For-Profit Enterprise in Health Care (1986) / Chapter Skim
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6 Quality of Care
6 Quality of Care
Pages 127-141
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From page 127... ...
Ideally, the committee would have liked to examine patient outcome data from carefully matched for-profit and not-for-profit settings, as well as from chain and independent institutions, in order to draw inferences about quality. Unfortunately, the committee had access only to studies using statistical controls and structure and process quality measures, such as hospital accreditation, board certification rates of staff physicians, and perceptions of physicians and hospital board chain, as well as some aggregate but nondefinitive pooled outcome data.
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From page 128... ...
The American Hospital Association, in its annual survey of hospitals, collects data on whether hospitals are accredited. A second source of data on ICAlI accreditation is from a paper prepared for the committee by Gary Gaumer (1986)
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From page 129... ...
(American Meclical Association, 1984~. These same data, however, were analyzed in a paper prepared for the committee, and it was found that when chain hospitals are separated Dom independent inshtubons, He rates of board certification of staff physicians TABLE 6.2 Results of ICAH Accreditation Visits for Fiscal Year Ending May 31, 1983 Accreditation Outcome Accredited Accredited Without with Contingencies Contingencies (%)
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From page 130... ...
Table 6.4 displays data from the 1983 AHA annual survey of hospitals and FOR-PROFIT ENTERPRISE IN HEALTH CARE shows no important differences between investor-owned chain hospitals and not-forprofit hospitals, although both inclependent for-profit hospitals and state and local government hospitals had lower levels of registered nurses. Physicians' Evaluations At the committee s request, the American Medical Association asked the physicians responding to its 1984 core survey to compare their primary hospital with other hospitals that they might be familiar with on four dimensions: the adequacy of nursing support, the responsiveness of the hospital's admin istration, the level of patient satisfaction, and the adequacy of technical resources and equipment (Musacchio et al., 1986~.
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From page 131... ...
(1986) attribute this difference, at least in part, to the fact Mat most physicians who TABLE 6.4 Nursing Personnel per 100 Adjusted Census, Short-Term General and Over Special Hospitals, 1983 Investor- For- Not-for- Not-for- State and Owned profit profit profit Local Chain Independent Chain Independent Government RNs/100 patients 82 70 84 83 71 LPNs/100 patients 32 28 26 25 30 SOURCE: Peter Kralovec, Hospital Data Center, American Hospital Association, 1985.
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From page 132... ...
Implications for quality are quite unclear. Board Chairman Evaluations Another source of perceptions comes from a survey of hospital governing board chairmen that was conducted by Arthur Young for the American Hospital Association's Trustee Magazine in 1983 (Arthur Young, 19831.
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From page 133... ...
Ensure integrity of operations Perfonn strategic planning Monitor CEO Monitor financial reporting Ensure competitive position Ensure quality patient care Ensure standards are met Monitor legal liability Approve medical stag Which board responsibilities are being performed "excellently"? Ensure integrity of operations Perform strategic planning Monitor CEO Monitor financial reporting Ensure competitive position Ensure quality patient care Ensure standards are met Monitor legal liability Approve medical stab 88 31 28 22 33 84 71 38 47 52 14 21 17 24 64 57 36 40 78 48 45 39 31 83 59 29 44 50 22 24 41 15 52 39 23 34 81 43 42 42 28 84 56 28 32 54 22 21 42 16 49 35 23 25 15 33 39 46 29 83 60 29 37 51 18 24 38 20 57 39 ~2 28 80 42 41 41 29 84 58 29 36 53 21 22 40 17 52 38 23 28 SOURCE: The Hospital Governing Board Chairman: Profile and Opinions: A National Study by Trustee Magazine and Arthur Young (1983~.
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From page 134... ...
Although high rates of elective Caesarean sections are considered by some as an indication of excessive surgery, the great professional debate about indicators for elective Caesarean sections makes it difficult to place too much reliance on such rates as a measure of excessive surgery. However, data from the National Hospital Discharge Survey show Caesarean section rates to be higher in "proprietary" hospitals than in governmental hospitals in all four areas of the country examined and FOR-PROFIT ENTERPRISE IN HEALTH CARE higher than voluntary not-for-profit hospitats in three of four areas of the country, as is shown in Table 6.8 (Placek et al., 1983~.
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From page 135... ...
Whereas most American hospitals have long had surplus capacity and have vigorously competed for the loyalty of physicians who controlled the flow of patients, nursing home beds in most parts of the country are in very short supply, and physicians tend not to be involved in the referral process or in the day-to-day care of nursing home residents. Because of their physical and mental disabilities and social isolation, and owing to the scarce financial resources of Medicaid patients, many nursing home residents are less able than hos pitalized patients to look out for their own interests or to have advocates to do so.
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From page 136... ...
Second, and more unfortunate for a study that is oriented toward understanding implications for the future, most studies lump together as "proprietaries" the independent "mom-and-pop" nursing homes that have been on the decline since the very different investor-owned chain facilities have appeared and have been rapidly growing.6 To broadly summarize available evidence, most studies on quality (or surrogate measures) of nursing home care tend to favor the not-for-profit mode of organization.
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From page 137... ...
Unless a change takes place in the cultural values that afford high prestige and funding for hospitals and low prestige and, frequently, meager funding for long-term care, the unfortunate contrast between hospitals and nursing homes may remain. QUALITY OF CARE AND THE NEED FOR MONITORING Assurance of health care quality has long relied heavily on professional and institutional self-regulatory mechanisms and on monitoring efforts focusing primarily on structural and procedural measures- staffing patterns, requirements for obtaining staff privileges, existence of certain facilities and procedures, and the operation of institutional quality assurance systems.
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From page 138... ...
Data systems already exist or are being developed that wiD allow monitoring of such things as · Caesarean section rates · wound infection rates after surgery · nosocomial infections · readmission rates · complication rates · fatality rates (with adjustments for di agnoses and severity) · functional status of nursing home patients · health status measures in geographic areas.
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From page 139... ...
Although lack of uniform standards for 139 reporting outcomes other than death make the monitoring of outcomes more difficult, research, standard development, and monitoring of other outcomes infection rates, readmission rates, complication rates, changes in functional status of nursing home patients are clearly needed. To assess broader changes in the health care system not only the growth of the for-profit sector, but also of multi-institutional arrangements, new freestanding centers, and vertically integrated organizations, the monitoring of national and regional health status measures is essential.
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From page 140... ...
6A notable exception in a literature that generally does not distinguish between chain and independent proprietary nursing homes are two studies that focused or the single largest nursing home company: "Beverly Enterpnses Patient Care Record" and "Beverly Enterprises in Michigan: A Case Study of Corporate Takeover of Health Care Resources." These studies, which were done in 1983 by the Food and Beverage Trades Department of the AF~CIO and two other AFL-CIO affiliates, both suggest a disturbing pattern of qualityof-care problems in Beverly Enterprises nursing homes with respect to complaints of patient abuse and violations of state regulations. However, because these reports were prepared as part of an innovative "corporate campaign" strategy (English, 1985)
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From page 141... ...
The Changing Structure of the Nursing Home Industry and the Impact of Ownership on Quality, Cost, and Access. This volume.
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