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

  • Indiana University Fairbanks School of Public Health


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.
The Joint Commission Journal on Quality and Patient Safety
Quality of Care in Accredited and Nonaccredited Ambulatory
Surgical Centers
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-
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-
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
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
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
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.
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.
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
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-
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
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
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)
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%)
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 severity0.75 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
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.
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.
September 2008 Volume 34 Number 9
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*
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
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 .8911.02 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 .9061.01 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*
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
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.
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.
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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
Copyright 2008 Joint Commission on Accreditation of Healthcare Organizations
Résumé Introduction Le métier de cadre de santé a dû s’adapter pour permettre aux équipes de s’approprier la démarche qualité. Objectif de l’étude Notre objectif est de réaliser un état des lieux des connaissances des soignants sur les indicateurs de qualité et de sécurité des soins (IQSS). Méthode Un courriel a été envoyé à 202 établissements. Les cadres de santé et soignants non cadres (SNC) ont eu la possibilité de répondre en ligne ou par courrier. Principaux résultats Au total, 69 % des SNC ont connaissance des indicateurs de qualité de leur service ; 47,7 % des SNC ne connaissent pas les indicateurs de qualité de la Haute Autorité de santé. Si les cadres de santé favorisent l’appropriation des IQSS par les SNC, cela ne semble pas suffisant. Le management visuel pourrait permettre aux cadres de santé de développer la connaissance des IQSS en responsabilisant les professionnels, en les rendant acteurs du recueil de ces IQSS.
Background The purpose of the present study was to determine whether patients receiving a stress echocardiogram or myocardial perfusion imaging (MPI) test have differences in subsequent testing and outcomes according to accreditation status of the original testing facility.Methods and resultsAn all-payer claims dataset from Maine Health Data Organization from 2012 to 2014 was utilized to define two cohorts defined by an initial stress echocardiogram or MPI test. The accreditation status (Intersocietal Accreditation Commission (IAC), American College of Radiology (ACR) or none) of the facility performing the index test was known. Descriptive statistics and multivariate regression were used to examine differences in subsequent diagnostic testing and cardiac outcomes.We observed 4603 index stress echocardiograms and 8449 MPI tests. Multivariate models showed higher odds of subsequent MPI testing and hospitalization for angina if the index test was performed at a non-accredited facility in both the stress echocardiogram cohort and the MPI cohort. We also observed higher odds of percutaneous coronary interventions (PCI) performed (OR 1.68, 95% CI 1.13-2.50), if the initial MPI test was done in a non-accredited facility.Conclusion Cardiac testing completed in non-accredited facilities were associated with higher odds of subsequent MPI testing, hospitalization for angina, and PCI.
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Background: Among different factors, accreditation is being widely used across the world to improve quality and safety in hospitals. Therefore, the purpose of the present study was to develop an accreditation model for teaching hospitals in Iran. Methods: This qualitative study was conducted in four phases from January, 2017 to March, 2018. To this end; firstly, existing accreditation models were extracted and reviewed comparatively. Within the second stage, dimensions and components of the accreditation model were extracted through semi-structured interviews. In the third stage, a new instruction was developed via integrating the findings from the first and the second stages. Finally, the model was validated in two phases of Delphi method and a specialized forum in the fourth step. Qualitative findings were then analyzed using content analysis method. Results: Models of Joint Commission International (JCI) and Word Federation for Medical Education (WFME) in other 6 countries were reviewed and compared with the current Iranian model. Extracted dimensions discovered to complement the present model included learner assessment, continuous reviews and revisions, and educational productivity. The final model was also developed with 12 dimensions and 94 standards. Content validity ratio (CVR) and content validity index (CVI) were also estimated to be 0.40 and 0.80, respectively. As well, the second round of Delphi method could increase the number of model standards to 97. Moreover, Cohen's kappa coefficient was calculated to be at least 0.71. Conclusion: This study led to the development of a comprehensive model for scientific accreditation of teaching hospitals through reviewing documentation, combining and comparing global approaches, as well as integrating them with the views of domestic experts.
