Holding Providers Accountable for Health Care Outcomes.

Federal public reporting and payment programs have increasingly emphasized the measurement of outcomes (such as readmission, health care-associated infections, and mortality). Yet, the criteria for assessing whether outcome measures are accurate and valid enough to use for public reporting, payment, and accreditation are not well-defined. An outcome measure should be used only if the outcome can be influenced substantially by providers (that is, a strong process-outcome link exists) and statistical adjustment can be made for differences in patient populations across providers so that differences in outcomes are truly attributable to differences in the care provided. Validly distinguishing differences in quality of care across providers requires precision in both the design of the outcome measure and the actual recording of all the measure's elements. Four criteria are proposed to assess outcome measures. First, strong evidence should exist that good medical care leads to improvement in the outcome within the time period for the measure. Second, the outcome should be measurable with a high degree of precision. Third, the risk-adjustment methodology should include and accurately measure the risk factors most strongly associated with the outcome. Fourth, implementation of the outcome measure must have little chance of inducing unintended adverse consequences. These criteria were applied to 10 outcome measures currently used or proposed for accountability programs. Three measures met all 4 criteria; 5, including all 4 claims-based 30-day mortality measures, failed to meet 1 or more criteria. Patient-reported outcome measures are problematic, because low response rates may cause bias. These findings raise concerns and suggest the need for a national dialogue about how to judge outcome measures currently in use or proposed for the future.

Using the Targeted Solutions Tool® to Improve Hand Hygiene Compliance Is Associated with Decreased Health Care-Associated Infections.

BACKGROUND: In 2010 Memorial Hermann Health System (MHHS) implemented the Joint Commission Center for Transforming Healthcare's (the Center's) Web-based Targeted Solutions Tool ®(TST ®) for improving hand hygiene through-out its 12 hospitals after participating in the Center's first project on hand hygiene, pilot testing the TST, and achieving significant improvement for each pilot unit. Because hand hygiene is a key contributing factor in health care-associated infections (HAIs), this project was an important part of MHHS's strategy to eliminate HAIs. METHODS: MHHS implemented the TST for hand hygiene in 150 inpatient units in 12 hospitals and conducted a system wide process improvement project from October 2010 through December 2014. The TST enabled MHHS to measure compliance rates, identify reasons for noncompliance, implement tested interventions provided by the TST, and sustain the improvements. Data on rates of ICU central line- associated bloodstream infections (CLABSIs) and ventilator- associated pneumonia (VAP) were also collected and analyzed. RESULTS: Based on 31,600 observations (October 2010- May 2011), MHHS's system wide hand hygiene compliance baseline rate averaged 58.1%. Compliance averaged 84.4% during the "improve" phase (June 2011-November 2012), 94.7% in the first 13 months of the "control phase" (December 2012-December 2014) and 95.6% in the final 12 months (p < 0.0001 for all comparisons to baseline). Con comitantly, adult ICU CLABSI and VAP rates decreased by 49% (p = 0.024) and 45% (p = 0.045), respectively. CONCLUSION: MHHS substantially improved hand hygiene compliance in its hospitals and sustained high levels of compliance for 25 months following implementation. Adult ICU CLABSI and VAP rates decreased in association with the hand hygiene compliance improvements.

Beyond the collaborative: spreading effective improvement in hand hygiene compliance.

BACKGROUND: Data assessing the effectiveness of quality improvement (QI) collaboratives are mixed; spreading improvement beyond the original collaborative group has proved difficult. Little is known about whether organizations that did not participate in the collaborative are able to effectively employ interventions developed or implemented by those organizations that did participate. METHODS: The Joint Commission Center for Transforming Healthcare conducted a collaborative QI project with eight hospitals, using Lean, Six Sigma, and change management methods to improve hand hygiene compliance. Participating hospitals achieved a 70.5% relative improvement (47.5% to 81.0%; p < .001). Following this project, working with an additional 19 hospitals, the Center created Web-based tools to enable health care organizations to use the same methods employed by the original eight hospitals without needing any knowledge or experience with Lean, Six Sigma, or change management. This Targeted Solutions Tool® (TST)® allowed organizations to discover the most important, specific causes of hand hygiene noncompliance in their facilities and to target interventions at those causes. RESULTS: In the first three years, 289 health care organizations used the TST to initiate 1,495 projects to improve hand hygiene compliance. Of the 769 projects at 174 organizations for which baseline and improvement data were available, average compliance improved from 57.9% to 83.5% (p < .0001). Similar improvement was observed in many clinical care settings, including ambulatory, long term care, inpatient pediatrics, critical care, and adult medical/surgical units. CONCLUSION: Hospitals and other health care organizations using the TST achieved levels of hand hygiene compliance comparable to those experienced by the participants in the original collaborative.

