Field Hospital Boston Hope: Defining Culture During Uncertainty.

As hospitals across the world realized their surge capacity would not be enough to care for patients with coronavirus disease-2019 (COVID-19) infection, an urgent need to open field hospitals prevailed. In this article the authors describe the implementation process of opening a Boston field hospital including the development of a culture unique to this crisis and the local community needs. Through first-person accounts, readers will learn (1) about Boston Hope, (2) how leaders managed and collaborated, (3) how the close proximity of the care environment impacted decision-making and management style, and (4) the characteristics of leaders under pressure as observed by the team.

The Cost of Quality: An Academic Health Center's Annual Costs for Its Quality and Patient Safety Infrastructure.

BACKGROUND: In the United States, regulatory bodies, state licensing boards, hospital accreditation organizations, and medical specialty boards have increased their demands for data, public reporting, and improvement. Survey research suggests that as much as $15 billion is spent on reporting quality measures, but those costs, as well as those associated with improvement, have not been sufficiently characterized. A study was conducted to examine, in detail, the costs incurred by one health care organization-an academic health center (AHC) with employed physicians-in responding to quality and safety requirements. METHODS: To identify annual costs associated with an AHC's quality and safety infrastructure, a conceptual model was developed for organizing costs into four domains-Measurement and Reporting, Safety, Quality Improvement, and Training and Communication. In an inventory approach, a purpose-specific instrument was used to aggregate and sort costs; clinicians and administrators were asked to identify all domain activities and the associated full-time equivalents and other direct costs (labor and nonlabor) allocated to each activity. RESULTS: For this AHC, nearly $30 million of direct costs-more than 1.1% of net patient service revenue-were incurred to maintain the quality infrastructure. Approximately 81.6% of the costs were associated with mandates by regulators, accreditors, and payers-49.8% of which supported required public reporting. CONCLUSION: Indisputable good for patients and providers has resulted from organizational investments in quality and safety. But policy makers must be cognizant of potential trade-offs and explicitly recognize the incremental costs of additional measurement, improvement, and mandated reporting in their decision making.

Physician and Patient Views on Public Physician Rating Websites: A Cross-Sectional Study.

BACKGROUND: Numerical ratings and narrative comments about physicians are increasingly available online. These physician rating websites include independent websites reporting crowd-sourced data from online users and health systems reporting data from their internal patient experience surveys. OBJECTIVE: To assess patient and physician views on physician rating websites. DESIGN: Cross-sectional physician (electronic) and patient (paper) surveys conducted in August 2015. PARTICIPANTS: Eight hundred twenty-eight physicians (response rate 43%) affiliated with one of four hospitals in a large accountable care organization in eastern Massachusetts; 494 adult patients (response rate 34%) who received care in this system in May 2015. MAIN MEASURES: Use and perceptions of physician rating websites. KEY RESULTS: Fifty-three percent of physicians and 39% of patients reported visiting a physician rating website at least once. Physicians reported higher levels of agreement with the accuracy of numerical data (53%) and narrative comments (62%) from health system patient experience surveys compared to numerical data (36%) and narrative comments (36%) on independent websites. Patients reported higher levels of agreement with trusting the accuracy of data obtained from independent websites (57%) compared to health system patient experience surveys (45%). Twenty-one percent of physicians and 51% of patients supported posting narrative comments online for all consumers. The majority (78%) of physicians believed that posting narrative comments online would increase physician job stress; smaller proportions perceived a negative effect on the physician-patient relationship (46%), health care overuse (34%), and patient-reported experiences of care (33%). Over one-fourth of patients (29%) believed that posting narrative comments would cause them to be less open. CONCLUSIONS: Physicians and patients have different views on whether independent or health system physician rating websites are the more reliable source of information. Their views on whether such data should be shared on public websites are also discordant.

Using Behavioral Economics to Design Physician Incentives That Deliver High-Value Care.

