Quality of care in accredited and non-accredited ambulatory surgical centers

Abstract

Little is known about quality outcomes in accredited and nonaccredited ambulatory surgical centers (ASCs). Quality outcomes in ASCs accredited by either the Accreditation Association for Ambulatory Health Care (AAAHC) or The Joint Commission were compared with those of nonaccredited ASCs in Florida.
Patient-level ambulatory surgery and hospital discharge data from Florida for 2004 were merged and analyzed. Multivariate logistic regressions were estimated separately for the five most common ambulatory surgical procedures: colonoscopy, cataract removal, upper gastroendoscopy, arthroscopy, and prostate biopsy. Statistical models examined differences in risk-adjusted 7-day and 30-day unexpected hospitalizations between nationally accredited and nonaccredited ASCs. In addition to risk adjustment, each model controlled for facility volume of procedure and patient demographic characteristics including gender, race, age, and insurance type.
In multivariate analyses that controlled for facility volume and patient characteristics, patients at Joint Commission-accredited facilities were still significantly less likely to be hospitalized after colonoscopy. Specifically, compared with patients treated in nonaccredited ASCs regulated by the state agency, patients treated at those facilities were 10.9% less likely to be hospitalized within 7 days (adjusted odds ratio [OR] = 0.891; 95% confidence interval [C.I.], 0.799-0.993) and 9.4% less likely to be hospitalized within 30 days (adjusted OR = 0.906; 95% C.I., 0.850-0.966). No other differences in unexpected hospitalization rates were detected in the other procedures examined.
With the exception of one procedure, systematic differences in quality of care do not exist between ASCs that are accredited by AAAHC, those accredited by the Joint Commission, or those not accredited in Florida.

Full text

The Joint Commission Journal on Quality and Patient Safety
Quality of Care in Accredited and Nonaccredited Ambulatory
Surgical Centers
Accreditation
546
Accreditation of health care facilities is considered a use-
ful way to foster accountability in the provision of
patient care.1–3 Positive accreditation status, often used
as a marketing tool, communicates to stakeholders that a given
organization has met established benchmarks associated with
excellence in processes of care.4,5 Quality of care has become an
important topic,6,7 particularly for ambulatory surgery centers
(ASCs), which have experienced significant growth in the past
decade.8,9 The number of Medicare-certified ASCs increased
more than 60%—from 3,028 in 2000 to 4,964 in 2007—and
Medicare payments more than doubled, from $1.4 billion to
$2.9 billion.
In Florida, ASCs must be accredited by a nationally recog-
nized organization or be subjected to annual licensure surveys
conducted by the state regulatory agency.10 In the United States,
ASCs can obtain accreditation by one of three main organiza-
tions—the Accreditation Association for Ambulatory Health
Care (AAAHC), The Joint Commission, or the American
Association for the Accreditation of Ambulatory Surgical
Facilities (AAAASF).11 Although regulations differ by state,3
accreditation by one of these organizations generally exempts
ASCs from annual licensing site visits by their state regulatory
agency. In Florida, accredited ASCs may still be subjected to
accreditation validity checks conducted annually by the state.10
The ultimate goal of any accrediting body, or state regulato-
ry agency, is to ensure quality of care among the organizations
for which it has oversight. However, each oversight body estab-
lishes and maintains unique criteria with emphasis on different
standards of excellence.2,11 Furthermore, regulators and accredi-
tation bodies have historically focused on processes of care
rather than outcomes.12,13 Thus, despite the growing and
increasingly important ambulatory surgical setting, no compar-
ative studies have examined quality outcomes in ASCs that are
governed by differing oversight bodies.14
This article compares quality outcomes of accredited ASCs
operating in Florida with those of nonaccredited facilities.