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance.

BACKGROUND: Hospitals and infection prevention specialists have attempted to achieve high levels of compliance with hand hygiene protocols for many decades. Despite these efforts, measured performance is disappointingly low. METHODS: The Joint Commission Center for Transforming Healthcare convened teams of experts in performance improvement and infectious disease from eight hospitals for its hand hygiene quality improvement project, which was conducted from December 2008 through September 2010. Together, they used Lean, Six Sigma, and change management methods to measure the magnitude of hand hygiene noncompliance, assess specific causes of hand hygiene failures, develop and test interventions targeted to specific causes, and sustain improved levels of performance. RESULTS: At baseline, hand hygiene compliance averaged 47.5% across all eight hospitals. Initial data revealed 41 different causes of hand hygiene noncompliance, which were condensed into 24 groups of causes. Key causes varied greatly among the hospitals. Each hospital developed and implemented specific interventions targeted to its most important causes of hand hygiene noncompliance. The improvements were associated with a 70.5% increase in compliance across the eight hospitals from 47.5% to 81.0% ( p < .001), a level of performance that was sustained for 11 months through the end of the project period. CONCLUSION: Lean, Six Sigma, and change management tools were used to identify specific causes of hand hygiene noncompliance at individual hospitals and target specific interventions to remedy the most important causes. This approach allowed each hospital to customize its improvement efforts by focusing on the causes most prevalent at its own facility. Such a targeted approach may be more effective, efficient, and sustainable than "one-size-fits-all" strategies.

High-reliability health care: getting there from here.

CONTEXT: Despite serious and widespread efforts to improve the quality of health care, many patients still suffer preventable harm every day. Hospitals find improvement difficult to sustain, and they suffer "project fatigue" because so many problems need attention. No hospitals or health systems have achieved consistent excellence throughout their institutions. High-reliability science is the study of organizations in industries like commercial aviation and nuclear power that operate under hazardous conditions while maintaining safety levels that are far better than those of health care. Adapting and applying the lessons of this science to health care offer the promise of enabling hospitals to reach levels of quality and safety that are comparable to those of the best high-reliability organizations. METHODS: We combined the Joint Commission's knowledge of health care organizations with knowledge from the published literature and from experts in high-reliability industries and leading safety scholars outside health care. We developed a conceptual and practical framework for assessing hospitals' readiness for and progress toward high reliability. By iterative testing with hospital leaders, we refined the framework and, for each of its fourteen components, defined stages of maturity through which we believe hospitals must pass to reach high reliability. FINDINGS: We discovered that the ways that high-reliability organizations generate and maintain high levels of safety cannot be directly applied to today's hospitals. We defined a series of incremental changes that hospitals should undertake to progress toward high reliability. These changes involve the leadership's commitment to achieving zero patient harm, a fully functional culture of safety throughout the organization, and the widespread deployment of highly effective process improvement tools. CONCLUSIONS: Hospitals can make substantial progress toward high reliability by undertaking several specific organizational change initiatives. Further research and practical experience will be necessary to determine the validity and effectiveness of this framework for high-reliability health care.

The contribution of geography to black/white differences in the use of low neonatal mortality hospitals in New York City.

BACKGROUND: Racial differences in the use of high-quality hospital care contribute to racial disparities in mortality for very low birth weight (VLBW) neonates. OBJECTIVES: We explored the role that geographic distribution of hospitals plays in the racial disparity in the use of top-tier hospitals by mothers of VLBW neonates in New York City. RESEARCH DESIGN: Retrospective analysis of Vital Statistics and administrative databases. SUBJECTS: VLBW deliveries in New York City from 1996 to 2001 to non-Hispanic Black (n = 4947) and non-Hispanic White (n = 1615) mothers. RESULTS: Black mothers were less likely to deliver in a top-tier hospitals (White = 44%, Black = 28%; P < 0.001) and top-tier hospitals were less likely to be located in Black mothers' neighborhoods (White = 40%, Black = 33%; P < 0.001). Distance, however, did not contribute to the disparity in use of top-tier hospitals. Non-Hispanic Black mothers lived marginally closer to a top-tier hospital than non-Hispanic White mothers (0.65 miles closer; P < 0.001), and mothers of both the races often bypassed their neighborhood hospital (Black = 62% bypassed, White = 71%; P < 0.001). Inattention to recommended prenatal behaviors was associated with using a closer hospital, suggesting that geographic proximity was most important to mothers of vulnerable neonates. Purported measures of hospital quality such as Neonatal Intensive Care Unit level and volume were more strongly associated with use of hospital for White mothers than for Black mothers. CONCLUSIONS: The influence of geography on the use of top-tier hospitals for mothers of VLBW neonates is complex. Other personal and hospital characteristics, not just distance or geography, also influenced hospital use in New York City.

