The Path to Quality in Outpatient Practice: Meaningful Use, Patient-Centered Medical Homes, Financial Incentives, and Technical Assistance.

Adoption and meaningful use of electronic health records is considered an essential step to improve the quality of health care. The authors assessed whether a series of Connecticut primary care providers who achieved Stage I Meaningful Use of electronic health records used quality improvement strategies that are associated with improvements in care. Practice structural characteristics, quality improvement-related electronic health record processes, outcomes, and barriers were assessed in 14 primary care practices. Implementation of quality improvement-related electronic health record processes was variable and barriers were common. Only 4 practices used data consistently to assess their performance, and only 3 reported improvements in care. Practices that were patient-centered medical homes scored higher on all quality improvement domains and received financial rewards more commonly. These findings suggest that primary care quality may be improved by formal alignment of Meaningful Use and Patient-Centered Medical Home criteria and by ongoing technical assistance to practices.

A descriptive study of educational outreach to promote use of quality improvement tools in primary care private practice.

The objective of this study was to describe the experience of a Quality Improvement Organization (QIO) providing educational outreach to promote use of quality improvement (QI) tools in primary care private practice. Two QIO outreach workers conducted visits with physicians and targeted staff. Data were analyzed on physician demographics, visits, and use of QI tools using standard quantitative and qualitative methods. QIO staff frequently encountered difficulty in accessing physicians and administrative staff and reported many barriers to QI. Despite these challenges, outreach visits were associated with adoption of QI tools, and certain physician characteristics were associated with greater numbers of outreach visits and tools adopted. QIOs and other external parties who seek to improve quality of care in private practice primary care physician offices face challenges in gaining access to physicians and administrative personnel. Additional study is needed to better understand associations between physician characteristics, educational outreach visits, and adoption of QI tools.

Using public reports of patient satisfaction for hospital quality improvement.

OBJECTIVE: To explore the impact of statewide public reporting of hospital patient satisfaction on hospital quality improvement (QI), using Rhode Island (RI) as a case example. DATA SOURCE: Primary data collected through semi-structured interviews between September 2002 and January 2003. STUDY DESIGN: The design is a retrospective study of hospital executives at all 11 general and two specialty hospitals in RI. Respondents were asked about hospital QI activities at several points throughout the public reporting process, as well as about hospital structure and processes to accomplish QI. Qualitative analysis of the interview data proceeded through an iterative process to identify themes and categories in the data. PRINCIPAL FINDINGS: Data from the standardized statewide patient satisfaction survey process were used by hospitals to identify and target new QI initiatives, evaluate performance, and monitor progress. While all hospitals fully participated in the public reporting process, they varied in the stage of development of their QI activities and adoption of the statewide standardized survey for ongoing monitoring of their QI programs. Most hospitals placed responsibility for QI within each department, with results reported to top management, who were perceived as giving strong support for QI. The external environment facilitated QI efforts. CONCLUSION: Public reporting of comparative data on patient views can enhance and reinforce QI efforts in hospitals. The participation of key stakeholders facilitated successful implementation of statewide public reporting. This experience in RI offers lessons for other states or regions as they move to public reporting of hospital quality data.

Improving the quality of preventive cardiovascular care provided by primary care physicians: insights from a US Quality Improvement Organization.

