A question of quality.

I must take issue with the April 2001 "Legal Briefs" column that examined the link between accreditation and quality of care. (See "New QC research refutes some common notions," page 45.)

To the millions of Americans seeking long term care services for a loved one, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) accreditation offers assurances that an organization has made a commitment to quality improvement and the prevention of harmful incidents--a commitment evident when comparing performance in HCFA surveys.

A recent study clearly shows that long term care facilities accredited by JCAHO have significantly fewer health-related deficiencies involving actual harm or immediate jeopardy.

LTCQ Inc., an independent long term care information services company, analyzed the latest JCAHO accreditation files and merged them with HCFA public-use survey and certification data from surveys done between January 1998 and December 2000. The analysis employed standard statistical methods--cross-tabulations and t-tests--to compare accredited versus non-accredited facilities.

For each of the 16,966 HCFA-certified facilities, a variable was created to indicate whether a facility was JCAHO-accredited at the time of its most recent state survey. Of the 2,320 nursing facilities accredited by JCAHO, 1,714 were accredited prior to the time of the most recent state survey reported in the HCFA public use database. These 1,714 facilities were compared with all other facilities to assess the relationship of JCAHO accreditation to health-related survey deficiencies.

Results: JCAHO-accredited facilities had significantly lower rates of higherlevel deficiencies, using three different cut points for severity of higher-level deficiencies.

Risk management is one of several ways in which JCAHO-accredited facilities differ from non-accredited facilities. Others will be addressed in a forthcoming paper based on LTCQ's complete study.

The specific methodology used by LTCQ stands in contrast to Mr. Bua's claims regarding "quality," which are based on criteria not defined in his article. Presumably, his quality-of-care categories are based on survey deficiencies as well, but he makes no mention of adjustment for scope and severity. Differences of 2 percent are extremely important if one is talking about incidents resulting in serious injury or death. Also, he does not address specific categories of deficiencies, such as resident-rights violations, which turn out to be better in JCAHO-accredited facilities, and which have been shown repeatedly to matter greatly to nursing home residents.

Finally, Mr. Bua does not fully disclose his current, active role as the CEO of a company that sells reports to consumers on nursing homes' quality of care.

Thank you for the opportunity to set the record straight.

Marianna Kern Grachek, MSN, CNHA, CALA, is the executive director,

Long Term Care and Assisted Living Accreditation Programs, JGAHO

She made a difference, but not a good one

I found it interesting that your tribute to Nancy-Ann DeParle in the June 2001 issue (see "People who Make a Difference," page 30) was placed immediately before the article, "Medicare Decision Reversed" (page 35), which described a recent survey of a California facility which went very, very wrong. In my opinion, the Medicare article highlighted what was very., very wrong about the Clinton administration's treatment of health care providers and DeParle's role as his political appointee at HCFA.

I believe that Administrator DeParle helped build and oversee the harshest, most unfair, and heavy-handed enforcement system health care delivery has ever witnessed. Under her leadership, HCFA's oversight role was characterized by political scapegoating, the systematic demonization of health care providers, more regulations piled ever higher upon failed regulations, and blind enforcement of sanctions, penalties, and even criminal charges. That her targets were often innocent people--denied due process--guilty only of trying to take care of our nation's frail elders within a failing system designed and mal-administered by the government itself added insult to injury. The "savings" that were wrung from the Medicare and Medicaid programs during her watch, coupled with stricter and harsher rules, made it impossible to "be in compliance" with what had become a standard of perfection rather than substantial compliance.

During DeParle's watch, people of good will and intent were purposely denied the resources required for the job, yet commanded to do it, then punished when they were unable. That is her legacy and she does not deserve praise for it.

Winston Dollahon is the administrator of University Place, a retirement community in Houston, Texas.

Editor's note: Nancy-Ann DeParle was a political appointee who was reportedly uninformed about health care operations on a day-to-day basis. DeParle was said to have a lot of pressure from certain congressmen asking for her to be tough with nursing homes, issuing deficiencies, etc. Lacking insight as to the impact of her agency's decisions on the beneficiaries and on the providers, she is said to have relied totally on advisers and staff to tell her what to think. As a result, she bought into the politically expedient thing to do. The intent of CLTCs "People who make a difference" was to identify those who had the "greatest" impact--not necessarily the "best" impact--on the health care profession. Unfortunately, neither the section on DeParle nor the introduction was finessed to better reflect that agenda.