Is JCAHO Accreditation
Associated with Better Patient Outcomes
in Rural Hospitals?
Laura Morlock, PhD
Bloomberg School of Public Health
Johns Hopkins University
Project Sponsorship
This
analysis is part of a larger study:
“Rural Hospitals: Environment, Strategy,
and Viability” (RO1 HS011444)
Funded by the Agency for Healthcare
Research and Quality
Research Team

Johns Hopkins Bloomberg School of Public Health
Laura Morlock, PhD
David Salkever, PhD
Peter Pronovost, MD, PhD
Marlene Miller, MD, MSc
Lilly Engineer, MD, MHA
Cyrus Engineer, MHA,MHS
Maureen Fahey, MLA
Andrew Shore, PhD
Rebecca Clark, BA
Ann Skinner, MSW
Research Team cont.

Virginia Commonwealth University
Stephen Mick, PhD and team

Rural Policy Research Institute (RUPRI)
Keith Mueller, PhD—Nebraska Medical Center
Andrew Coburn, PhD—Univ. of Southern Maine
Timothy McBride, PhD—St. Louis University
A. Clinton MacKinney, MD, MS
Mary Wakefield, PhD—Univ. of North Dakota
Rebecca Slifkin, PhD—Univ. of North Carolina
Overall Project Objective
 To
assess the impact of Federal policy
changes and healthcare market forces on
the organizational and management
strategies, financial viability and clinical
performance of U.S. rural hospitals.
Project Design
Outcome Measures
Federal Policy
Legislation
Healthcare
Market Forces
Rural
Hospitals
• Survival
• Organizational &
Management Strategies,
including Conversion
• Financial Viability
• Clinical Performance
Objective of This Analysis
 To
examine whether rural hospitals
accredited by the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) have better patient outcomes than
non-accredited rural hospitals.
Background and Significance:
Rural Hospitals
Over 54 million people in the US live in rural
areas and are served by about 2200 rural hospitals.
 Rural hospitals play a critical role in their
communities by:

– Providing access to health care;
– Serving as a hub for public health, wellness, and social
services;
– Providing jobs, recruiting health practitioners, making
communities more attractive places to live and work.
Background and Significance:
JCAHO Accreditation
 Fewer
than 60% of rural hospitals seek
JCAHO accreditation in contrast to 95% of
urban hospitals.
 Cost is a major deterrent.
 It is not known whether JCAHO
accreditation is associated with better
quality as measured by patient outcomes.
Study Design
Study sample: All patients discharged from a
random sample of about half of the rural hospitals
(N=186) in 9 states.
 Time Frame: 1999-2001
 Outcome variables: HCUP risk-adjusted inpatient
mortality rates
 Independent (predictor) variable: Presence or
absence of JCAHO accreditation
 Control variables: Hospital size, financial status,
ownership, system membership, subsequent
conversion to Critical Access Hospital

States Included in the Analysis
 Arizona
 California
 Colorado
 Florida
 Iowa
 Kentucky
 New York
 Washington
 Wisconsin
Outcome Measures
Inpatient Quality Indicators (IQIs)



Risk-adjusted in-hospital mortality rates during 1999-2001 for:
– Congestive heart failure (CHF)
– Stroke
– Pneumonia
Rationale for selection of specific indicators: Majority of both
accredited and non-accredited rural hospitals met volume
threshold of at least 30 patients with these conditions over the
three year time period.
Source of data: AHRQ-sponsored Healthcare Cost and Utilization
Project (HCUP) State Inpatient Databases for 9 states
Independent (Predictor) Variable
Hospital Accreditation Status
 Source
of data: Information on the most recent
accreditation status was provided by the Joint
Commission on Accreditation of Healthcare
Organizations (JCAHO)
Control Variables*
 Hospital
size: number of beds in operation
 Financial status: hospital total margins averaged over
fiscal years 1999-2001
– Source of data: Medicare Cost Report files
 Multi-hospital
system membership (yes/no)
 Ownership (public, private not-for-profit, private forprofit
 Subsequent conversion to Critical Access Hospital
(CAH) (yes/no)
* Source of data for all variables except financial status is the American
Hospital Association.
Methods of Analysis
Multivariate regressions with bed size,
average total margin, system membership,
ownership and subsequent CAH conversion
status used as control variables
 Generalized Estimating Equations (GEE)
used to adjust for the clustering of hospitals
within states

Study Results
 110
of 186 hospitals (59%) were accredited by the
JCAHO
 JCAHO accreditation is positively associated with:
– Larger number of beds (p<.0001)
– Better financial condition (p<.05)
– System membership (p<.001)
– Private not-for-profit ownership (p<.001)
 JCAHO accreditation is negatively associated with:
– Non-federal public ownership (p<.0001)
– Subsequent conversion to CAH (p<.0001)
Analysis Strategy
 Importance
of using risk-adjusted rates that take
into consideration severity of illness and risk of
mortality based on the patient’s underlying
condition (HCUP uses the All Patient Refined
DRG software to do this)
 Importance of controlling for variables associated
with seeking and obtaining JCAHO accreditation
Differences by JCAHO Accreditation Status
in Observed and Risk-Adjusted Mortality Rates
Diagnoses
Hospital Status
Accredited
Non-accredited
Obs.
R.A.
Congestive heart failure 4.6%
5.2%
Stroke
10.7% 12.9%
Pneumonia
6.6% 8.1%
Note: Obs.=Observed
R.A.=Risk-Adjusted
Obs.
R.A.
4.8%
14.8%
6.0%
6.0%
16.6%
8.6%
Multivariate Analysis Results
 After
controlling for hospital size, financial status,
ownership, system membership, and subsequent
conversion to a CAH,
 JCAHO accreditation is significantly associated with
lower risk-adjusted in-hospital mortality rates for:
– Congestive heart failure (p<.02)
– Stroke (p<.01) and
– Pneumonia (p<.0001)
 A similar
pattern is evident in within-state comparisons.
Policy Implications
 These
findings, if supported by further analyses,
suggest that accreditation status may be a useful
indicator of hospital clinical performance for
rural health care consumers, payers and
regulators.
 These findings may also be encouraging to the
many rural hospitals with resource constraints
that are considering the costs and benefits of
embarking on the accreditation process.