BACKGROUND: During 2000-03, Qualidigm, a US Quality Improvement Organization, conducted a project to improve the care received by elderly Medicare patients with coronary artery disease or cardiovascular risk factors. METHODS: We recruited primary care physicians in private practice in the state of Connecticut. Then, we identified approximately 30-50 patients per physician from the periods 1 January 2000 to 31 December 2000 and 1 November 2001 to 31 October 2002. We abstracted medical records to assess processes and outcomes of care, and we provided the physicians with performance data and a variety of practice-enhancing materials. The physicians utilized those materials that they perceived to be most helpful. RESULTS: We identified and recruited 974 primary care physicians to participate. Of these, 103 (10.6%) committed to participate, and 85 of the 103 completed the project. Among the intervention tools, physicians and their office personnel utilized personal digital assistants (PDAs) (36.5%) and patient education materials (34.1%) most commonly. Overall, quality of care improved for most physicians (mean quality score 62.0 to 67.8%, P < 0.001). However, not all improved, and most improvements were modest [mean absolute improvement in quality score 5.8%, standard deviation (SD) 6.8%]. CONCLUSIONS: Quality Improvement Organizations and others interested in improving outpatient quality of care face significant challenges in recruiting self-employed primary care physicians to quality improvement projects and in bringing about transformational change. Future primary care quality improvement projects should include careful assessments of practice-specific barriers, interventions that are linked to these barriers, and support of the practices on implementation.

Methodological issues in public reporting of patient perspectives on hospital quality.

BACKGROUND: Increasing attention is being focused on public reporting of patient satisfaction and experience with hospital care, both nationally and at the state level. Comparative reports on hospital patient satisfaction use a standard survey, but little is known about underlying methodological approaches for reporting these quality measures. METHODS: Literature, Web sites, and key informants were used to identify nine public reports. In-depth reviews were conducted to determine approaches to collecting, analyzing, and publicly reporting comparative data. Data were grouped into four analytic categories: survey, sampling, computation of scores, and reporting of scores. RESULTS: The reports were similar in response rates and sampling procedures but differed in the number of hospitals included, the survey instrument, and survey procedure. The reports varied considerably in the techniques for computing hospital scores and decisions about reporting scores. CONCLUSIONS: Reports from nine locales illustrate the decision making necessary to produce comparative reports on hospital patient satisfaction. Differences stem from decisions about the survey instrument and statistical decisions about how to interpret and report data. These issues should be clearly delineated as part of any public reporting process.

A collaborative initiative to improve the care of elderly Medicare patients with hypertension.

Qualidigm, the Connecticut Quality Improvement Organization (QIO), collaborated with 17 primary care physicians (PCPs) in private practice to improve the care of elderly patients with hypertension. Patients were identified from Medicare billing data and care was assessed from medical records. Improvement interventions included feedback of baseline performance data and provision of a variety of practice enhancing materials. Care was assessed for 590 patients in 1997 (16-47 patients/PCP) and 547 patients in 1999 (7-51 patients/PCP). Patient characteristics were similar in both periods. Use of recommended therapies and blood pressure control, ie, percent < 140/90 mm Hg, was low and did not improve significantly between the 2 periods (aggregate 39% in 1997 versus 42% in 1999; P = .24). Care of elderly patients with hypertension was not improved with a multifaceted QIO intervention. Additional study is required to determine incentives, barriers, and facilitating factors for quality improvement in the private practice primary care setting.

Preventing pressure ulcers in Connecticut hospitals by using the plan-do-study-act model of quality improvement.

BACKGROUND: Seventeen hospitals and the Peer Review Organization of Connecticut (Qualidigm) attempted to increase early identification of high-risk patients and utilization of pressure ulcer preventive measures. METHODS: A multihospital retrospective cohort study with medical record abstraction was used to obtain a total of 1,955 (baseline) and 891 (follow-up) patients aged 65 years and older discharged after treatment for pneumonia, cerebrovascular disease, or congestive heart failure with a length of stay > or = five days. During a nine-month period, the hospitals conducted four plan-do-study-act improvement cycles and shared their results in conference calls and group meetings. RESULTS: Statistically significant increases were noted from baseline (1/1/96-12/31/96) to follow-up (10/1/97-3/31/98) in identification of high-risk patients, repositioning of bed-bound or chair-bound patients, nutritional consults in malnourished patients, and staging of acquired Stage II pressure ulcers. Daily skin assessments occurred at a high rate in both periods. There were no statistically significant changes in other processes of care, pressure ulcer incidence, or mortality. DISCUSSION: Performance of four pressure ulcer prevention processes of care increased concurrently with a multifaceted improvement intervention.