Behavioral economics provides insights about the development of effective incentives for physicians to deliver high-value care. It suggests that the structure and delivery of incentives can shape behavior, as can thoughtful design of the decision-making environment. This article discusses several principles of behavioral economics, including inertia, loss aversion, choice overload, and relative social ranking. Whereas these principles have been applied to motivate personal health decisions, retirement planning, and savings behavior, they have been largely ignored in the design of physician incentive programs. Applying these principles to physician incentives can improve their effectiveness through better alignment with performance goals. Anecdotal examples of successful incentive programs that apply behavioral economics principles are provided, even as the authors recognize that its application to the design of physician incentives is largely untested, and many outstanding questions exist. Application and rigorous evaluation of infrastructure changes and incentives are needed to design payment systems that incentivize high-quality, cost-conscious care.

Hospital teaching intensity and mortality for acute myocardial infarction, heart failure, and pneumonia.

BACKGROUND: Under the Affordable Care Act, health care reimbursement will increasingly be linked to quality and costs. In this environment, teaching hospitals will be closely scrutinized, as their care is often more expensive. Furthermore, although they serve vital roles in education, research, management of complex diseases, and care of vulnerable populations, debate continues as to whether teaching hospitals deliver better outcomes for common conditions. OBJECTIVE: To determine the association between risk-standardized mortality and teaching intensity for 3 common conditions. RESEARCH DESIGN: Using CMS models, 30-day risk-standardized mortality rates were compared among US hospitals classified as Council of Teaching Hospital (COTH) members, non-COTH teaching hospitals, or nonteaching hospitals. These analyses were repeated using ratios of interns and residents to beds to classify teaching intensity. SUBJECTS: The study cohort included Medicare fee-for-service beneficiaries aged 66 years or older hospitalized in acute care hospitals during 2009-2010 for acute myocardial infarction (N = 342,145), heart failure (N = 647,081), or pneumonia (N = 598,366). OUTCOME MEASURE: The 30-day risk-standardized mortality rates for each condition, stratified by teaching intensity. RESULTS: For each diagnosis, compared with nonteaching hospitals there was a 10% relative reduction in the adjusted odds of mortality for patients admitted to COTH hospitals and a 6%-7% relative reduction for patients admitted to non-COTH teaching hospitals. These findings were insensitive to the method of classifying teaching intensity and only partially explained by higher teaching hospital volumes. CONCLUSIONS: Health care reimbursement strategies designed to increase value should consider not only the costs but also the superior clinical outcomes at teaching hospitals for certain common conditions.

Is the Gap Closing? Comparison of Sociodemographic Disparities in COVID-19 Hospitalizations and Outcomes Between Two Temporal Waves of Admissions.

OBJECTIVE: The COVID-19 pandemic has disproportionately impacted minority communities, yet little data exists regarding whether disparities have improved at a health system level. This study examined whether sociodemographic disparities in hospitalization and clinical outcomes changed between two temporal waves of hospitalized COVID-19 patients. METHODS: This is a retrospective cohort study of primary care patients at Mass General Brigham (a large northeastern health system serving 1.27 million primary care patients) hospitalized in-system with COVID-19 between March 1, 2020, and March 1, 2021, categorized into two 6-month "wave" periods. We used chi-square tests to compare demographics between waves, and regression analysis to characterize the association of race/ethnicity and language with in-hospital severe outcomes (death, hospice discharge, intensive unit care need). RESULTS: Hispanic/Latino, Black, and non-English-speaking patients constituted 30.3%, 12.5%, and 29.7% of COVID-19 admissions in wave 1 (N = 5844) and 22.2%, 9.0%, and 22.7% in wave 2 (N = 4007), compared to 2019 general admission proportions of 8.8%, 6.3%, and 7.7%, respectively. Admissions from highly socially vulnerable census tracts decreased between waves. Non-English speakers had significantly higher odds of severe illness during wave 1 (OR 1.35; 95% CI: 1.10, 1.66) compared to English speakers; this association was non-significant during wave 2 (OR 1.01; 95% CI: 0.76, 1.36). CONCLUSIONS: Comparing two COVID-19 temporal waves, significant sociodemographic disparities in COVID-19 admissions improved between waves but continued to persist over a year, demonstrating the need for ongoing interventions to truly close equity gaps. Non-English-speaking language status independently predicted worse hospitalization outcomes in wave 1, underscoring the importance of targeted and effective in-hospital supports for non-English speakers.