More specifically, we were interested in whether ASCs accredit-
Article-at-a-Glance
Background: Little is known about quality outcomes in
accredited and nonaccredited ambulatory surgical centers
(ASCs). Quality outcomes in ASCs accredited by either the
Accreditation Association for Ambulatory Health Care
(AAAHC) or The Joint Commission were compared with
those of nonaccredited ASCs in Florida.
Methods: Patient-level ambulatory surgery and hospital
discharge data from Florida for 2004 were merged and ana-
lyzed. Multivariate logistic regressions were estimated sepa-
rately for the five most common ambulatory surgical
procedures: colonoscopy, cataract removal, upper gastroen-
doscopy, arthroscopy, and prostate biopsy. Statistical mod-
els examined differences in risk-adjusted 7-day and 30-day
unexpected hospitalizations between nationally accredited
and nonaccredited ASCs. In addition to risk adjustment,
each model controlled for facility volume of procedure and
patient demographic characteristics including gender, race,
age, and insurance type.
Results: In multivariate analyses that controlled for facili-
ty volume and patient characteristics, patients at Joint
Commission–accredited facilities were still significantly less
likely to be hospitalized after colonoscopy. Specifically,
compared with patients treated in nonaccredited ASCs reg-
ulated by the state agency, patients treated at those facilities
were 10.9% less likely to be hospitalized within 7 days
(adjusted odds ratio [OR] = 0.891; 95% confidence inter-
val [C.I.], 0.799–0.993) and 9.4% less likely to be hospital-
ized within 30 days (adjusted OR = 0.906; 95% C.I.,
0.850–0.966). No other differences in unexpected hospital-
ization rates were detected in the other procedures exam-
ined.
Discussion: With the exception of one procedure, system-
atic differences in quality of care do not exist between ASCs
that are accredited by AAAHC, those accredited by the
Joint Commission, or those not accredited in Florida.
Nir Menachemi, Ph.D., M.P.H.; Askar Chukmaitov, M.D., Ph.D.; L. Steven Brown, M.S.; Charles Saunders, Ph.D.;
Robert G. Brooks, M.D., M.B.A.
September 2008 Volume 34 Number 9
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547
September 2008 Volume 34 Number 9
The Joint Commission Journal on Quality and Patient Safety
ed by AAAHC and the Joint Commission differed from their
nonaccredited counterparts with respect to quality outcomes.
The results of our study, which addresses the call for more re-
search on patient safety and quality outcomes,14,15 especially
among accredited and nonaccredited facilities,2,12,16 should shed
light on important factors that may be related to improved
quality.
Methods
DATA SOURCES
To examine differences in quality outcomes among ASCs, our
study draws on multiple data sources that were originally
assembled as part of a larger study.17 We examined differences
in outcomes between ASCs and hospital-based outpatient
departments17 and identified the existence of racial disparities in
ambulatory surgical outcomes.18 All the data were obtained
from the Florida Agency for Health Care Administration
(AHCA), the governmental agency responsible for state licen-
sure of health care facilities. We used the 2004 ambulatory sur-
gery discharge database, the 2004 hospital discharge database,
and a separate administrative database that contains ASC facil-
ity characteristics, including accreditation type.
PROCEDURES
Using the ambulatory discharge database, we identified the
five most common procedures performed in ASCs among
adults 18 years of age or older in 2004. Those procedures
included colonoscopy (n= 315,070), cataract removal (n=
245,154), upper gastrointestinal endoscopy (n = 122,682),
arthroscopy (n= 31,335), and biopsy of the prostate (n=
6,231). Note that these and other ambulatory procedures can
also be performed in hospital-based outpatient departments
(HOPDs) or physician offices. However, oversight of hospitals
and physician offices is performed by a different set of accredi-
tation bodies, and these organizations are therefore outside the
scope of the current analysis.
