Reducing risk and enhancing value through accreditation: Recent data indicate that accreditation has a quality impact that could be significant to risk management. (Feature Article).

The high cost and limited availability of liability insurance present a significant challenge for long-term care organizations. For insurers, rising litigation rates in long-term care mean that identifying significant risks in the provision of this care is increasingly important. Accreditation by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is one way organizations can demonstrate to insurers a commitment to doing the right things and doing them well.

Risk management in long-term care has evolved beyond managing liability and avoiding lawsuits. It means understanding the entire continuum of care and focusing on performance improvement, all the while maintaining a focus on outcomes of care. LTCQ, Inc., an independent long-term care information services company, recently completed an empirical study demonstrating that JCAHO-accredited long-term care facilities have better outcomes and fewer high-risk events.

The LTCQ study examined how accredited and nonaccredited facilities fared in surveys conducted by the Centers for Medicare and Medicaid Services (CMS). LTCQ analyzed both routine triennial surveys and special surveys triggered by resident or family complaints. All surveys were conducted from November 2000 through October 2001. Facilities were included in the sample if they had a triennial survey during that year; complaint surveys were included in the analysis if they took place during that year.

In all there were 13,654 facilities in the study sample. Of those, 1,538 were accredited; 617 were first accredited during the year of the study. The other 921 had been accredited before the start of the year in which the study was performed.

LTCQ's study found that JCAHO-accredited facilities had fewer healthcare deficiencies and fewer life-safety code deficiencies than nonaccredited facilities. In addition, facilities accredited prior to the study year had fewer healthcare deficiencies than those first accredited within the study year, suggesting that there is a cumulative benefit from the JCAHO accreditation process. All differences were statistically significant.

JCAHO-accredited nursing facilities had significantly fewer health-related deficiencies in categories, or levels, H and higher--deficiencies involving actual harm to more than an isolated number of residents, up to immediate jeopardy to any resident. Of nonaccredited facilities, 4.6% were found to have such deficiencies; only 2.2% of accredited facilities were cited for such deficiencies (Figure 1). Deficiencies involving immediate jeopardy were reported for 2.6% of nonaccredited facilities, but only 1.0% of accredited ones.

CMS reports on complaint surveys include the specific allegations made by the complainant (there might be several), whether the allegations were substantiated on the complaint survey and whether new health-related deficiencies were encountered. JCAHO-accredited facilities had fewer complaints, total allegations, substantiated allegations, abuse allegations and substantiated abuse allegations (Figure 2).

Quality Indicators and Accreditation Status

The Nursing Home Compare database reports several prevalence-based quality indicators (QIs), including the prevalence rates for pressure ulcers, restraints and contractures; there are also statistics for recent weight loss. The full survey database (aka OSCAR [Online Survey and Certification Reporting]) contains prevalence rates for the same conditions on admission to the facility, thus permitting the estimation of incidence rates. It also includes the rate of administration errors per 100 medication passes.

Accredited facilities had:

* An 18% lower prevalence of restraint use

* A 13% lower incidence of restraint use

* An 8% lower prevalence of contractures

* A 25% lower incidence of contractures

* A 5% lower rate of recent weight loss

* A 13% lower rate of medication administration errors

Raw rates of pressure ulcers were higher in accredited facilities, but risk-adjusted rates were not. Other differences in favor of accredited facilities all remained so after risk adjustment.

The relationship between accreditation status and survey deficiencies was greatest for facilities belonging to for profit chains. Those facilities accredited for more than a year averaged 1.5 fewer survey deficiencies than did the nonaccredited facilities. Differences in rates of severe deficiencies were dramatic (Figure 3): For example, 4% of nonaccredited facilities had deficiencies of level H or higher. Only 2% of accredited facilities had such deficiencies.

Adjustments for Location, Staffing and Size

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.

These models express differences between accredited and nonaccredited facilities as odds ratios: estimates of how much more or less likely the outcome is among accredited facilities, assuming other factors are the same. Factors considered included geography, number of beds, ratio of licensed nurses to residents, ratio of CNAs to residents, proportion of contract licensed nurses and proportion of contract CNAs.

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%)

The adjusted models for facilities belonging to for-profit chains showed even larger positive effects of accreditation. Among such facilities, those that are JCAHO-accredited had less than half the likelihood of a deficiency of level H or higher than their nonaccredited peers.

Specifically:

* 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 organizational 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 prompt] y 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.

Figure 1

Life-safety code deficiencies [greater than or equal to] category H.

               Percentage
               of facilities

Accredited     2.2%
Nonaccredited  4.6%

Note: Table made from bar graph

Figure 2

Average number of complaints or allegations.

                                Accredited  Nonaccredited

Complaints                         3.9           4.4
Allegations                        7.0           8.2
Sustantiated Allegations           2.2           2.8
Abuse Allegations                   .85          1.17
Sustantiated Abuse Allegations      .47           .64

Note: Table made from bar graph

Figure 3

Comparison of severe deficiencies in accredited vs nonaccredited
facilities.

                                Percentage of facilities
CMS deficiency level          Accredited     Nonaccredited

[greater than or equal to] H     2.0%            4.0%
[greater than or equal to] I     1.0%            2.6%
[greater than or equal to] J     1.0%            2.3%

Note: Table made from bar graph

Marianna Kern Grachek, MSN, CNHA, FACHCA, is the executive director for the Long Term Care and Assisted Living Accreditatian Programs at JCAHO. She is responsible for all accreditation activities related to tong-term care and assisted living services, including the development of standards and survey processes. For further information, phone JCAHO at [phone] or visit www.jcaho.org; or phone LTCQ, Inc., at (781) 2754567 or visit www.itcq.com. To comment on this article, please send e-mail to [e-mail].