Organizational Characteristics Associated with High Performance in Medicare's Comprehensive End-Stage Renal Disease Care Initiative.

BACKGROUND AND OBJECTIVES: Medicare plans to extend financial structures tested through the Comprehensive End-Stage Renal Disease Care (CEC) Initiative-an alternative payment model for maintenance dialysis providers-to promote high-value care for beneficiaries with kidney failure. The End-Stage Renal Disease Seamless Care Organizations (ESCOs) that formed under the CEC Initiative varied greatly in their ability to generate cost savings and improve patient health outcomes. This study examined whether organizational or community characteristics were associated with ESCOs' performance. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We used a retrospective pooled cross-sectional analysis of all 37 ESCOs participating in the CEC Initiative during 2015-2018 (n=87 ESCO-years). Key exposures included ESCO characteristics: number of dialysis facilities, number and types of physicians, and years of CEC Initiative experience. Outcomes of interest included were above versus below median gross financial savings (2.4%) and standardized mortality ratio (0.93). We analyzed unadjusted differences between high- and low-performing ESCOs and then used multivariable logistic regression to construct average marginal effect estimates for parameters of interest. RESULTS: Above-median gross savings were obtained by 23 (52%) ESCOs with no program experience, 14 (32%) organizations with 1 year of experience, and seven (16%) organizations with 2 years of experience. The adjusted likelihoods of achieving above-median gross savings were 23 (95% confidence interval, 8 to 37) and 48 (95% confidence interval, 24 to 68) percentage points higher for ESCOs with 1 or 2 years of program experience, respectively (versus none). The adjusted likelihood of achieving above-median gross savings was 1.7 (95% confidence interval, -3 to -1) percentage points lower with each additional affiliated dialysis facility. Adjusted mortality rates were lower for ESCOs located in areas with higher socioeconomic status. CONCLUSIONS: Smaller ESCOs, organizations with more experience in the CEC Initiative, and those located in more affluent areas performed better under the CEC Initiative.

Systems analysis and improvement approach to optimize the hypertension diagnosis and care cascade for PLHIV individuals (SAIA-HTN): a hybrid type III cluster randomized trial.

BACKGROUND: Across sub-Saharan Africa, evidence-based clinical guidelines to screen and manage hypertension exist; however, country level application is low due to lack of service readiness, uneven health worker motivation, weak accountability of health worker performance, and poor integration of hypertension screening and management with chronic care services. The systems analysis and improvement approach (SAIA) is an evidence-based implementation strategy that combines systems engineering tools into a five-step, facility-level package to improve understanding of gaps (cascade analysis), guide identification and prioritization of low-cost workflow modifications (process mapping), and iteratively test and redesign these modifications (continuous quality improvement). As hypertension screening and management are integrated into chronic care services in sub-Saharan Africa, an opportunity exists to test whether SAIA interventions shown to be effective in improving efficiency and coverage of HIV services can be effective when applied to the non-communicable disease services that leverage the same platform. We hypothesize that SAIA-hypertension (SAIA-HTN) will be effective as an adaptable, scalable model for broad implementation. METHODS: We will deploy a hybrid type III cluster randomized trial to evaluate the impact of SAIA-HTN on hypertension management in eight intervention and eight control facilities in central Mozambique. Effectiveness outcomes include hypertension cascade flow measures (screening, diagnosis, management, control), as well as hypertension and HIV clinical outcomes among people living with HIV. Cost-effectiveness will be estimated as the incremental costs per additional patient passing through the hypertension cascade steps and the cost per additional disability-adjusted life year averted, from the payer perspective (Ministry of Health). SAIA-HTN implementation fidelity will be measured, and the Consolidated Framework for Implementation Research will guide qualitative evaluation of the implementation process in high- and low-performing facilities to identify determinants of intervention success and failure, and define core and adaptable components of the SAIA-HTN intervention. The Organizational Readiness for Implementing Change scale will measure facility-level readiness for adopting SAIA-HTN. DISCUSSION: SAIA packages user-friendly systems engineering tools to guide decision-making by front-line health workers to identify low-cost, contextually appropriate chronic care improvement strategies. By integrating SAIA into routine hypertension screening and management structures, this pragmatic trial is designed to test a model for national scale-up. TRIAL REGISTRATION: ClinicalTrials.gov NCT04088656 (registered 09/13/2019; https://clinicaltrials.gov/ct2/show/NCT04088656).

