VITAL SIGNS: Measuring the quality of care

      The hospital brochures are bright and glossy.
      "For over 35 years, Sunrise has taken medicine to a higher ground," states one from Columbia Sunrise Hospital and Medical Center.
      The front of a University Medical Center brochure reads: "Care how much we know. Know how much we care."
      But how much do patients, in Southern Nevada and elsewhere, really know about what goes on behind hospitals' brightly polished front lobbies?
      Very little, acknowledge even industry insiders.
      "I think there needs to be more (information)," said Alicia Mitchell, an American Hospital Association spokeswoman. "I think anyone you talk to in health care is going to say that."
      The fancy brochures won't reveal whether a registered nurse or minimally trained aide will provide care following surgery, said Charles Inlander, president of the Pennsylvania-based People's Medical Society. They don't provide any independent data about infection problems or the rates of complications from Caesarean sections or other procedures.
      "This isn't a hotel you are going to," said Inlander, who heads the nonprofit medical consumer group. "The lobby is not very important. What you really want to know is, 'Are you going to come out alive and well? And do they really know what they are doing?` "
      Burgeoning Southern Nevada enjoys a competitive hospital market amid a national economic squeeze that's forcing many hospitals to merge or close their doors. At least 40 hospitals have closed every year since 1990, according to the American Hospital Association.
      Locally, eight acute care hospitals compete for patients, including Sunrise MountainView, which opened last year. A ninth hospital, Summerlin Medical Center, will open this fall in the city's northwest.
      Very little information can be obtained through state agencies about how Nevada hospitals care for patients. Nevada residents, like those in most other states, must largely depend upon the surveys conducted every three years by the Joint Commission on Accreditation of Healthcare Organizations.
      The Chicago-based commission, which until last year only reported a hospital's overall rating, has taken some steps to expand public access to information.
      The federal government says hospitals that meet joint commission standards can be reimbursed for treating Medicaid and Medicare patients. But the commission, which surveys about 5,200 hospitals, continues to face heat about the usefulness of its information and its self-proclaimed role as an independent accrediting organization.
      Critics are quick to point out that the joint commission almost never withholds its stamp of approval. In 1996, four of the about 1,700 hospitals surveyed were denied accreditation; there were no denials the previous year.
      The commission's focus is not to measure quality in terms of infection rates or mortality outcomes of, for example, heart bypass surgery, commission spokeswoman Alice Brown said. Instead, the commission studies whether the hospital has procedures in place to prevent or handle problems that do arise.
      "Is the organization doing the right things?" Brown said. "Our review is really process-oriented.
      "We are not saying they are all `A' hospitals," she continued. "Accreditation is not a guarantee. It's a risk reduction activity. We believe that if an organization is doing these things, that you or I as a patient will likely have good care. But it's no guarantee that nothing bad will happen there."
      Not all insurance plans provide a choice of hospitals, said Chris Thompson, chief of the state's health care financial analysis unit. If patients do have a choice, and enough time to do research, they should start with their personal physician, he said.
      "The doctors will have much more knowledge into individual hospitals and have reasons for their preferences," he said.
      But physicians may be influenced by financial incentives unknown to their patients, said Lauren Dame, staff attorney for Public Citizen's Health Research Group. Consumers have a right to obtain information compiled by an independent source that examines infection control and other measurements of quality of care, she said.
      "There are studies that show there are very serious adverse events that happen in hospitals," she said. "It's hard for consumers to know what hospitals will be better than other hospitals. To a large extent, they (patients) have to trust their doctor because there are no other sources of information."
      Once in the hospital, patients see very little of their doctors, Inlander said.
      "Your doctor doesn't prep you for surgery. The doctor doesn't do the anesthesia. The doctor doesn't do infection control. The doctor then comes to see you for 35 seconds to three minutes a day."
     Bypassing complications
      The Harvard Medical Practice Study is frequently cited as a benchmark for how often preventable medical complications occur in hospitals.
      The study's analysis of 30,121 New York State hospital records found a complication rate of 4 percent. Drug complications were the most common, followed by wound infections and technical difficulties, according to the results, published in February 1991 in the New England Journal of Medicine.
