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Patients treated at hospitals during unannounced accreditation inspections appear to have a slightly lower risk of dying within 30 days of admission, compared with patients treated in the few weeks before or after such surveys take place, according to a study led by researchers at Harvard Medical School and the Harvard T.H. Chan School of Public Health.
Notably, the research team said, the effect does not seem to be directly related to any of the factors that inspectors focus on, such as hospital-acquired infections or other aspects of patient safety. Rather, the authors said, overall heightened awareness and increased vigilance by clinicians, as a result of intense observation, may explain the effect. The study findings are published March 20 in JAMA Internal Medicine.
While the differences in mortality risk were small and dissipated soon after the survey visits were over, according to the researchers, even minuscule drops in mortality can have serious aggregate effects on the U.S. population. The trend underscores an opportunity to further minimize preventable harm and boost patient safety efforts across U.S. hospitals, the researchers wrote in the paper.
“As physicians, we have the health and safety of our patients first and foremost in our minds and in all of our efforts,” said study senior author Anupam Jena, the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School. “It is critical to understand how clinical decisions get made and what can make them better.”
Medical error is a significant cause of preventable death in U.S. hospitals. To ensure compliance and help hospitals identify gaps in their patient safety and quality of care protocols, the hospital-accrediting body known as the Joint Commission performs unannounced on-site inspections as a core part of their surveillance process.
They happen without warning once every 18 to 36 months across all U.S. hospitals. Teams of inspectors descend on the hospital, observing how rigorously clinicians follow patient safety and care procedures, ranging from hand-washing and medication management to clinical note keeping and myriad other routine and unexpected procedures involved in patient care. Low-performing hospitals face penalties, loss of accreditation and, in extreme cases, even closure.
To measure the impact of hospital inspections on patient outcomes, the researchers analyzed records from Medicare patient admissions at 1,984 surveyed hospitals from 2008 to 2012. The researchers focused on inspection weeks and compared patient outcomes to the three weeks before and the three weeks after the inspection took place.
The researchers found that across all hospitals, patients treated during an inspection week had a 1.5 percent lower risk of dying, on average, within 30 days of admission than patients treated in the three weeks before or after an inspection.
The decrease was more pronounced at major teaching hospitals, where patients admitted during survey weeks had a nearly 6 percent lower chance of dying in the month following admission than patients admitted in the weeks before or after a survey. The researchers found that the steeper drop in mortality risk at teaching hospitals may stem from these institutions’ having more resources and clinical staff and from the intense preparation they have traditionally invested in accreditation performance.
While the cause of the effect remains unclear, the researchers speculate that improvements may stem from the basic human impulse to perform better when being watched and evaluated. In other words, they wrote, the effect may stem from heightened clinician vigilance during periods of intense observation.
Challenging Common Knowledge: An HMS Labcast Episode with Anupam Jena
Jena talks about finding research questions in unusual places, what happens when a result contradicts “common knowledge,” what’s fun and challenging about his work, and learning when to let a project go.
“Our results suggest that heightened focus and attention during periods of intense observation may influence clinical decision making and downstream patient outcomes,” Jena said.
The researchers note that the findings require further analysis to tease out precisely what changes in behavior fueled the decline in mortality.
“Interruptions in clinical care occur frequently. Efforts to minimize distractions and increase clinician focus and attention could have measurable impact on patients,” Jena said.
Finding a way to harness that reaction and the behavioral shifts it precipitates could give patient safety efforts a healthy boost, the researchers said.
“We’ve all seen how traffic slows when drivers see a police officer ahead of them on the road,” said the study’s lead author Michael Barnett, assistant professor of health policy and management at the Harvard Chan School and an HMS instructor of medicine at Brigham and Women’s Hospital. “We believe the same dynamic may be at play here, and physicians and staff find ways to step up the overall quality of care when they know they are being observed.”
While the team found significant decreases in 30-day mortality risk among patients admitted during the inspection week, they didn’t find any evidence that patients were doing better because staff were more focused on the specific things that the inspectors were scrutinizing. For example, there was no difference in the levels of hospital- acquired infections, which might be attributed to changes in hand-washing practices or in other infection-prevention measures while inspectors were present. There were no differences in other patient-safety indicators such as the number of preventable pressure ulcers or the number of nonfatal cardiac arrests. Analysis of the differences between preventable postsurgical complications revealed a small reduction during inspection weeks.
"It's an enormous fire drill for hospitals when the inspectors arrive,” said Jena, who is also a physician at Massachusetts General Hospital. “It was entirely possible that the distraction of a Joint Commission visit could lead to worse patient outcomes, but we found the opposite.”
This research was supported with funding from the Office of the Director, National Institutes of Health (NIH Early Independence Award, Grant 1DP5OD017897-01) and the Health Resources and Services Administration (T32-HP10251).
Jena received consulting fees unrelated to this research from Pfizer, Inc., Hill Room Services, Inc., Bristol-Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals and Precision Health Economics.
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