MEASURES
The primary outcomes measure is hospitalization after
ambulatory procedures, which represents an important measure
of quality for ambulatory procedures.19 Hospital admissions fol-
lowing ambulatory surgery is an easily identifiable quality indi-
cator and an important outcome measure in this setting
because it reflects perioperative complications, adds to health
care cost, and is disruptive for patients.20 The main purpose of
accountability through accreditation is frequently to improve
quality by achieving better outcomes and to improve efficiency
by reducing costs. Thus, hospitalizations are important out-
comes measures to consider when examining the affect of
accreditation on quality of care.
Using patient-level identifiers, we linked the ambulatory dis-
charge database to the hospital discharge database. We then
determined unexpected hospitalizations at 7 days and at 30
days after ambulatory surgical procedures. Using both 7- and
30-day measures allows for the capture of adverse events that
take longer than one week to develop and accounts for patient
lag times from symptom development to presentation at the
hospital for care.
Not all hospital admissions after an ambulatory surgical pro-
cedure are related to the procedure itself. As such, the research
team [the authors], consisting of a panel of physicians and
researchers, evaluated hospital admissions for each individual
procedure using diagnosis-related group (DRG) codes. The rea-
sons for hospitalization from the DRG codes were discussed,
and, with a high degree of agreement, admissions deemed unre-
lated to the ambulatory procedure were excluded. For example,
hospital admissions due to substance abuse, HIV/AIDS, or psy-
chiatric or reproductive systems’ disorders were excluded
because there were no direct relationships with any of the
ambulatory surgical procedures being examined. By excluding
nonrelated hospitalizations we ensured the greater reliability of
the quality indicators.
Our main independent variable, accreditation status, was
obtained by AHCA along with other ASC characteristics from
the most recent licensure forms on file with the agency.
Accreditation status was defined as accreditation by the either
the Joint Commission, AAAHC, or AAAASF, or not accredit-
ed (that is, oversight provided by the state regulatory agency).
For the top five 2004 procedures that were the focus of our
analyses, no ASC was accredited by AAAASF, which typically
focuses on reconstructive and cosmetic surgical facilities.
Therefore, we present results comparing ASCs regulated by the
state and those accredited by either AAAHC or the Joint
Commission.
STATISTICAL ANALYSES
Standard descriptive statistics, including frequencies and
measures of central tendency, were first used to examine the
data. Next, to examine the effect of accreditation type on qual-
ity of care in ASCs, adjusted odds ratios (ORs) were calculated
using logistic regression modeling techniques. To separate the
potential effect of cumulative procedures conducted on the
same patient, each outcome was separately examined for each
of the five procedures. When patients received the same proce-
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548 September 2008 Volume 34 Number 9
The Joint Commission Journal on Quality and Patient Safety
dure twice (for example, removal of two cataracts) and were
subsequently hospitalized, only one of their procedures count-
ed as an unexpected hospitalization.
Increasing evidence in the literature suggests that facility
volume plays an important role in improved outcomes.21–23
Thus, we controlled for total facility volume of a given proce-
dure in each of the models. In addition, we controlled for
patient characteristics—race, age, insurance type, gender (with
the obvious exception of prostate biopsy), and severity of ill-
ness. Severity of illness was calculated using the Diagnosis Cost
Groups-Hierarchical Condition Categories (DCG-HCC)
methodology (RiskSmartTM StandAlone software, release 2.1;
DxCG, Boston), which was previously validated24,25 and is cur-
rently used by the U.S. Centers for Medicare & Medicaid
Services for calculating adjusted payment amounts.26 The
DCG-HCC method produces a continuous measure of comor-
bidities that is based on primary diagnosis and up to five sec-
ondary diagnoses for each patient.
Data management was conducted in SAS version 9.0 (SAS
Institute, Inc., Cary, North Carolina), and data analysis was
conducted in SPSS version 14.0 (SPSS, Inc., Chicago). Our use
of this data was approved by our university Institutional Review
Board.