Regionalization of Congenital Heart Surgery in the United States.

The objective of this study is to simulate regionalization of congenital heart surgery (CHS) in the United States and assess the impact of such a system on travel distance and mortality. Patients ≤18 years of age who underwent CHS were identified in 2012 State Inpatient Databases. Operations were stratified by the Risk Adjustment for Congenital Heart Surgery, version 1 (RACHS-1) method, with high risk defined as RACHS-1 levels 4-6. Regionalization was simulated by progressive closure of hospitals, beginning with the lowest volume hospital. Patients were moved to the next closest hospital. Analyses were conducted (1) maintaining original hospital mortality rates and (2) estimating mortality rates based on predicted surgical volumes after absorbing moved patients. One hundred fifty-three hospitals from 36 states performed 1 or more operation (19,064 operations). With regionalization wherein, all hospitals performed >310 operations, 37 hospitals remained, from 12.5% to 17.4% fewer deaths occurred (83-116/666), and median patient travel distance increased from 38.5 to 69.6 miles (P < 0.01). When only high-risk operations were regionalized, 3.9-5.9% fewer deaths occurred (26-39/666), and the overall mortality rate did not change significantly. Regionalization of CHS in the United States to higher volume centers may reduce mortality with minimal increase in patient travel distance. Much of the mortality reduction may be missed if solely high-risk patients are regionalized.

Validação colaborativa de macrodimensões e indicadores-chave para avaliação de performance de serviços de saúde no Brasil / Collaborative validation of macrodimensions and key indicators for health services performance evaluation in Brazil

RESUMO A criação do Sistema Único de Saúde (SUS) no Brasil, em 1988, representou avanços na organização sistêmica e descentralização da gestão única; entretanto, passados 30 anos a governança de resultados parece frágil. A nova gestão pública tem exigido esforços de monitoramento de resultados, controladoria e responsabilização dos gastos (accountability). Este estudo explora a translação de conhecimentos de uma amostra de gestores e profissionais (stakeholders), para validação de um painel de indicadores do SUS. A aplicação dos instrumentos de captação e validação das percepções obteve resultados das três fases iniciais (n=108) que consolidaram um instrumento aplicado para validação de campo (n=112), cuja análise descritiva validou cinco dimensões e 24 indicadores-chave para gestão de resultados em organizações de saúde. A análise inferencial gerou um modelo final que garantiu confiabilidade e validade das cinco dimensões (macrodomínios), mas apenas de 17 indicadores (domínios) de desempenho propostos pelos decisores a partir de seus conhecimentos prévios.

ABSTRACT The creation of the Unified Health System (SUS) in Brazil, in 1988, represented advances in the systemic organization and decentralization of the unified management; however, after 30 years the governance of results seems fragile. The new public management has demanded efforts to monitor results, controllership and accountability. This study explores the translation of knowledge from a sample of managers and professionals (stakeholders), for validation of a panel of SUS indicators. The application of perceptual capture and validation instruments yielded results from the three initial phases (n=108), which consolidated an instrument validated for field validation (n=112), whose descriptive analysis validated five dimensions and 24 key indicators for management of results in health organizations. Inferential analysis generated a final model that guaranteed reliability and validity of the five dimensions (macrodomains), but only of 17 performance indicators (domains) proposed by the decision makers based on their previous knowledge.

A framework for value-creating learning health systems.