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Background Over recent decades, numerous medical procedures have migrated out of hospitals and into freestanding ambulatory surgery centers (ASCs) and physician offices, with possible implications for patient outcomes. In response, states have passed regulations for office-based surgeries, private organizations have established standards for facility accreditation, and professional associations have developed clinical guidelines. While abortions have been performed in office setting for decades, states have also enacted laws requiring that facilities that perform abortions meet specific requirements. The extent to which facility requirements have an impact on patient outcomes—for any procedure—is unclear. Methods and findings We conducted a systematic review to examine the effect of outpatient facility type (ASC vs. office) and specific facility characteristics (e.g., facility accreditation, emergency response protocols, clinician qualifications, physical plant characteristics, other policies) on patient safety, patient experience and service availability in non-hospital-affiliated outpatient settings. To identify relevant research, we searched databases of the published academic literature (PubMed, EMBASE, Web of Science) and websites of governmental and non-governmental organizations. Two investigators reviewed 3049 abstracts and full-text articles against inclusion/exclusion criteria and assessed the quality of 22 identified articles. Most studies were hampered by methodological challenges, with 12 of 22 not meeting minimum quality criteria. Of 10 studies included in the review, most (6) examined the effect of facility type on patient safety. Existing research appears to indicate no difference in patient safety for outpatient procedures performed in ASCs vs. physician offices. Research about specific facility characteristics is insufficient to draw conclusions. Conclusions More and higher quality research is needed to determine if there is a public health problem to be addressed through facility regulation and, if so, which facility characteristics may result in consistent improvements to patient safety while not adversely affecting patient experience or service availability.
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Background Public policymaking is complex and lacks research evidences, particularly in the Eastern Mediterranean Region (EMR). This policy analysis aims to generate insights about the process of hospital accreditation policy making in Iran, to identify factors influencing policymaking and to evaluate utilization of evidence in policy making process. Methods The study examined the policymaking process using Walt and Gilson framework. A qualitative research design was employed. Thirty key informant interviews with policymakers and stakeholders were conducted. In addition hundred and five related documents were reviewed. Data was analyzed using framework analysis. Results The accreditation program was a decision made at Ministry of Health and Medical Education in Iran. Many healthcare stakeholders were involved and evidence from leading countries was used to guide policy development. Poor hospital managers’ commitment, lack of physicians’ involvement and inadequate resources were the main barriers in policy implementation. Furthermore, there were too many accreditations standards and criteria, surveyors were not well-trained, had little motivation for their work and there was low consistency among them. Conclusion This study highlighted the complex nature of policymaking cycle and highlighted various factors influencing policy development, implementation and evaluation. An effective accreditation program requires a robust well-governed accreditation body, various stakeholders’ involvement, sufficient resources and sustainable funds, enough human resources, hospital managers’ commitment, and technical assistance to hospitals.
A number of hospitals around the world have allowed themselves to develop cultures of “normalized deviance,” where (below) average performance becomes the norm, people are afraid to speak out and leaders are either unaware of or deny failure. Such weaknesses have led to high-profile incidents. The patients who come to surgery are generally among the sickest and at more advanced stages of disease. The very act of treatment involves interventions that are often considerably invasive with vigorous and unpredictable physiologic responses. The level of complexity, both in task-oriented and cognitive demands on clinical team, results in a dynamic, unforgiving environment that can magnify the consequences of even small process failures, lapses and errors. Because of better-educated patients, more demanding payers, push towards transparency, more discerning regulatory agencies, safety and quality have become prominent criteria for evaluating surgical care. Providers are increasingly asked to document these areas, and patients are using this documentation to select surgeons and hospitals. Payers are using the data to direct patients to providers, and potentially to adjust reimbursement rates. Therefore, health care policy makers, health service researchers, and others are aggressively developing and implementing quality indicators for surgical practice. Given the complex interplay of structure, process, and outcomes, assessment of surgical quality presents a daunting task. Most importantly, health care providers must acknowledge mistakes and poor practices, and empathize with patients and their families. We must firmly establish the links between these elements to validate current and future metrics to support public reporting, while engendering more robust support by surgeons, health care executives, regulators and payers.
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Background: The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. Methods: We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. Results: The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. Conclusion: Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.
With the continued growth of ambulatory surgical centers (ASC), the regulation of facilities has evolved to include new standards and requirements on both state and federal levels. Accreditation allows for the assessment of clinical practice, improves accountability, and better ensures quality of care. In some states, ASC may choose to voluntarily apply for accreditation from a recognized organization, but in others it is mandated. Accreditation provides external validation of safe practices, benchmarking performance against other accredited facilities, and demonstrates to patients and payers the facility's commitment to continuous quality improvement.
/st>To identify and analyse research on the use of economic evaluation in health services accreditation. /st>Seven online health and economic databases, and key accreditation agency and health department websites were searched between June and December 2011. /st>The selection criteria were English language and published empirical research studies on the topic of economic evaluation of health service accreditation. No formal economic evaluation of health services accreditation has been carried out to date. Empirical data on costs and benefits were analysed in 6 and 15 studies, respectively.Data extractionMeta-analysis was unsuitable due to output variability. Attributes relating to STUDY DESIGN: scalability and independence of outcome data were collected. For the benefit studies, we also assessed the strength of claim that accreditation improved patient safety and quality, and sources of potential bias. /st>The incremental costs ranged from 0.2 to 1.7% of total costs averaged over the accreditation cycle. The benefit studies were inconclusive in terms of showing clear evidence that accreditation improves patient safety and quality of care. /st>The lack of formal economic appraisal makes it difficult to evaluate accreditation in comparison to other methods to improve patient safety and quality of care. The lack of a clear relationship between accreditation and the outcomes measured in the benefit studies makes it difficult to design and conduct such appraisals without a more robust and explicit understanding of the costs and benefits involved.