Results
SAMPLE
In 2004, a total of 364 ASCs were in operation in Florida, of
which 106 (29%) indicated they were accredited by AAAHC,
95 (26%) indicated accreditation by the Joint Commission, and
the remaining 163 ASCs (45%) had no national accreditation
and received oversight by AHCA, the state regulatory agency. A
total of 720,472 patients received care in 2004 for one of the
five most common ambulatory surgical procedures. Given this
large sample size, statistical differences in patient demographics
were detected among facilities receiving oversight from each of
the accreditation/regulatory bodies (Table 1, above). For exam-
ple, facilities receiving oversight from the state agency were
more likely than facilities with national accreditation to treat
Hispanic patients (p< .001) and were less likely to treat white
patients (p< .001). Moreover, Joint Commission–accredited
ASCs treated slightly fewer Medicare patients and slightly more
indemnity-insured patients than their counterparts.
Ambulatory Surgical Center Oversight By:
Joint Commission AAAHC State Regulatory Agency
(n= 95 facilities) (n= 106 facilities) (n = 163 facilities)
Race/Ethnicity
White 219,100 (85.61%) 201,890 (80.26%) 157,998 (74.17%)
African American/Black 13,339 (5.21%) 14,093 (5.60%) 9,067 (4.26%)
Hispanic 13,013 (5.08%) 23,089 (9.18%) 28,577 (13.42%)
Other or unknown 10,479 (4.09%) 12,458 (4.95%) 17,369 (8.15%)
Patient Age
18-49 years 42,742 (16.70%) 30,013 (11.93%) 28,543 (13.40%)
50-64 years 80,768 (31.56%) 64,728 (25.73%) 57,363 (26.93%)
65-74 years 67,807 (26.49%) 76,833 (30.55%) 64,962 (30.50%)
75-84 years 54,782 (21.40%) 67,480 (26.83%) 52,601 (24.69%)
84 years or greater 9,825 (3.84%) 12,471 (4.96%) 9,533 (4.48%)
Gender
Male 111,731 (43.66%) 108,343 (43.07%) 93,012 (43.67%)
Payer Type
Medicaid 5,062 (1.98%) 3,107 (1.24%) 5,175 (2.43%)
Medicare 124,982 (48.83%) 140,769 (55.97%) 111,124 (52.17%)
Indemnity insurance 86,918 (33.96%) 73,535 (29.24%) 63,213 (29.68%)
Managed care 28,833 (11.27%) 26,814 (10.66%) 28,889 (13.56%)
Other 10,136 (3.96%) 7,305 (2.91%) 4,610 (2.17%)
Severity of Illness
Average patient severity†0.75 0.84 0.80
* All pvalues < 0.01. Numbers may not add up to 100% because of rounding. AAAHC, Accreditation Association for Ambulatory Health Care.
†Average patient severity score is relative to 1.0 for all surgical outpatients in Florida (1997–2004), as calculated with Diagnosis Cost Groups-Hierarchical
Condition Categories software.
Table 1. Patient Demographic Information by Facility Type*
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations

UNANTICIPATED HOSPITALIZATIONS
Unadjusted (raw) rates of unanticipated hospitalizations at 7
and 30 days are presented in Table 2 (above). Overall, no dif-
ferences in unadjusted hospitalization rates existed between
ASCs receiving oversight from the Joint Commission,
AAAHC, or the state agency. However, among colonoscopy
patients, Joint Commission–accredited facilities had lower raw
rates of 30-day (1.83% versus 1.96% for AAAHC versus
2.00% for state agency; p= .01) unexpected hospitalizations
and marginally lower raw rates of 7-day (0.61% versus 0.63%
for AAAHC versus 0.69% for state agency; (p= .09) unexpect-
ed hospitalizations. In addition, AAAHC facilities had margin-
ally lower unadjusted 30-day hospitalization rates among
cataract patients (1.13% versus 1.25% for the Joint
Commission versus 1.20% for state agency; p= .08).