BACKGROUND: Interest in value-based healthcare, generally defined as providing better care at lower cost, has grown worldwide, and learning health systems (LHSs) have been proposed as a key strategy for improving value in healthcare. LHSs are emerging around the world and aim to leverage advancements in science, technology and practice to improve health system performance at lower cost. However, there remains much uncertainty around the implementation of LHSs and the distinctive features of these systems. This paper presents a conceptual framework that has been developed in Canada to support the implementation of value-creating LHSs. METHODS: The framework was developed by an interdisciplinary team at the Institut national d'excellence en santé et en services sociaux (INESSS). It was informed by a scoping review of the scientific and grey literature on LHSs, regular team discussions over a 14-month period, and consultations with Canadian and international experts. RESULTS: The framework describes four elements that characterise LHSs, namely (1) core values, (2) pillars and accelerators, (3) processes and (4) outcomes. LHSs embody certain core values, including an emphasis on participatory leadership, inclusiveness, scientific rigour and person-centredness. In addition, values such as equity and solidarity should also guide LHSs and are particularly relevant in countries like Canada. LHS pillars are the infrastructure and resources supporting the LHS, whereas accelerators are those specific structures that enable more rapid learning and improvement. For LHSs to create value, such infrastructures must not only exist within the ecosystem but also be connected and aligned with the LHSs' strategic goals. These pillars support the execution, routinisation and acceleration of learning cycles, which are the fundamental processes of LHSs. The main outcome sought by executing learning cycles is the creation of value, which we define as the striking of a more optimal balance of impacts on patient and provider experience, population health and health system costs. CONCLUSIONS: Our framework illustrates how the distinctive structures, processes and outcomes of LHSs tie together with the aim of optimising health system performance and delivering greater value in health systems.

Leading Practices in Antimicrobial Stewardship: Conference Summary.

The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS: The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS: The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION: The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.

Use of Internal Performance Measurement to Guide Improvement Within Medical Groups.

BACKGROUND: Public reporting of provider performance currently encompasses a range of measures of quality, cost, and patient experience of care. However, little is known about how medical groups use measures for performance improvement. This information could help medical groups undertake internal measurement while helping payers, policy makers, and measurement experts develop more useful publicly reported measures and quality improvement strategies. METHODS: An exploratory, qualitative study was conducted of ambulatory care medical groups across the United States that currently gather their own performance data. RESULTS: Eighty-three interviews were conducted with 91 individuals representing 37 medical groups. Findings were distilled into three major themes: (1) measures used internally, (2) strategies for using internal measurement for performance improvement, and (3) other uses of internal measurement. Medical groups used both clinical and business process measures, including measures from external measure sets and internally derived measures. Strategies for using internal measurement for quality improvement included taking a gradual, iterative approach and setting clear goals with high priority, finding workable approaches to data sharing, and fostering engagement by focusing on actionable measures. Measurement was also used to check accuracy of external performance reports, clarify and manage conflicting external measurement requirements, and prepare for anticipated external measurement requirements. Respondents in most groups did not report a need to assess costs of internal measurement or the capacity to do so. CONCLUSION: Despite challenges and barriers, respondents found great value in conducting internal measurement. Their experiences may provide valuable lessons and knowledge for medical group leaders in earlier stages of establishing internal measurement programs.

The "Waze" of Inequity Reduction Frameworks for Organizations: a Scoping Review.

BACKGROUND: Different conceptual frameworks guide how an organization can change its policies and practices to make care and outcomes more equitable for patients, and how the organization itself can become more equitable. Nonetheless, healthcare organizations often struggle with implementing these frameworks. OBJECTIVE: To assess what guidance frameworks for health equity provide for organizations implementing interventions to make care and outcomes more equitable. STUDY DESIGN: Fourteen inequity frameworks from scoping literature review 2000-2017 that provided models for improving disparities in quality of care or outcomes were assessed. We analyzed how frameworks addressed key implementation factors: (1) outer and inner organizational contexts; (2) process of translating and implementing equity interventions throughout organizations; (3) organizational and patient outcomes; and (4) sustainability of change over time. PARTICIPANTS: We conducted member check interviews with framework authors to verify our assessments. KEY RESULTS: Frameworks stressed assessing the organization's outer context, such as population served, for tailoring change strategies. Inner context, such as existing organizational culture or readiness for change, was often not addressed. Most frameworks did not provide guidance on translation of equity across multiple organizational departments and levels. Recommended evaluation metrics focused mainly on patient outcomes, leaving organizational measures unassessed. Sustainability was not addressed by most frameworks. CONCLUSIONS: Existing equity intervention frameworks often lack specific guidance for implementing organizational change. Future frameworks should assess inner organizational context to guide translation of programs across different organizational departments and levels and provide specific guidelines on institutionalization and sustainability of interventions.