Population turnover and leakage in commercial ACOs.

OBJECTIVES: Commercial accountable care organization (ACO) contracts attempt to mitigate spending growth, but past evaluations have been limited to continuously enrolled ACO members in health maintenance organization (HMO) plans, excluding many members. The objective of this study was to examine the magnitude of turnover and leakage within a commercial ACO. STUDY DESIGN: A historical cohort study using detailed information from multiple commercial ACO contracts within a large health care system between 2015 and 2019. METHODS: Individuals insured through 1 of the 3 largest commercial ACO contracts during the study period, 2015-2019, were included. We examined patterns of entry and exit and the characteristics that predicted remaining in the ACO compared with leaving the ACO. We also examined predictors of the amount of care delivered in the ACO compared with outside the ACO. RESULTS: Among the 453,573 commercially insured individuals in the ACO, approximately half left the ACO within the initial 24 months after entry. Approximately one-third of spending was for care occurring outside the ACO. Patients who remained in the ACO differed from those who left earlier, including being older, having a non-HMO plan, having lower predicted spending at entry, and having more medical spending for care performed within the ACO during the initial quarter of membership. CONCLUSIONS: Both turnover and leakage hamper the ability of ACOs to manage spending. Modifications that address potentially intrinsic vs avoidable sources of population turnover and increase patient incentives for care within vs outside of ACOs could help address medical spending growth within commercial ACO programs.

Tacking upwind: reducing spending among high-risk commercially insured patients.

OBJECTIVES: The study examined a commercial accountable care organization (ACO) population and then assessed the impact of an integrated care management program on medical spending and clinical event rates. STUDY DESIGN: Retrospective cohort study of high-risk individuals (n = 487) in a population of 365,413 individuals aged 18 to 64 years within the Mass General Brigham health system who were part of commercial ACO contracts with 3 large insurers between 2015 and 2019. METHODS: Using medical spending claims and other enrollment data, the study assessed the demographic and clinical characteristics, medical spending, and clinical event rates of patients in the ACO and its high-risk care management program. The study then examined the impact of the program using a staggered difference-in-difference design with individual-level fixed effects and compared outcomes of those who had entered the program with those of similar patients who had not entered. RESULTS: The commercially insured ACO population was healthy on average but included several hundred high-risk patients (n = 487). After adjustment, patients within the ACO's integrated care management program for high-risk patients had lower monthly medical spending (by $1361 per person per month) as well as lower emergency department visit and hospitalization rates compared with similar patients who had yet to start the program. Accounting for early ACO departure decreased the magnitude of the program effects as expected. CONCLUSIONS: Commercial ACO populations may be healthy on average but still include some high-risk patients. Identifying which patients might benefit from more intensive care management could be critical for reaping the potential savings.

Advancing the science of patient safety.

Despite a decade's worth of effort, patient safety has improved slowly, in part because of the limited evidence base for the development and widespread dissemination of successful patient safety practices. The Agency for Healthcare Research and Quality sponsored an international group of experts in patient safety and evaluation methods to develop criteria to improve the design, evaluation, and reporting of practice research in patient safety. This article reports the findings and recommendations of this group, which include greater use of theory and logic models, more detailed descriptions of interventions and their implementation, enhanced explanation of desired and unintended outcomes, and better description and measurement of context and of how context influences interventions. Using these criteria and measuring and reporting contexts will improve the science of patient safety.

A case for safety leadership team training of hospital managers.