In multivariate analyses that controlled for facility volume
and patient characteristics, patients at Joint Commission–
accredited facilities were still significantly less likely to be hos-
pitalized after colonoscopy (Table 3, page 550). Specifically,
compared with patients treated in ASCs regulated by the state
agency, patients treated at those facilities were 10.9% less like-
ly to be hospitalized within 7 days (adjusted OR = 0.891; 95%
confidence interval [C.I.], 0.799–0.993) and 9.4% less likely to
be hospitalized within 30 days (adjusted OR = 0.906; 95%
C.I., 0.850–0.966). No other differences in unexpected hospi-
talization rates were detected in the other procedures examined.
Discussion
The purpose of the current study was to explore quality out-
comes among the most common procedures performed in
Florida-based ASCs that are either accredited by a national
organization or unaccredited and regulated by the state. The
main findings of our analyses suggest that systematic differ-
ences in quality of care do not exist between ASCs that are
accredited by the AAAHC or the Joint Commission or that are
regulated by the state agency responsible for licensure in
Florida. With the exception of colonoscopy, where Joint
Commission–accredited facilities exhibited slightly lower unex-
pected hospitalizations relative to nonaccredited ASCs, no dif-
ferences were noted. This finding suggests that perhaps the
work flow for colonoscopies lends itself to improvement as a
direct result of accreditation standards.
549
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The Joint Commission Journal on Quality and Patient Safety
Ambulatory Surgical Center Oversight By:
Joint Commission AAAHC State Regulatory Agency
(n= 95 facilities) (n= 106 facilities) (n = 163 facilities) pValue
Arthroscopy (Total N= 31,335)
Number of patients treated 14,893 11,096 5,346
Raw 7-day unexpected hospitalization rate 0.36% 0.43% 0.45% .51
Raw 30-day unexpected hospitalization rate 1.01% 0.90% 1.09% .48
Colonoscopy (Total N= 315,070)
Number of patients treated 124,375 94,877 95,818
Raw 7-day unexpected hospitalization rate 0.61% 0.63% 0.69% .09
Raw 30-day unexpected hospitalization rate 1.83% 1.96% 2.00% .01
Upper Gastroendoscopy (Total N= 122,682)
Number of patients treated 54,801 30,487 37,394
Raw 7-day unexpected hospitalization rate 0.81% 0.78% 0.77% .78
Raw 30-day unexpected hospitalization rate 2.58% 2.45% 2.55% .50
Cataract Removal (Total N= 245,154)
Number of patients treated 59,338 114,643 71,173
Raw 7-day unexpected hospitalization rate 0.33% 0.29% 0.31% .39
Raw 30-day unexpected hospitalization rate 1.25% 1.13% 1.20% .08
Prostate Biopsy (Total N= 6,231)
Number of patients treated 2,524 427 3,280
Raw 7-day unexpected hospitalization rate 0.75% 0.47% 0.85% .68
Raw 30-day unexpected hospitalization rate 2.85% 1.87% 2.35% .32
* Unadjusted (raw) hospitalization rates have unrelated hospitalizations (for example, HIV/AIDS, substance abuse, psychiatric disorders) excluded. AAAHC,
Accreditation Association for Ambulatory Health Care.
Table 2. Unadjusted Rates of Unexpected Hospitalizations in Ambulatory Surgical Centers
by Procedure in Florida, 2004*
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550 September 2008 Volume 34 Number 9
The Joint Commission Journal on Quality and Patient Safety
These findings suggest that despite differences in review cri-
teria by oversight organizations, facilities performing the five
most common ambulatory surgical procedures offer their
patients comparable quality as measured by unexpected hospi-
talizations, an important patient outcome. These findings are
somewhat different from the inpatient and health plan litera-
ture, where accredited organizations generally perform better
on quality measures. For example, several researchers have
reported that accredited hospitals perform better on various
quality measures,27–29 and others have reported that accredited
health plans have higher scores on some quality measures.30
The lack of difference noted in the ambulatory setting, com-
pared with other settings of care, may reflect the nature of sur-
gical procedures performed in ASCs. Most patients treated in
ASCs are relatively healthy, and adverse outcomes are some-
what rare events. In addition, the elective nature of many
ambulatory surgical procedures makes the outpatient setting
very different from procedures performed in a hospital.