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Aims: To systematically identify and synthesise health service accreditation literature. Methods: A systematic identification and narrative synthesis of health service accreditation literature published prior to 2012 were conducted. The search identified 122 empirical studies that examined either the processes or impacts of accreditation programmes. Study components were recorded, including: dates of publication; research settings; levels of study evidence and quality using established rating frameworks; and key results. A content analysis was conducted to determine the frequency of key themes and subthemes examined in the literature and identify knowledge-gaps requiring research attention. Results: The majority of studies (n=67) were published since 2006, occurred in the USA (n=60) and focused on acute care (n=79). Two thematic categories, that is, 'organisational impacts' and 'relationship to quality measures', were addressed 60 or more times in the literature. 'Financial impacts', 'consumer or patient satisfaction' and 'survey and surveyor issues' were each examined fewer than 15 times. The literature is limited in terms of the level of evidence and quality of studies, but highlights potential relationships among accreditation programmes, high quality organisational processes and safe clinical care. Conclusions: Due to the limitations of the literature, it is not prudent to make strong claims about the effectiveness of health service accreditation. Nonetheless, several critical issues and knowledge-gaps were identified that may help stimulate and inform discussion among healthcare stakeholders. Ongoing effort is required to build upon the accreditation evidence-base by using high quality experimental study designs to examine the processes, effectiveness and financial value of accreditation programmes and their critical components in different healthcare domains.
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When comparing outcomes of medical care, it is essential to adjust for patient risk, including severity of illness. A variety of severity measures exist, but perceptions of outcomes may differ depending on how severity is defined. We used two severity-adjustment approaches to demonstrate that comparisons of outcomes across subgroups of patients can vary dramatically depending on how severity is assessed. We studied two approaches: model 1 was the admission MedisGroups score; model 2 was computed from age and 12 chronic conditions defined by diagnosis codes. Although common summary measures of model performance (R-squared and C) both suggested that model 1 is a better predictor of in-hospital death than model 2, the weaker model consistently produced more accurate expectations by payer class and age group. Using model 1 for severity adjustment suggested that Medicare patients did substantially worse than expected and Medicaid patients substantially better. In contrast, use of model 2 found Medicare patients doing as expected, but Medicaid patients faring poorly.
To compare quality outcomes from surgical procedures performed at freestanding ambulatory surgery centers (ASCs) and hospital-based outpatient departments (HOPDs). Patient-level ambulatory surgery (1997-2004), hospital discharge (1997-2004), and vital statistics data (1997-2004) for the state of Florida were assembled and analyzed. We used a pooled, cross-sectional design. Logistic regressions with time fixed-effects were estimated separately for the 12 most common ambulatory surgical procedures. Our quality outcomes were risk-adjusted 7-day and 30-day mortality and 7-day and 30-day unexpected hospitalizations. Risk-adjustment for patient demographic characteristics and severity of illness were calculated using the DCG/HCC methodology adjusting for primary diagnosis only and separately for all available diagnoses. Although neither ASCs nor HOPDs performed better overall, we found some difference by procedure that varied based on the risk-adjustment approach used. There appear to be important variations in quality outcomes for certain procedures, which may be related to differences in organizational structure, processes, and strategies between ASCs and HOPDs. The study also confirms the importance of risk-adjustment for comorbidities when using administrative data, particularly for procedures that are sensitive to differences in severity.
Objective: To examine the association of surgeon and hospital case volumes with the short-term outcomes of in-hospital death, total hospital charges, and length of stay for resection of colorectal carcinoma. Methods: The study design was a cross-sectional analysis of all adult patients who underwent resection for colorectal cancer using Maryland state discharge data from 1992 to 1996. Cases were divided into three groups based on annual surgeon case volume--low (< or =5), medium (5 to 10), and high (>10)--and hospital volume--low (<40), medium (40 to 70), and high (> or =70). Poisson and multiple linear regression analyses were used to identify differences in outcomes among volume groups while adjusting for variations in type of resections performed, cancer stage, patient comorbidities, urgency of admission, and patient demographic variables. Results: During the 5-year period, 9739 resections were performed by 812 surgeons at 50 hospitals. The majority of surgeons (81%) and hospitals (58%) were in the low-volume group. The low-volume surgeons operated on 3461 of the 9739 total patients (36%) at an average rate of 1.8 cases per year. Higher surgeon volume was associated with significant improvement in all three outcomes (in-hospital death, length of stay, and cost). Medium-volume surgeons achieved results equivalent to high-volume surgeons when they operated in high- or medium-volume hospitals. Conclusions: A skewed distribution of case volumes by surgeon was found in this study of patients who underwent resection for large bowel cancer in Maryland. The majority of these surgeons performed very few operations for colorectal cancer per year, whereas a minority performed >10 cases per year. Medium-volume surgeons achieved excellent outcomes similar to high-volume surgeons when operating in medium-volume or high-volume hospitals, but not in low-volume hospitals. The results of low-volume surgeons improved with increasing hospital volume but never equaled those of the high-volume surgeons.