Adherence to standards of care by health maintenance organizations in Israel and the USA.

BACKGROUND: The health-care systems in the USA and Israel differ in organization, financing and expenditure levels. However, managed care organizations play an important role in both countries, and a comparison of the performance of their community-based health plans could inform policymakers about ways to improve the quality of care. OBJECTIVE: To compare the adherence to standards of care in Israel and in the USA. STUDY DESIGN: An observational study comparing trends in performance using data from reports of the National Quality Measures Program in Israel and of the National Committee for Quality Assurance in the USA. RESULTS: Differences in specifications preclude a comparison between most measures in the two reports. However, the comparison of 11 similar measures in the 2007 reports indicates that performance was higher in the USA by 10 or more percentage points on four measures (flu immunization, medication for asthma, screening for colorectal cancer and monitoring for diabetic nephropathy). Performance was higher in Israel on three measures in patients with diabetes (blood pressure, low-density lipoprotein (LDL) cholesterol and glycemic control), and similar on the remaining four measures. Between 2005 and 2007, quality of care improved in both countries. However, improvement was slower in the USA than in Israel. CONCLUSIONS: In comparison with the USA, Israel achieves comparable health maintenance organization (HMO) quality on several primary care indicators and more rapid quality improvement, despite its substantially lower level of expenditure. Considering the differences between the two countries in settings and populations, further research is needed to assess the causes, generalizability and policy implications of these findings.

Approaching NIH guideline recommended care for maternal-infant health: clinical failures to use recommended antenatal corticosteroids.

To assess the use of antenatal corticosteroids in clinical circumstances for which both the NIH Guideline and local experts recommend their use and to describe characteristics associated with failure to use recommended antenatal steroids. We convened local experts to adapt the NIH statement by identifying clinical circumstances for which they agree antenatal steroids should always be used. We conducted a retrospective chart review on a cohort study of mothers who delivered premature (24-34 weeks) infants between 2000 and 2002 at three New York City hospitals and investigated the association of failure to treat with antenatal steroids with characteristics of the mother, pregnancy, delivery, and hospital. Twenty percent (101/515) of eligible mothers failed to receive indicated antenatal corticosteroid therapy. Of these, 43% delivered more than 2 h after admission, and 33% delivered more than 4 h after admission, indicating sufficient time to have treated them. Lack of prenatal care, longer gestation, advanced cervical exam, and intact membranes at admission were associated with failure to receive the recommended therapy. Antenatal steroids were under-utilized in our sample. If our results our generalizable, opportunities for quality improvement in the antenatal management of mothers in preterm labor exist.

Racial and ethnic disparities in outcomes and appropriateness of carotid endarterectomy: impact of patient and provider factors.

