HEALTH INDUSTRY ONLINE - Important New Report from The Joint Commission on the Quality of Health Care and Patient Safety

In 2001, in its well-known report entitled Crossing the Quality Chasm, the Institute of Medicine described an American health care system that is performing below its potential. Moreover, the IOM set forth a persuasive case for the proposition that quality and effectiveness of health care could be dramatically improved if health care providers, and particularly hospitals, provided certain treatments and followed certain practices which, based on evidence-based studies, were shown to result in improved outcomes.

Since the publication of the IOM study, there has been a significant increase in the effort by health care organizations to track and disseminate performance and quality data, all as part of the larger effort to improve health care quality and patient safety on a systemic level. In that context, The Joint Commission has recently released an important new report regarding the quality of health care and patient safety. Disseminated to the public on March 20, 2007, Improving America's Hospitals: A Report on Quality and Patient Safety, is the first of what is intended to be an annual report assessing the performance of accredited hospitals in the United States by comparing data reported by those hospitals to certain standardized national performance measures ("evidence-based quality measures") pertaining to various aspects of patient care.

Standards in Specified Areas of Patient Care

This initial report attempts to assess the degree to which the nation's accredited hospitals are adhering to such standards in four areas of patient care: heart attacks, heart failure, pneumonia, and prevention of surgical infection. The report also assesses performance of American hospitals in complying with The Joint Commission's 2005 National Patient Safety Goals. Significant findings from the report include the following:

Heart Attack Care: The Joint Commission analyzed the frequency with which hospitals provided eight evidence-based measures for treatment of heart attack. The eight treatment measures, the reported performance rates for each treatment measure, and the comparison to 2002 performance rates were as follows:

Aspirin provided to heart attack patients at arrival (within 24 hours): 95.4% (up 2.4% since 2002)
Aspirin provided to heart attack patients at discharge: 95.6% (up 3.6% since 2002)
ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) prescribed at discharge: 83.6% (up 7.8% since 2002)
Smoking cessation advice provided: 92.1% (up 25.5% since 2002)
Beta blocker provided at arrival (within 24 hours): 92.2% (up 7.2% since 2002)
Beta blocker prescribed at discharge: 94.8% (up 7.5% since 2002)
Thrombolytic medication therapy within 30 minutes of arrival: 38.6% (no comparable data from 2002)
Percutaneous coronary intervention (PCI) balloon therapy within 120 minutes of arrival: 68.3% (no comparable data from 2002)

In addition to calculating performance data for the eight individual heart attack treatments or measures, The Joint Commission calculated a "composite" measure rate in an effort to show how consistently hospitals provided evidence-based care for heart attack patients. The composite rate was calculated by adding or rolling up the number of times recommended care was provided to patients and dividing this sum by the total number of opportunities to provide this care. According to The Joint Commission, the national average for hospitals providing the eight evidence-based heart attack treatments or measures evaluated in the study was 90% (based on heart attack care data provided by 2,726 hospitals), which was up 3.1% as compared to 2002.

Heart Failure Care: The Joint Commission also analyzed the frequency with which hospitals provided four evidence-based measures for treatment of heart failure. The four treatments or measures, the reported performance rates for each measure, and the comparison to 2002 performance rates were as follows:

In-depth evaluation of left ventricular function (through echocardiography, cardiac catheterization, radionuclide angiography, etc.): 90.8% (up 9.3% since 2002)
ACEI or ARB prescribed at discharge: 83% (up 8.8% since 2002)
Specific patient education and discharge instructions given regarding heart failure (regarding activities, diet, weight, worsening symptoms, follow-up care, medications, etc.): 59.2% (up 28.3% since 2002)
Patient counseled by health care provider to quit smoking: 83.8% (up 41.6% since 2002)

The "composite" measure rate, or national average, for hospitals providing the four heart failure treatments or measures evaluated in the study was 76% (based on data provided by 3,120 hospitals), which represented an improvement of 15.3% as compared to 2002.