Epidemiology of pericardial diseases in Africa: a systematic scoping review.

OBJECTIVES: This scoping review sought to summarise available data on the prevalence, aetiology, diagnosis, treatment and outcome of pericardial disease in Africa. METHODS: We searched PubMed, Scopus and African Journals Online from 1 January 1967 to 30 July 2017 to identify all studies published on the prevalence, aetiologies, diagnosis, treatment and outcomes of pericardial diseases in adults residing in Africa. RESULTS: 36 studies were included. The prevalence of pericardial diseases varies widely according to the population of interest: about 1.1% among people with cardiac complaints, between 3.3% and 6.8% among two large cohorts of patients with heart failure and up to 46.5% in an HIV-infected population with cardiac symptoms. Tuberculosis is the most frequent cause of pericardial diseases in both HIV-uninfected and HIV-infected populations. Patients with tuberculous pericarditis present mostly with effusive pericarditis (79.5%), effusive constrictive pericarditis (15.1%) and myopericarditis (13%); a large proportion of them (up to 20%) present in cardiac tamponade. The aetiological diagnosis of pericardial diseases is challenging in African resource-limited settings, especially for tuberculous pericarditis for which the diagnosis is not definite in many cases. The outcome of these diseases remains poor, with mortality rates between 18% and 25% despite seemingly appropriate treatment approaches. Mortality is highest among patients with tuberculous pericarditis especially those coinfected with HIV. CONCLUSION: Pericardial diseases are a significant cause of morbidity and mortality in Africa, especially in HIV-infected individuals. Tuberculosis is the most frequent cause of pericardial diseases, and it is associated with poor outcomes.

Metrics of Antimicrobial Stewardship Programs.

Appropriate metrics are needed to measure the quality, clinical, and financial impacts of antimicrobial stewardship programs. Metrics are typically categorized into antibiotic use measures, process measures, quality measures, costs, and clinical outcome measures. Traditionally, antimicrobial stewardship metrics have focused on antibiotic use, antibiotic costs, and process measures. With health care reform, practice should shift to focusing on clinical impact of stewardship programs over financial impact. This article reviews the various antimicrobial stewardship metrics that have been described in the literature, evidence to support these metrics, controversies surrounding metrics, and areas in which future research is necessary.

Measuring Efficiency at the Interface of Behavioral and Physical Health Care.

BACKGROUND: Measures of efficiency in healthcare delivery, particularly between different parts of the healthcare system could potentially improve health resource utilization. We use a typology adapted from the Agency for Healthcare Research and Quality to characterize current measures described in the literature by stakeholder perspective (payer, provider, patient, policy-maker), type of output (reduced utilization or improved outcomes) and input (physical, financial or both). AIMS OF THE STUDY: To systematically describe measures of healthcare efficiency at the interface of behavioral and physical healthcare and identify gaps in the literature base that could form the basis for further measure development. METHODS: We searched the Medline database for studies published in English in the last ten years with the terms 'efficiency', 'inefficiency', 'productivity', 'cost' or 'QALY' and 'mental' or 'behavioral' in the title or abstract. Studies on healthcare resource utilization, costs of care, or broader healthcare benefits to society, related to the provision of behavioral health care in physical health care settings or to people with physical health conditions or vice versa were included. RESULTS: 85 of 6,454 studies met inclusion criteria. These 85 studies described 126 measures of efficiency. 100 of these measured efficiency according to the perspective of the purchaser or provider, whilst 13 each considered efficiency from the perspective of society or the consumer. Most measures counted physical resources (such as numbers of therapy sessions) rather than the costs of these resources as inputs. Three times as many measures (95) considered service outputs as did quality outcomes (31). DISCUSSION: Measuring efficiency at the interface of behavioral and physical care is particularly difficult due to the number of relevant stakeholders involved, ambiguity over the definition of efficiency and the complexity of providing care for people with multimorbidity. Current measures at this interface concentrate on a limited range of outcomes. LIMITATIONS: We only searched one database and did not review the gray literature, nor solicit a call for relevant but unpublished work. We did not assess the methodological quality of the studies identified. IMPLICATION FOR HEALTH CARE PROVISION AND USE: Most measures of healthcare efficiency are currently viewed from the perspective of payers and providers, with very few studies addressing the benefits of healthcare to society or the individual interest of the consumer. One way this imbalance could be addressed is through much stronger involvement of consumers in measurement-development, for example, by an expansion in patient-reported outcome measures in assessing quality of care. IMPLICATIONS FOR HEALTH POLICIES: Integrating behavioral and physical care is a major area of implementation as health systems in high income countries move from volume to value based care delivery. Measuring efficiency at this interface has the potential to incentivize and also evaluate integration efforts. IMPLICATIONS FOR FURTHER RESEARCH: There has been only one previous systematic review of efficiency measurement and none at the interface of behavioral and physical care. We identify gaps in the evidence base for efficiency measurement which could inform further research and measurement development.

[Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers]. / Komplexitätssteigerung in der Leistungserstellung ­ Managementansätze für ein Zentrumsspital.

Increasing Complexity in Performance Delivery - Management Approach for Tertiary Care Centers Abstract. General social trends such as individualization and female shift increase the complexity for management in both technical and system management in addition to the inherent development in the hospital industry such as subspecialization, ageing societies and multimorbidity. Reduction of complexity is therefore absolutely necessary in order to be able to manage in a patient-friendly way as a maximum care provider. Reducing complexity means resolving therapeutic conflicts. Essential tools for this are digitization, a comprehensive quality paradigm that includes patient experience, patient assessment of treatment outcomes, indication and service quality, and good management. The latter integrates the fragmentation of skills and knowledge of a subspecialized medicine through appropriate system design. This requires the appropriate functional strategies and a comprehensive process management competence that can transform the numerous interfaces into seams.

Functional and Spatial Design of Emergency Departments Using Quality Function Deployment.

Inadequate design of emergency departments (EDs) is a major cause of crowding, increased length of stay, and higher mortality. The main reason behind this inadequacy is the lack of stakeholders' involvement in the design process. This work reports and analyzes the results of a large survey of the requirements of ED stakeholders. It then compares these requirements with existing designs on the one hand and international standards on the other. Further, we propose a new hybrid design which combines the requirements of both the stakeholders and international standards using quality function deployment (QFD), also known as the House of Quality, method. The proposed method was used to assess two existing EDs located in two countries. The analysis of the survey responses showed certain discrepancies between stakeholder requirements and the existing designs such as the absence of an initial admission unit and insufficient space of the treatment unit. The results showed a strong correlation between the QFD-based design and stakeholder requirements (r = 0.92 for ED1 and r = 0.93 for ED2) which is attributed to the incorporation of stakeholders' opinions into the QFD method. The new design was also positively correlated to the international standards (r = 0.94 for ED1 and r = 0.91 for ED2). Our findings suggest that international design standards should be based on more structured methods for incorporating stakeholders' views and that a certain degree of difference should be allowed depending on the region in which the hospital is located to reflect both cultural and environmental differences.

Implementing routine outcome monitoring in public mental health services in Israel: Shared and unique challenges.