Although oversight, including accreditation, may be important,
outcomes in this setting may be more reliant on physician skill.
The extent to which board certification and other physician
characteristics is related to improved outcomes is well known in
both the inpatient31,32 and outpatient33 settings.
Despite the overall trend of no quality differences in ASCs,
we found that colonoscopy patients treated at Joint
Commission–accredited facilities had improved outcomes after
controlling for confounders. Even though oversight organiza-
tions have traditionally focused on processes of care, about 50%
of the Joint Commission standards relate directly to patient
safety,11 and Joint Commission leadership has been outspoken
about its organization’s role in reducing medical errors.34
Furthermore, the Joint Commission has increasingly been
interested in monitoring and evaluating actual results of care,
especially in the hospital setting.1,13 Whether this emerging
focus on outcomes is affecting the results for colonoscopy
patients is unknown. However, patients should consider
accreditation status and overseeing organization when selecting
ASCs for colonoscopies in Florida.
Despite the new information that this study presents, sever-
al research limitations are worth mentioning. First, our findings
are based on the use of administrative data sets that were origi-
nally collected for reasons other than research. The well-docu-
mented limitations35,36 of secondary data, including the
potential for coding inaccuracy and the bias associated with
nonclinical data, may apply to the current study. An addition-
al potential source of bias is related to the imperfect nature of
any risk-adjustment methodology,37 although we used the best
available method for ambulatory risk adjustment in our analy-
ses. Another limitation of our work includes the fact that our
study was conducted in a single state, where demographic char-
acteristics of patients and their physicians may be different than
other geographic locations. Thus, generalizability of our find-
ings to other geographical areas must be done with caution. By
design, our cross-sectional study focused exclusively on ASCs
and not on other locations where ambulatory surgeries are per-
formed. Therefore, our results should be validated with longi-
tudinal studies, and they do not generalize to HOPDs or
physician offices that perform similar ambulatory procedures to
Ambulatory Surgical Procedure
Arthroscopy Colonoscopy Upper Gastroendoscopy Cataract Removal Prostate Biopsy
(n= 31,335) (n= 315,070) (n= 122,682) (n= 245,154) (n= 6,231)
7-Day Unexpected Hospitalization
ASC accredited by:
State regulatory agency (n= 163) 1.00 1.00 1.00 1.00 1.00
AAAHC (n= 106) .981 .925 .986 .981 .318
Joint Commission (n= 95) .771 .891†1.02 1.03 .913
30-Day Unexpected Hospitalization
ASC accredited by:
State regulatory agency (n = 163) 1.00 1.00 1.00 1.00 1.00
AAAHC (n= 106) .785 .985 .940 .987 .594
Joint Commission (n= 95) .989 .906‡1.01 1.04 1.17
* Each model controls for facility procedure volume and patient characteristics, including severity of illness, age, race, and payer type. AAAHC, Accreditation
Association for Ambulatory Health Care.
† p< .05
‡ p< .01
Table 3. Adjusted Odds Ratios for Unexpected Hospitalizations in Ambulatory Surgical Centers (ASC)
by Procedure in Florida, 2004*
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September 2008 Volume 34 Number 9
The Joint Commission Journal on Quality and Patient Safety
the ASCs we examined. Finally, future research should examine
the specific reasons and lengths of stay for hospitalizations of
patients after receiving care in an ASC.