BACKGROUND AND PURPOSE: Prior work documented racial and ethnic disparities in incidence of stroke, stroke risk factors, and use of carotid endarterectomy. Less is known about disparities in outcomes and appropriateness of carotid endarterectomy or reasons for such inequalities. METHODS: This was a population-based cohort of carotid endarterectomy performed in Medicare beneficiaries in New York. Clinical data were abstracted from medical charts to assess sociodemographics, clinical indication for carotid endarterectomy, disease severity, comorbidities, and deaths and strokes within 30 days of surgery. Appropriateness was based on validated criteria from a national expert panel. Differences in patients, providers, outcomes, and appropriateness were compared using chi(2) tests. Differences in risk-adjusted rates of death or nonfatal stroke were compared using multiple logistic regression accounting for patient, physician, and hospital-level risk factors. RESULTS: Overall, 95.3% of patients undergoing carotid endarterectomy were white, 2.5% black, and 2.2% Hispanic (N=9093). Minorities had more severe neurological disease and more comorbidities and were more likely to be cared for by lower-volume surgeons and hospitals (P<0.0001). Rates of 30-day death/stroke were higher in Hispanics (9.5%) and blacks (6.9%) than whites (3.8%; P<0.0001). Multivariable analyses that adjusted for presurgical patient risk and provider characteristics found that blacks no longer had significantly worse outcomes (OR=1.37; CI, 0.78 to 2.40), although the higher risk of death/stroke in Hispanics persisted (OR=1.87; CI, 1.09 to 3.19). Minorities had higher rates of inappropriate surgery (Hispanics 17.6%, black 13.0%, white 7.9%; P<0.0001) largely due to higher comorbidity. CONCLUSIONS: Minorities had worse outcomes and higher rates of inappropriate surgery. Differences in underlying presurgical risk factors and provider characteristics explained the higher risk of complications in blacks, but not Hispanics.

Risk factors for perioperative death and stroke after carotid endarterectomy: results of the new york carotid artery surgery study.

BACKGROUND AND PURPOSE: The benefit of carotid endarterectomy is heavily influenced by the risk of perioperative death or stroke. This study developed a multivariable model predicting the risk of death or stroke within 30 days of carotid endarterectomy. METHODS: The New York Carotid Artery Surgery (NYCAS) Study is a population-based cohort of 9308 carotid endarterectomies performed on Medicare patients from January 1998 through June 1999 in New York State. Detailed clinical data were abstracted from medical charts to assess sociodemographic, neurological, and comorbidity risk factors. Deaths and strokes within 30 days of surgery were confirmed by physician overreading. Multivariable logistic regression was used to identify independent patient risk factors. RESULTS: The 30-day rate of death or stroke was 2.71% among asymptomatic patients with no history of stroke/transient ischemic attack (TIA), 4.06% among asymptomatic ones with a distant history of stroke/TIA, 5.62% among those operated on for carotid TIA, 7.89% of those with stroke, and 13.33% in those with crescendo TIA/stroke-in-evolution. Significant multivariable predictors of death or stroke included: age >/=80 years (OR, 1.30; 95% CI, 1.03 to 1.64), nonwhite (OR, 1.83; 1.23 to 2.72), admission from the emergency department (OR, 1.95; 1.50 to 2.54), asymptomatic but distant history of stroke/TIA (OR, 1.40; 1.02 to 1.94), TIA as an indication for surgery (OR, 1.81; 1.39 to 2.36), stroke as the indication (OR, 2.40; 1.74 to 3.31), crescendo TIA/stroke-in-evolution (OR, 3.61; 1.15 to 11.28), contralateral carotid stenosis >/=50% (OR, 1.44; 1.15 to 1.79), severe disability (OR, 2.94; 1.91 to 4.50), coronary artery disease (OR, 1.51; 1.20 to 1.91), and diabetes on insulin (OR, 1.55; 1.10 to 2.18). Presence of a deep carotid ulcer was of borderline significance (OR, 2.08; 0.93 to 4.68). CONCLUSIONS: Several sociodemographic, neurological, and comorbidity risk factors predicted perioperative death or stroke after carotid endarterectomy. This information may help inform decisions about appropriate patient selection, assessments about the impact of different surgical processes of care on outcomes, and facilitate comparisons of risk-adjusted outcomes among providers.

Improving patient satisfaction with pain management using Six Sigma tools.

BACKGROUND: Patient satisfaction as a direct and public measure of quality of care is changing the way hospitals address quality improvement. The feasibility of using the Six Sigma DMAIC (Define, Measure, Analyze, Improve, Control) methodology to improve patient satisfaction as it relates to pain management was evaluated. METHODS: This project used the DMAIC methodology to improve patients' overall satisfaction with pain management on two inpatient units in an urban academic medical center. Pre- and postintervention patient surveys were conducted. The DMAIC methodology provided a data-driven structure to determine the optimal improvement strategies, as well as a long-term plan for maintaining any improvements. In addition, the Change Acceleration Process (CAP) was used throughout the project's various DMAIC stages to further the work of the team by creating a shared need to meet the objectives of the project. RESULTS: Overall satisfaction with pain management "excellent" ratings increased from 37% to 54%. Both units surpassed the goal of at least 50% of responses in the "excellent" category. Several key drivers of satisfaction with pain management were uncovered in the Analyze phase of the project, and each saw rating increases from the pre-intervention to postintervention surveys. Ongoing monitoring by the hospital inpatient satisfaction survey showed that the pain satisfaction score improved in subsequent quarters as compared with the pre-intervention period. DISCUSSION: The Six Sigma DMAIC methodology can be used successfully to improve patient satisfaction. The project led to measurable improvements in patient satisfaction with pain management, which have endured past the duration of the Six Sigma project. The Control phase of DMAIC allows the improvements to be incorporated into daily operations.

