In the latest advance for health care accountability, the country's leading hospital accreditation board, the Joint Commission, released a list on Tuesday of 405 medical centers that have been the most diligent in following protocols to treat conditions like
heart attack and
pneumonia. Almost without exception, most highly regarded hospitals in the United States, from Johns Hopkins in Baltimore to the Mayo Clinic in Rochester, Minn., did not make the list.
Thereport found that hospital performance nationwide continued to improve steadily in 2010 on a variety of measures and is now at high levels. Assessing more than 12 million treatment actions, like whether heart attack patients are given aspirin upon admission or surgical patients receive
antibiotics within an hour, the commission found that hospitals followed standards 97 percent of the time. That is up from 82 percent in 2002.
In addition, more than nine in 10 hospitals had composite compliance scores of at least 90 percent, more than four times the figure of nine years ago.
But with evidence-based ratings gaining prevalence, and a strengthening link between quality and payment, the Joint Commission report raised questions about how consumers should best use the data newly available to them. Increasingly, one component of that inquiry may be whether hospital reputations are deserved or mythologized.
"Reputation and performance on important measures of quality do not always correlate," said Dr. Mark R. Chassin, the Joint Commission's president.
As an example, none of the 17 medical centers listed by U.S. News & World Report on its "Best Hospitals Honor Roll" this year are on the Joint Commission's list of 405 hospitals that received at least a 95 percent composite score for compliance with treatment standards. About one-third of a hospital's score in the U.S. News methodology is based on its reputation as gauged by a survey of physicians.
The Joint Commission list, at www.jointcommission.org, omitted the Cleveland Clinic; Massachusetts General Hospital in Boston; Duke University Medical Center in Durham, N.C.; Ronald Reagan U.C.L.A. Medical Center; and the University of California San Francisco Medical Center, among others. It did not include a single hospital in New York City, or the most prominent centers in Chicago and Houston.
"It's pretty glaring that they're not there," said Dr. Peter J. Pronovost, the senior vice president for patient safety and quality for Johns Hopkins Medicine.
Rather, the Joint Commission list of top performers included a disproportionate share of small and rural hospitals, as well as 20 Veterans Affairs medical centers. About 14 percent of roughly 3,000 eligible hospitals made the cut.
Hospital quality experts, including at large academic centers that did not make the list, did not diminish the Joint Commission measurements. They acknowledged that because the commission focused on measures of process rather than outcomes, they could not explain away a hospital's failure to surpass the 95 percent threshold simply by pointing to a complicated mix of patients with acute conditions.
Dr. Chassin pointed out in a call with reporters on Wednesday that compliance should be close to 100 percent with standard procedures like vaccinating pneumonia patients for influenza and properly removing hair before surgeries.
"For these particular measures," said Nancy E. Foster, vice president for quality and patient safety at the American Hospital Association, "I would not say that the difference in case mix is very relevant."
But hospital officials did point out that a number of well-known medical centers did not miss the 95 percent threshold by much, and that small numbers of patients may have made a statistical difference. They also said the volume of cases at busy hospitals makes complete compliance more difficult than at less busy ones. And at times, they said, teaching hospitals may not follow standard procedure because they are ahead of the curve, using new therapies that are not widely accepted.
Many advised consumers to review not only the Joint Commission assessments available on its Web site, but also ratings on the federal government's
Hospital Compare site, which includes outcome measurements like mortality and readmission rates.
To suggest that one set of ratings should undercut a hospital's reputation "would be wrong," said Kenneth E. Raske, president of the Greater New York Hospital Association, which represents centers in the New York City region. "The provision of care is a very complicated business ranging over a whole host of maladies and to suggest that any one list is definitive would be a mistake."
But Dr. Chassin said the criteria used by his group were the best available for gauging performance.
"It is certainly true that larger hospitals, particularly if they are reporting on more measures than smaller hospitals, have a lot more work to do," he said, in order to make sure that every patient is treated with standard care. "But on the other hand, they have more resources than small hospitals to do that. It may be a question of priority setting."
As it is, both private and government health insurers are beginning to tie hospital reimbursements to quality measures like infection rates and readmissions. Next year, compliance with procedural standards will become even more consequential, as the Joint Commission plans to withhold accreditation from any hospital that posts a composite score below 85 percent.
Dr. Chassin said there were 121 hospitals that would not pass that mark based on their 2010 scores. "They know who they are," he said. "We'll see if they have heeded the warning." The point of Wednesday's report, he said, is not to embarrass the laggards but to honor high achievement and encourage improvement.
But Lisa McGiffert, director of Consumer Union's safe patient project, said the commission's report carried one fundamental flaw.
"It's only highlighting the best performers and they should be highlighting the poorest performers," Ms. McGiffert said, "because evidence shows that when you publicly report, it's the poorest performers that improve the most. And the public wants to know which are the poorest performing hospitals so they can avoid them."