Reducing disparities in utilization of mamography: reaching dually eligible women in Connecticut.

This article describes a two-pronged intervention by the health care Quality Improvement Organization (QIO) for Connecticut to address the disparity in rates of mammography screening between women eligible for both Medicare and Medicaid (i.e., "dually eligible") and other Medicare beneficiaries. The interventions were directed beneficiaries. One intervention addressed information and access needs of the target population: an education session was followed by a mobile mammography van session at low-income housing sites in specific geographic areas. The second intervention was a culturally-sensitive direct mailing to dually eligible beneficiaries across the state. Implementation methods are described including: defining and identifying the target population; specifying the disparity; developing community collaboration; and testing the mail materials. Preliminary results of the education sessions and community testing of the direct mail materials generated information about the target population. Issues in implementation and analysis include: reaching the target population, building community relations, and developing design approaches to test the intervention.

Public reporting of hospital patient satisfaction: the Rhode Island experience.

This article describes a collaborative process for legislatively mandated public reporting of health care performance in Rhode Island that began with hospital patient satisfaction. The goals of the report were both quality improvement and public accountability. Key features addressed include: the legislative context for public reporting; widespread participation of stakeholders; the structure for decision making; and the use of formative testing with cognitive interviews to get responses of consumers and others about the report readability and comprehensibility. This experience and the lessons learned can guide other States considering public reporting on health care performance.

Patient and hospital characteristics associated with recommended processes of care for elderly patients hospitalized with pneumonia: results from the medicare quality indicator system pneumonia module.

BACKGROUND: Unexplained wide variability exists in the performance of key initial processes of care associated with improved survival of elderly patients (those > or =65 years) hospitalized with pneumonia. The objective of this study was to assess which patient and hospital characteristics are associated with performance of these key initial processes of care for hospitalized elderly patients with pneumonia. METHODS: A retrospective cohort analysis was performed using data from the Medicare Quality Indicator System Pneumonia Module for 14 069 patients 65 years or older hospitalized with pneumonia throughout the United States. Associations were calculated using multivariate logistic regression analysis between specific patient and hospital characteristics and 2 processes of care associated with improved 30-day survival: administration of antibiotics within 8 hours of hospital arrival and blood culture collection within 24 hours of arrival. RESULTS: Timely antibiotic administration was negatively associated with nonwhite race (African American: odds ratio [OR], 0.71; 95% confidence interval [CI], 0.60-0.85; and other racial minorities: OR, 0.79; 95% CI, 0.68-0.92), major hospital teaching status (OR, 0.79; 95% CI, 0.67-0.93), and larger hospital size (> or =250 beds vs. <100 beds: OR, 0.68; 95% CI, 0.59-0.80). Timely blood culture collection was positively associated with larger hospital size (OR, 1.61; 95% CI, 1.39-1.87). Performance of both processes of care were positively associated with registered nurse-bed ratios of 1.25 or higher (for antibiotic administration: OR, 1.23; 95% CI, 1.10-1.38; and for blood culture collection: OR, 1.43; 95% CI, 1.26-1.61) and fever (for antibiotic administration: OR, 1.35; 95% CI, 1.23-1.49; and for blood culture collection: OR, 3.07; 95% CI, 2.81-3.34) and were negatively associated with hospital location in the South (for antibiotic administration: OR, 0.77; 95% CI, 0.69-0.86; and for blood culture collection: OR, 0.85; 95% CI, 0.77-0.93). CONCLUSIONS: Minority race, fever, nurse-bed ratio, hospital size and teaching status, and southern location are among the major patient and hospital characteristics associated, either negatively or positively, with the timeliness of performance of initial antibiotic administration and blood culture collection for patients hospitalized with pneumonia. Because performance of these processes of care is associated with improved likelihood of survival, medical providers should seek to eliminate the variations in care associated with these patient and hospital characteristics. In addition, the impact of nurse staffing changes on performance of key time-sensitive processes of care should be weighed carefully.