Conclusion
On the basis of the single outcome measure we examined, pre-
liminary evidence suggests that the State of Florida does an
equally successful job at regulating nonaccredited ASCs as the
two major national accreditation bodies. In Florida, AHCA
conducts a single annual site visit for licensure purposes that is
scheduled a few days in advance. Additional site visits are not
made unless they are in response to a specific complaint. More
research examining other outcomes will be needed to ultimate-
ly determine the relationship between accreditation and quali-
ty of care. As the ambulatory surgical setting continues to
expand, comparative quality studies that consider structure,
process, and outcomes will be of interest to consumers,
providers, policymakers, and health care payers alike.
This study was funded by the Florida Agency for Health Care Administration. The
funding agency did not participate in any aspect this study.
References
1. Schyve P.M.: The evolution of external quality evaluation: Observations
from the Joint Commission on Accreditation of Healthcare Organizations. Int
J Qual Health Care 12:255–258, Jun. 2000.
2. Viswanathan H.N., Salmon J.W.: Accrediting organizations and quality
improvement. Am J Manag Care 6:1117–1130, Oct. 2000.
3. Lapetina E.M., Armstrong E.M.: Preventing errors in the outpatient set-
ting: A tale of three states. Health Aff (Millwood) 21:26–39, Jul.–Aug. 2002.
4. Anello S.A.: One nurse's experience in obtaining Joint Commission accred-
itation for office-based surgery centers. Plast Surg Nurs 24:48–50, Jun. 2004.
5. Brown S.: Accreditation of ambulatory surgery centers. AORN J
70:814–818, 821, Nov. 1999.
6. Blumenthal D.: Quality of health care. Part 4: The origins of the quality-
of-care debate. N Engl J Med 335:1146–1149, Oct. 10, 1996.
7. Bodenheimer T.: The American health care system––The movement for
improved quality in health care. N Engl J Med 340:488–492, Feb. 11, 1999.
8. Medicare Payment Advisory Commission(MedPac): A Data Book: Health-
care Spending and the Medicare Program, Jun. 2008.
http://www.medpac.gov/documents/Jun08DataBook_Entire_report.pdf (last
accessed Jul. 31, 2008).
9. Winter A.: Comparing the mix of patients in various outpatient surgery set-
tings. Health Aff (Millwood) 22:68–75, Nov.–Dec. 2003.
10. Agency for Health Care Administration: Hospital & Outpatient Services
Unit––Ambulatory Surgical Centers. http://www.fdhc.state.fl.us/MCHQ/
Health_Facility_Regulation/Hospital_Outpatient/ambulatory.shtml (last
accessed Jul. 24, 2008).
11. Saufl N.M., Fieldus M.H.: Accreditation: A “voluntary” regulatory
requirement. J Perianesth Nurs 18:152–159, Jun. 2003.
12. Pawlson L.G., et al.: The role of accreditation in an era of market-driven
accountability. Am J Manag Care 11:290–293, May 2005.
13. Loeb J.M., O’Leary D.S.: From the Joint Commission on Accreditation of
Healthcare Organizations: A call for collaboration in performance measure-
ment. JAMA 273:1405, May 10, 1995.
14. Institute of Medicine: To Err Is Human: Building a Safer Health System.
Washington, DC: National Academy Press, 2000.
15. Institute of Medicine: Crossing the Quality Chasm: A New Health System for
the 21st Century. Washington, DC: National Academy Press, 2001.
16. Pawlson L.G., O’Kane M.E.: Professionalism, regulation, and the market:
Impact on accountability for quality of care. Health Aff (Millwood)
21:200–207, May–Jun. 2002.
17. Chukmaitov A., et al.: A comparative study of quality outcomes in free-
standing ambulatory surgery centers and hospital-based outpatient depart-
ments: 1997–2004. Health Serv Res, in press, 2008.
18. Menachemi N., et al.: Quality of care differs by patient characteristics:
Outcome disparities after ambulatory surgical procedures. Am J Med Qual
22:395–401, Nov.–Dec. 2007.
19. Gold B.S., et al.: Unanticipated admission to the hospital following ambu-
latory surgery. JAMA 262:3008–3010, Dec. 1, 1989.