OBJECTIVES: This study aimed to assess the feasibility, benefits, and challenges of routine outcome monitoring (ROM) in a public mental health centre in Israel. This is the first initiation of ROM implementation in a setting of a large psychiatric hospital, affiliated with the largest health maintenance organization in Israel, Clalit Health Services. METHODS: Four ambulatory units were invited to participate in the implementation of ROM. Prior to initiation of recruitment, staff meetings were held and broad descriptions of current knowledge regarding benefits and challenges were discussed. Upon initiation of recruitment, patients completed outcome and process questionnaires during each session, and reports of patients' progress were sent to therapists soon after sessions ended. RESULTS: One hundred sixty-three patients were invited to participate in measurement and feedback of therapy outcomes. Overall, 101 patients and 32 therapists agreed and actively participated in the implementation phase of ROM, producing 535 evaluated measurements and reports. Clinical, methodological, legal, administrative, and ethical aspects of the implementation were encountered and documented throughout the implementation process. CONCLUSIONS: Medical confidentiality issues, as well as the multidisciplinary nature of hospital staff work, serve as central and unique challenges for incorporating ROM in a public psychiatric hospital. Other challenges that were previously reported in other implementation studies were also encountered and included therapist overload and objections, attrition, and the need for organizational support. Recommendations for future pioneering efforts for ROM implementation in large psychiatric facilities are discussed.

Collaborative Quality Improvement in the Congenital Heart Defects: Development of the ASSIST Consortium and a Preliminary Surgical Outcomes Report.

OBJECTIVE: ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. METHODS: A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. RESULTS: Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). CONCLUSION: The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.

Using Lean Process Improvement to Enhance Safety and Value in Orthopaedic Surgery: The Case of Spine Surgery.

Lean methodology was developed in the manufacturing industry to increase output and decrease costs. These labor organization methods have become the mainstay of major manufacturing companies worldwide. Lean methods involve continuous process improvement through the systematic elimination of waste, prevention of mistakes, and empowerment of workers to make changes. Because of the profit and productivity gains made in the manufacturing arena using lean methods, several healthcare organizations have adopted lean methodologies for patient care. Lean methods have now been implemented in many areas of health care. In orthopaedic surgery, lean methods have been applied to reduce complication rates and create a culture of continuous improvement. A step-by-step guide based on our experience can help surgeons use lean methods in practice. Surgeons and hospital centers well versed in lean methodology will be poised to reduce complications, improve patient outcomes, and optimize cost/benefit ratios for patient care.

Collaborative quality improvement in the congenital heart defects: development of the assist consortium and a preliminary surgical outcomes report

Abstract Objective: ASSIST is the first Brazilian initiative in building a collaborative quality improvement program in pediatric cardiology and congenital heart disease. The purposes of this manuscript are: (a) to describe the development of the ASSIST project, including the historical, philosophical, organizational, and infrastructural components that will facilitate collaborative quality improvement in congenital heart disease care; (b) to report past and ongoing challenges faced; and (c) to report the first preliminary data analysis. Methods: A total of 614 operations were prospectively included in a comprehensive online database between September 2014 and December 2015 in two participating centers. Risk Adjustment for Congenital Heart Surgery (RACHS) 1 and Aristotle Basic Complexity (ABC) scores were obtained. Descriptive statistics were provided, and the predictive values of the two scores for mortality were calculated by multivariate logistic regression models. Results: Many barriers and challenges were faced and overcome. Overall mortality was 13.4%. Independent predictors of in-hospital death were: RACHS-1 categories (3, 4, and 5/6), ABC level 4, and age group (≤ 30 days, and 30 days - 1 year). Conclusion: The ASSIST project was successfully created over a solid base of collaborative work. The main challenges faced, and overcome, were lack of institutional support, funding, computational infrastructure, dedicated staff, and trust. RACHS-1 and ABC scores performed well in our case mix. Our preliminary outcome analysis shows opportunities for improvement.

Adding Value to the Health Care System: Identifying Value-Added Systems Roles for Medical Students.

To catalyze learning in Health Systems Science and add value to health systems, education programs are seeking to incorporate students into systems roles, which are not well described. The authors sought to identify authentic roles for students within a range of clinical sites and explore site leaders' perceptions of the value of students performing these roles. From 2013 to 2015, site visits and interviews with leadership from an array of clinical sites (n = 30) were conducted. Thematic analysis was used to identify tasks and benefits of integrating students into interprofessional care teams. Types of systems roles included direct patient benefit activities, including monitoring patient progress with care plans and facilitating access to resources, and clinic benefit activities, including facilitating coordination and improving clinical processes. Perceived benefits included improved value of the clinical mission and enhanced student education. These results elucidate a framework for student roles that enhance learning and add value to health systems.