Incomplete coding of secondary diagnoses may bias assessments of patient risks of poor outcomes using administrative health care databases, most of which allow only five diagnoses. The Medicare program is expanding the number of possible diagnoses from five to nine, aiming to improve coding completeness. We examined the impact of having more diagnosis codes available on assessments of risk of death. We used 1988 computerized hospital discharge abstract data from California, which allow up to 25 diagnoses per discharge, to select a sample of hospitalized patients and assessed the relationship between the presence of 29 specific secondary diagnoses and the risk of in-hospital death. Nonfederal acute-care hospitals in California. All patients at least 65 years of age who were hospitalized for stroke, pneumonia, acute myocardial infarction, or congestive heart failure in California in 1988 (N = 162,790). Relative risk of death for each specific secondary diagnosis. Many conditions that on a clinical basis would be expected to increase the risk of death, such as adult-onset diabetes mellitus, previous myocardial infarction, angina, and ventricular premature beats, were associated with a lower risk of in-hospital death. Bias against coding of chronic or comorbid conditions on the computerized discharge abstracts of patients who die best explains these results. Efforts to improve diagnosis coding completeness solely by increasing the number of available coding spaces may not succeed.
The Health Care Financing Administration (HCFA) publishes hospital mortality rates each year. We undertook a study to identify characteristics of hospitals associated with variations in these rates. To do so, we obtained data on 3100 hospitals from the 1986 HCFA mortality study and the American Hospital Association's 1986 annual survey of hospitals. The mortality rates were adjusted for each hospital's case mix and other characteristics of its patients. The mortality rate for all hospitalizations was 116 per 1000 patients. Adjusted mortality rates were significantly higher for for-profit hospitals (121 per 1000) and public hospitals (120 per 1000) than for private not-for-profit hospitals (114 per 1000; P less than 0.0001 for both comparisons). Osteopathic hospitals also had an adjusted mortality rate that was significantly higher than average (129 per 1000; P less than 0.0001). Private teaching hospitals had a significantly lower adjusted mortality rate (108 per 1000) than private nonteaching hospitals (116 per 1000; P less than 0.0001). Adjusted mortality rates were also compared for hospitals in the upper and lower fourths of the sample in terms of certain hospital characteristics. The mortality rates were 112 and 121 per 1000 for the hospitals in the upper and lower fourths, respectively, in terms of the percentage of physicians who were board-certified specialists (P less than 0.0001), 112 and 120 per 1000 for occupancy rate (P less than 0.0001), 113 and 120 per 1000 for payroll expenses per hospital bed (P less than 0.0001), and 113 and 119 per 1000 for the percentage of nurses who were registered (P less than 0.0001).
We conducted a case-control study to identify clinical and demographic risk factors for admission to the hospital following ambulatory surgery. Of 9616 adult patients who underwent ambulatory surgery at a university-affiliated hospital between 1984 and 1986, one hundred were admitted. The most common reasons for admission were pain (18), excessive bleeding (18), and intractable vomiting (17). The mean age (+/- SD) of patients who were admitted was 37 +/- 13 years, and 96% had American Society of Anesthesiologists' physical status scores of 1 or 2. Factors that were independently associated with an increased likelihood of admission were general anesthesia (odds ratio, 5.2), postoperative emesis (odds ratio, 3.0), lower abdominal and urologic surgery (odds ratio, 2.9), time in the operating room greater than 1 hour (odds ratio, 2.7), and age (odds ratio, 2.6). Our results indicate that the likelihood of unanticipated admission is related more to the type of anesthesia and surgical procedure rather than to the patient's clinical characteristics.
Data on 216 state psychiatric hospitals were analyzed to determine whether accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or certification by the Health Care Financing Administration (HCFA) were related to seven hospital characteristics generally accepted as reflecting quality of care. The characteristics were average cost per patient, per diem bed cost, total staff hours per patient, clinical staff hours per patient, percent of staff hours provided by medical staff, bed turnover, and percent of beds occupied. While a majority of the hospitals had either JCAHO accreditation, HCFA certification, or both, analysis revealed a weak relationship between accreditation or certification status and the indicators of quality of care. Accredited or certified hospitals were, however, more likely to have higher values on specific indicators than hospitals without accreditation.