20. Shnaider I., Chung F.: Outcomes in day surgery. Curr Opin Anaesthesiol
19:622–629, Jun. 2006.
21. Hughes R.G., Hunt S.S., Luft H.S.: Effects of surgeon volume and hospi-
tal volume on quality of care in hospitals. Med Care 25:489–503, Jun. 1987.
22. Hannan E.L., et al.: Predictors of readmission for complications of coro-
nary artery bypass graft surgery. JAMA 290:773–780, Aug. 13, 2003.
23. Harmon J.W., et al.: Hospital volume can serve as a surrogate for surgeon
volume for achieving excellent outcomes in colorectal resection. Ann Surg
230:404–411, Sep. 1999.
24. Petersen L., et al.: Comparison of the predictive validity of diagnosis-based
risk adjusters for clinical outcomes. Med Care 43:61–67, Jan. 2005.
25. Meciejewski M., et al.: The performance of administrative and self-report-
ed measures for risk adjustment of Veterans Affairs expenditures. Health Serv
Res 40:887–904, Jun. 2005.
26. Pope G., et al.: Risk adjustment of Medicare capitation payments using the
CMS-HCC model. Health Care Financ Rev 25:119–141, Summer 2004.
27. Chen J., et al.: JCAHO accreditation and quality of care for acute myocar-
dial infarction. Health Aff (Millwood) 22:243–254, Mar.–Apr. 2003.
28. Landon B.E., et al.: Quality of care for the treatment of acute medical con-
ditions in US hospitals. Arch Intern Med 166:2511–2517, Dec. 11–25, 2006.
29. Hadley T.R., McGurrin M.C.: Accreditation, certification, and the quali-
ty of care in state hospitals. Hosp Community Psychiatry 39:739–742, Jul.
1988.
30. Dean Beaulieu N., Epstein A.M.: National Committee on Quality
Assurance health-plan accreditation: Predictors, correlates of performance, and
market impact. Med Care 40:325–337, Apr. 2002.
31. Kelly J.V., Hellinger F.J.: Physician and hospital factors associated with
mortality of surgical patients. Med Care 24:785–800, Sep. 1986.
32. Hartz A.J., et al.: Hospital characteristics and mortality rates. N Engl J Med
321:1720–1725, Dec. 21, 1989.
33. Pham H.H., et al.: Delivery of preventive services to older adults by pri-
mary care physicians. JAMA 294:473–481, Jul. 27, 2005.
34. O’Leary D.S.: Accreditation's role in reducing medical errors. BMJ
320(7237):727–728, Mar. 18, 2000.
35. Iezzoni L.I., et al.: Comorbidities, complications, and coding bias: Does
the number of diagnosis codes matter in predicting in-hospital mortality?
JAMA 267:2197–2203, Apr. 22–29, 1992.
36. Iezzoni L.I., et al.: Risk adjustment methods can affect perceptions of out-
comes. Am J Med Qual 9:43–48, Summer 1994.
37. Iezzoni L.I.: Using risk-adjusted outcomes to assess clinical practice: An
overview of issues pertaining to risk adjustment. Ann Thorac Surg 58:1822-
1826, Dec. 1994.
J
Nir Menachemi, Ph.D., M.P.H., formerly Associate Professor and
Director, Center on Patient Safety, Division of Health Affairs at
Florida State University College of Medicine, Tallahasee, Florida, is
Associate Professor, Department of Health Care Organization and
Policy, University of Alabama at Birmingham School of Public
Health, Birmingham, Alabama. Askar Chukmaitov, M.D., Ph.D., is
Assistant Professor, Division of Health Affairs at Florida State
University College of Medicine; L. Steven Brown, M.S., is
Research Assistant; Charles Saunders, Ph.D., is Assistant
Professor; and Robert G. Brooks, M.D., M.B.A., is Professor and
Associate Dean. Please address correspondence to Nir
Menachemi, nmenachemi@uab.edu.
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations