its performance and promptly institute quality-improvement activities if performance is deteriorating, or fails to attain a standard associated with good practice. The processes of preparing for accreditation and maintaining the level of standards compliance necessary for accreditation can create a quality-oriented culture in a facility or chain. In addition, accreditation advertises to consumers and regulators that a facility or chain has made a commitment to a quality culture and to voluntary external surveillance. This is a powerful, message in today’s environment.

In conclusion, the LTCQ findings strongly suggest that JCAHO accreditation is associated with lower risk, because preparation for accreditation surveys is, in itself, a risk-reduction activity. There appear to be real, substantial and consequential differences in the quality-improvement and risk-management activities of accredited facilities. The reduced exposure to risk experienced by JCAHO-accredited facilities warrants lower liability insurance rates. NH