BACKGROUND: Delivering safe patient care remains an elusive goal. Resolving problems in complex organizations like hospitals requires managers to work together. Safety leadership training that encourages managers to exercise learning-oriented, team-based leadership behaviors could promote systemic problem solving and enhance patient safety. Despite the need for such training, few programs teach multidisciplinary groups of managers about specific behaviors that can enhance their role as leadership teams in the realm of patient safety. PURPOSE: The aims of this study were to describe a learning-oriented, team-based, safety leadership training program composed of reinforcing exercises and to provide evidence confirming the need for such training and demonstrating behavior change among management groups after training. METHODS: Twelve groups of managers from an academic medical center based in the Northeast United States were randomly selected to participate in the program and exposed to its customized, experience-based, integrated, multimodal curriculum. We extracted data from transcripts of four training sessions over 15 months with groups of managers about the need for the training in these groups and change in participants' awareness, professional behaviors, and group activity. FINDINGS: Training transcripts confirmed the need for safety leadership team training and provided evidence of the potential for training to increase targeted behaviors. The training increased awareness and use of leadership behaviors among many managers and led to new routines and coordinated effort among most management groups. Enhanced learning-oriented leadership often helped promote a learning orientation in managers' work areas. PRACTICE IMPLICATIONS: Team-based training that promotes specific learning-oriented leader behaviors can promote behavioral change among multidisciplinary groups of hospital managers.

The essential role of population health during and beyond COVID-19.

The coronavirus disease 2019 (COVID-19) pandemic has fundamentally changed how health care systems deliver services and revealed the tenuousness of care delivery based on face-to-face office visits and fee-for-service reimbursement models. Robust population health management, fostered by value-based contract participation, integrates analytics and agile clinical programs and is adaptable to optimize outcomes and reduce risk during population-level crises. In this article, we describe how mature population health programs in a learning health system have been rapidly leveraged to address the challenges of the pandemic. Population-level data and care management have facilitated identification of demographic-based disparities and community outreach. Telemedicine and integrated behavioral health have ensured critical primary care and specialty access, and mobile health and postacute interventions have shifted site of care and optimized hospital utilization. Beyond the pandemic, population health can lead as a cornerstone of a resilient health system, better prepared to improve public health and mitigate risk in a value-based paradigm.

Patient safety climate in hospitals: act locally on variation across units.

BACKGROUND: An appreciation of how human factors affect patient safety has led to development of safety climate surveys and recommendations that hospitals regularly assess safety attitudes among caregivers. A better understanding of variation in patient safety climate across units within hospitals would facilitate internal efforts to improve safety climate. A study was conducted to assess the extent and nature of variation in safety climate across units within an academic medical center. METHODS: The Agency for Healthcare Research and Quality (AHRQ) Hospital Survey of Patient Safety was administered in 2008 to all nurses and attending physicians (N=4283) in a 900-bed acute care hospital (overall response rate, 69% [n=2961]). Responses were analyzed from the 2,163 physicians and nurses (73% of respondents) who could be assigned to one specific clinical unit. Results were examined for 57 units, categorized into six types. RESULTS: Ratings of various safety climate domains differed markedly across the 57 units, with the percentage reporting a safety grade of excellent ranging from 0% to 50%. The overall percentage of positive ratings was lower for the operating and emergency unit types than for inpatient medical and other clinical units. Even within the six unit types, substantial variation across individual units was evident. Unlike previous findings, physicians reported more negative ratings than nurses for some safety climate dimensions. CONCLUSIONS: Safety climate may vary markedly within hospitals. Assessments of safety climate and educational and other interventions should anticipate considerable variation across units within individual hospitals. Furthermore, clinicians at individual hospitals may offer different relative perceptions of the safety climate than their professional peers at other hospitals.

Factors Associated With Increased Collection of Patient-Reported Outcomes Within a Large Health Care System.