Cost-effectiveness of nurse-led disease management for heart failure in an ethnically diverse urban community.

BACKGROUND: Randomized, controlled trials have shown that nurse-led disease management for patients with heart failure can reduce hospitalizations. Less is known about the cost-effectiveness of these interventions. OBJECTIVE: To estimate the cost-effectiveness of a nurse-led disease management intervention over 12 months, implemented in a randomized, controlled effectiveness trial. DESIGN: Cost-effectiveness analysis conducted alongside a randomized trial. DATA SOURCES: Medical costs from administrative records, and self-reported quality of life and nonmedical costs from patient surveys. PARTICIPANTS: Patients with systolic dysfunction recruited from ambulatory clinics in Harlem, New York. TIME HORIZON: 12 months. PERSPECTIVE: Societal and payer. INTERVENTION: 12-month program that involved 1 face-to-face encounter with a nurse and regular telephone follow-up. OUTCOME MEASURES: Quality of life as measured by the Health Utilities Index Mark 3 and EuroQol-5D and cost-effectiveness as measured by the incremental cost-effectiveness ratio (ICER). RESULTS OF BASE-CASE ANALYSIS: Costs and quality of life were higher in the nurse-managed group than the usual care group. The ICERs over 12 months were $17,543 per EuroQol-5D-based quality-adjusted life-year (QALY) and $15,169 per Health Utilities Index Mark 3-based QALY (in 2001 U.S. dollars). RESULTS OF SENSITIVITY ANALYSIS: From a payer perspective, the ICER ranged from $3673 to $4495 per QALY. Applying national prices in place of New York City prices yielded a societal ICER of $13,460 to $15,556 per QALY. Cost-effectiveness acceptability curves suggest that the intervention was most likely cost-effective for patients with less severe (New York Heart Association classes I to II) heart failure. LIMITATION: The trial was conducted in an ethnically diverse, inner-city neighborhood; thus, results may not be generalizable to other communities. CONCLUSION: Over 12 months, the nurse-led disease management program was a reasonably cost-effective way to reduce the burden of heart failure in this community.

Quality of care and racial health disparities: a strategic overview.

Substantial racial and ethnic disparities in health and health care exist in the United States. The Department of Health Policy at the Mount Sinai School of Medicine has developed a strategy for reducing those disparities that builds upon its quality improvement experience. This article discusses the utility of applying quality improvement principles to the development of interventions to eliminate underuse of effective treatments and reduce the disparities that may arise from this quality problem. We present a conceptual model of racial disparities in health and our underuse hypothesis. Parallels between our disparities research strategy and six sigma quality improvement methods are described. Finally, the article provides an example of how we have been able to successfully implement proven-effective health improvement programs in the Harlem community even after grant funding has ended.

Does managed care affect quality? Appropriateness, referral patterns, and outcomes of carotid endarterectomy.

This was a population-based observational study to assess the impact of managed care (MC) on several dimensions of quality of surgical care among Medicare beneficiaries undergoing carotid endarterectomies (CEAs) (N = 9308) in New York. Clinical data were abstracted from medical charts to assess appropriateness and deaths or strokes within 30 days of surgery. Differences in patients, appropriateness, and outcomes were compared using chi-square tests; risk-adjusted outcomes were compared using regression. Fee-For-Service (FFS, N = 8691) and MC (N = 897) CEA patients had similar indications for surgery, perioperative risk, and comorbidities. There were no differences in inappropriateness between FFS and MC (8.6% vs 8.4%). MC patients were less likely to use a high-volume surgeon (20.1% vs 13.5%) or hospital (20.5% vs 13.0%, P < .05). There were no differences in risk-adjusted rates of death or stroke (OR = 0.97; 95% CI = 0.69-1.37). Medicare MC plans did not have a positive impact on inappropriateness, referral patterns, or outcomes of CEA.