      But those rates of complications are based only on written records, argues a more recent study, published in February in The Lancet, a highly regarded British journal. In the study, researchers spent nine months attending meetings, case conferences, nursing shift changes and other informal settings where complications are discussed. Of 1,047 patients tracked in the study, 18 percent had some complication -- formally described as an "adverse event."
      Hospitals do monitor mortality rates internally, said Ann Lynch, a spokeswoman at Columbia Sunrise Hospital and Medical Center. But accurately comparing mortality rates and other patient care indicators is very difficult, she said, explaining why Sunrise does not release such data.
      "Let's say you and I were both cardiac surgeons," she said. "And most of the cases I chose to take were people in their 50s, nonsmokers. I would have a wonderful rate.
      "You must trust the fact that every hospital does track their own and does track their surgeons."
      Certainly, many types of health data are difficult to quantify, said Dame, the Public Citizen attorney.
      "On the other hand, this argument has been used by hospitals for every single attempt consumers have made to get information," she said. "What we say is sometimes the interests of patients and hospitals diverge. And one way they diverge is hospitals don't want data released and consumers do want access to this kind of information."
      Pennsylvania hospitals were very critical when the Health Care Cost Containment Council was founded in the mid-1980s to collect and publish mortality data, spokesman Joe Martin said. The state agency adjusts death rates according to risk.
      "It's hard to say how much of that was related to the methodology itself," Martin said. "And how much of it was a reaction to the process of public reporting."
      The council fielded more than 10,000 requests for its first report on coronary bypass procedures, Martin said.
      "What we have seen is in coronary bypass surgery, the mortality rate has dropped 26 percent over the four years we reported the data," he said. During the same period, hospitalization rates increased at a slower pace than before, he said.
     How accredited?
      A hospital can be accredited by the joint commission, even though problems were found in important areas, according to a highly critical report published in July 1996 by Public Citizen's Health Research Group.
      Based on internal joint commission documents, Public Citizen found that 49 percent of accredited hospitals in 1992 were cited for inadequate infection control programs and 38 percent demonstrated poor monitoring and evaluation of surgery and anesthesia.
      In recent months, Rep. Pete Stark, D-CA, has picked up a criticism levied by Public Citizen and several other groups that contend the commission should not depict itself as an independent judge.
      Hospitals pay for their inspections, Stark said in a written statement. For example, University Medical Center recently paid a $73,770 fee for its own inspection.
      Nearly all the board's seats are filled by the American Hospital Association, American Medical Association and other industry groups, Dame said.
      "Our main criticism is it's essentially an industry-dominated self-regulatory group," she said. "It's supposed to be independent."
     Using the seal
      Accreditation, though, is frequently pointed to by hospitals as validation of their quality performance.
      "They (the joint commission) are accepted as kind of the equivalent to the Good Housekeeping seal of approval," said the American Hospital Association's Mitchell.
      For example, Columbia/HCA's Internet site publicizes that 36 percent of the company's hospitals achieved accreditation with commendation, compared with 10 percent nationally. Columbia, the nation's largest hospital company, owns Sunrise Hospital and Sunrise MountainView.
      The joint commission's inspection of Sunrise late last year drew loud criticism from a union organizing nurses at the facility.
      In the days before the survey, the hospital "padded the staffing" for the days of the inspection, and housekeeping put in hundreds of hours of overtime to make the facility glisten, said Jeri Woolston, a registered nurse at Sunrise.
      At the time, a Sunrise official said the hospital wasn't doing anything substantially different from usual staffing education efforts. The facility received an accreditation with commendation -- the highest level of accreditation.
      Woolston sides with Public Citizen and other consumer groups, saying the surveys shouldn't be pre-scheduled. The regular three-year inspections are scheduled at least a month ahead.
      "I think it's appalling," she said. "I think it should be like the health department where they come in and do spot checks."
      Given the tight controls on information, consumers should start researching local hospitals before they get sick, said Inlander, with the People's Medical Society.
      "You have to do all the digging yourself," he said. "My advice is ignore hospital advertising that does not include evidence that what they do, they do well. To be accredited is not a big deal."
     
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