Importance: The collection of patient-reported outcomes (PROs) has garnered intense interest, but dissemination of PRO programs has been limited, as have analyses of the factors associated with successful programs. Objective: To identify factors associated with improving PRO collection rates within a large health care system using a centralized PRO infrastructure. Design, Setting, and Participants: This cohort study included 205 medical and surgical clinics in the Partners Healthcare system in Massachusetts that implemented a PRO program between March 15, 2014, and December 31, 2018, using a standardized centralized infrastructure. Data were analyzed from March to April 2019. Exposures: Relevant clinical characteristics were recorded for each clinic launching a PRO program. Main Outcomes and Measures: The primary outcome was the mean PRO collection rate during each clinic's most recent 6 months of collection prior to January 2019. Data were analyzed using a linear regression model with the 6-month PRO collection rate as the dependent variable and clinic characteristics as independent variables. Secondary analysis used a logistic regression model to assess clinical factors associated with successful clinics, defined as those that collected PROs at a rate greater than 50%. Results: Between March 2014 and December 2018, 205 Partners Healthcare clinics were available for analysis, and 4 061 205 PRO measures from 745 028 encounters were collected. Among these, 103 clinics (50.2%) collected at a rate greater than 50%. Increased collection rates were associated with more than 50% of physicians in a clinic trained on PROs (change, 19.6% [95% CI, 9.9%-29.4%]; P < .001), routine administrative oversight of collection rates (change, 16.0% [95% CI, 6.6%-25.5%]; P = .001), previous collection of PROs on paper (change, 12.5% [95% CI, 4.7%-20.3%]; P = .002), presence of a clinical champion (change, 11.2% [95% CI, 2.5%-20.0%]; P = .01) and payer incentive (change, 10.5% [95% CI, 2.0%-18.9%]; P = .02). Conclusions and Relevance: These findings suggest that training physicians on the use of PROs, administrative surveillance of collection rates, and the presence of a local clinical champion may be promising interventions for increasing PRO collection. Clinics that have previously collected PROs may have greater success in increasing collections. Payer incentive for collection was associated with improved collections, but not associated with successful programs.

A challenge to all. A primer on inter-country differences of high-need, high-cost patients.

BACKGROUND: Across countries, a small group of patients accounts for the majority of health care spending. These patients are more likely than other patients to experience problems with quality and safety in their care, suggesting that efforts targeting efficiency and quality among this population might have significant payoffs for health systems. Better understanding of similarities and differences in patient characteristics and health care use in different countries may ultimately inform further efforts to improve care for HNHC patients in these health systems. METHODS: We conducted a cross-sectional descriptive study using one year of patient-level data on high-cost patients in seven high-income OECD member countries. Countries were selected based on availability of detailed information (large enough samples of claims, administrative, and survey data of high-cost patients). We studied concentration of spending among high-cost patients, characteristics of high-cost patients, and per capita spending on high-cost patients. FINDINGS: Cost-concentration of the top 5% of patients varied across countries, from 41% in Japan to 60% in Canada, driven primarily by variation in the top 1% of spenders. In general, high-cost patients were more likely to be female (57.7% on average), had a significant number of multi-morbidities (up to on average 10 major diagnostic categories (ICD chapters), and had a lower socioeconomic status. Characteristics of high-cost patients varied as well: median age ranged from 62 in the Netherlands to 75 in Germany and the difference in socioeconomic status is particularly stark in the US. Lastly, utilization, particularly for inpatient care, varied with an average number of inpatient days ranging from 6.6 nights (US) to 97.7 nights in Japan. INTERPRETATION: In this descriptive study, there is substantial variation in the cost concentration, characteristics, and per capita spending on high-cost patient populations across high-income countries. Differences in the way that health systems are structured likely explains some of this variation, which suggests the potential of cross-system learning opportunities. Our findings highlight the need for further studies including comparable performance metrics and institutional analysis.

Transforming concepts in patient safety: a progress report.

In 2009, the National Patient Safety Foundation's Lucian Leape Institute (LLI) published a paper identifying five areas of healthcare that require system-level attention and action to advance patient safety.The authors argued that to truly transform the safety of healthcare, there was a need to address medical education reform; care integration; restoring joy and meaning in work and ensuring the safety of the healthcare workforce; consumer engagement in healthcare and transparency across the continuum of care. In the ensuing years, the LLI convened a series of expert roundtables to address each concept, look at obstacles to implementation, assess potential for improvement, identify potential implementation partners and issue recommendations for action. Reports of these activities were published between 2010 and 2015. While all five areas have seen encouraging developments, multiple challenges remain. In this paper, the current members of the LLI (now based at the Institute for Healthcare Improvement) assess progress made in the USA since 2009 and identify ongoing challenges.