Pneumonia Care: The Joint Commission also analyzed the frequency with which hospitals provided five evidence-based treatments and measures for care of pneumonia. The five treatments or measures, the reported performance rates for each treatment/measure, and the comparison to 2002 performance rates were as follows:

Oxygenation assessment (assessment of the level of oxygen in the patient's bloodstream): 99.3% (up 4.3% since 2002)
Antibiotics provided within four hours of hospital arrival: 74.5% (no comparable data from 2002)
Blood cultures taken before giving antibiotics to pneumonia patients: 83.1% (up 1.1% since 2002)
Pneumococcal screening and vaccination (pneumonia patients 65 and older): 62.8% (up 32.6% since 2002)
Patient counseled by health care provider to quit smoking: 80% (up 42.8% since 2002)

The "composite" measure rate, or national average, for hospitals providing the four pneumonia treatments or measures evaluated in the study was 81% (based on heart failure care data provided by 3,013 hospitals), representing an improvement of 8.7% as compared to 2002.

Surgical Infection Prevention: The Joint Commission also analyzed and reported data regarding two treatments or measures pertaining to prevention of surgical infections, though a much smaller number of hospitals reported data pertaining to this area. The two treatments or measures, the reported performance rates for each treatment/measure, and the comparison to 2002 performance rates were as follows:

Prophylactic antibiotic received within one hour prior to surgical incision: 81.8% (only 358 hospitals reporting; no comparable data from 2002)
Prophylactic antibiotic discontinued within 24 hours after completion of surgery: 73.5% (357 hospitals reporting; no comparable data from 2002)

2005 National Patient Safety Goals

In addition to assessing the four specific patient care areas discussed above, The Joint Commission report also assesses the degree to which accredited hospitals are complying with the 2005 National Patient Safety Goals (eight goals and 16 associated requirements). This assessment was done based on data taken from the 1,153 hospitals that underwent on-site accreditation surveys in 2005. In summary, the report finds percentages of compliance in the range of 95% or greater with respect to all of the goals and associated requirements with the exception of these three: (1) Goal 1, Requirement 1B (improving accuracy of patient identification by using a "time-out" verification process before starting any surgical or invasive procedure) - Compliance 82.7%; Non-compliance 17.3%); (2) Goal 2, Requirement 2B (improving the effectiveness of communication among caregivers by standardizing a list of abbreviations, acronyms, and symbols to be used) Compliance 61.4%; Non-compliance 38.6%; and (3) Requirement 2C (improving the effectiveness of communication among caregivers by measuring, assessing, and, if necessary, improving timeliness and accuracy of reporting critical test results to responsible care givers - Compliance 90.5%; Non-compliance 9.5%.

Broader Observations and Conclusions

It seems fair to say that the overall news from this report is good. With respect to the assessment of the four specific patient care areas, comparison of 2005 data with data from 2002 shows significant and real improvement in quality of care. Adherence to the evidence-based treatments and measures that were studied improved by a magnitude ranging from 1.1% to 42.8%, with performance improving most dramatically in those areas where the initial performance results were lowest (e.g. counseling heart attack and heart failure patients regarding cessation of smoking). In addition, the composite scores for heart attack, heart failure, and pneumonia all reflected improvement in quality of care.

However, the study also demonstrates that there is still definite room for improvement in many of the areas that were addressed. For instance, providing pneumococcal vaccinations to elderly patients with pneumonia, providing counseling on cessation of smoking to pneumonia patients, and providing discharge instructions to patients treated for heart failure are three of the more obvious areas where there is room for a significant increase in adherence to the standards. In addition, the data regarding prevention of surgical infections suggests that there is much room for improvement there, although the number of reporting hospitals in that area may be too small to draw definitive conclusions.

One of the interesting findings, not included in the summary data set forth here, is the variability that exists between hospitals in different states. For example, statewide averages for providing patient education and discharge instructions to heart failure patients ranged from 33.5% to 89%. Finally, the report demonstrates that there is tremendous variability from hospital to hospital, and that some hospitals perform much better than others in treating specific conditions. In fact, the report shows that approximately 90% of the nation's hospitals are performing at or above the 90% adherence level in only one of the areas measured.

The section of the report assessing hospital compliance with the 2005 National Patient Safety Goals also appears to bear good news. Compliance with almost all of the goals and associated requirements was well above 95%, and a number of the compliance measures were above 99%, though there are several specific areas addressed by the goals and requirements where there is still obvious room for improvement.

Undoubtedly, this report and others to follow by The Joint Commission will be much discussed over the coming months and years.