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Original Investigation
Health Care Policy and Law
May 2017

Patient Mortality During Unannounced Accreditation Surveys at US Hospitals

Author Affiliations
  • 1Department of Health Care Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
  • 2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
  • 3Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 4Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
  • 5National Bureau of Economic Research, Cambridge, Massachusetts
JAMA Intern Med. 2017;177(5):693-700. doi:10.1001/jamainternmed.2016.9685
Key Points

Question  What is the effect of heightened vigilance during unannounced hospital accreditation surveys on the quality and safety of inpatient care?

Findings  In an observational analysis of 1984 unannounced hospital surveys by The Joint Commission, patients admitted during the week of a survey had significantly lower 30-day mortality than did patients admitted in the 3 weeks before or after the survey. This change was particularly pronounced among major teaching hospitals; no change in secondary safety outcomes was observed.

Meaning  Changes in practice occurring during periods of surveyor observation may meaningfully improve quality of care.


Importance  In the United States, hospitals receive accreditation through unannounced on-site inspections (ie, surveys) by The Joint Commission (TJC), which are high-pressure periods to demonstrate compliance with best practices. No research has addressed whether the potential changes in behavior and heightened vigilance during a TJC survey are associated with changes in patient outcomes.

Objective  To assess whether heightened vigilance during survey weeks is associated with improved patient outcomes compared with nonsurvey weeks, particularly in major teaching hospitals.

Design, Setting, and Participants  Quasi-randomized analysis of Medicare admissions at 1984 surveyed hospitals from calendar year 2008 through 2012 in the period from 3 weeks before to 3 weeks after surveys. Outcomes between surveys and surrounding weeks were compared, adjusting for beneficiaries’ sociodemographic and clinical characteristics, with subanalyses for major teaching hospitals. Data analysis was conducted from January 1 to September 1, 2016.

Exposures  Hospitalization during a TJC survey week vs nonsurvey weeks.

Main Outcomes and Measures  The primary outcome was 30-day mortality. Secondary outcomes were rates of Clostridium difficile infections, in-hospital cardiac arrest mortality, and Patient Safety Indicators (PSI) 90 and PSI 4 measure events.

Results  The study sample included 244 787 and 1 462 339 admissions during survey and nonsurvey weeks with similar patient characteristics, reason for admission, and in-hospital procedures across both groups. There were 811 598 (55.5%) women in the nonsurvey weeks (mean [SD] age, 72.84 [14.5] years) and 135 857 (55.5%) in the survey weeks (age, 72.76 [14.5] years). Overall, there was a significant reversible decrease in 30-day mortality for admissions during survey (7.03%) vs nonsurvey weeks (7.21%) (adjusted difference, −0.12%; 95% CI, −0.22% to −0.01%). This observed decrease was larger than 99.5% of mortality changes among 1000 random permutations of hospital survey date combinations, suggesting that observed mortality changes were not attributable to chance alone. Observed mortality reductions were largest in major teaching hospitals, where mortality fell from 6.41% to 5.93% during survey weeks (adjusted difference, −0.38%; 95% CI, −0.74% to −0.03%), a 5.9% relative decrease. We observed no significant differences in admission volume, length of stay, or secondary outcomes.

Conclusions and Relevance  Patients admitted to hospitals during TJC survey weeks have significantly lower mortality than during nonsurvey weeks, particularly in major teaching hospitals. These results suggest that changes in practice occurring during periods of surveyor observation may meaningfully affect patient mortality.