The Volume and Cost of Quality Metric Reporting.

Importance: US hospitals report data on many health care quality metrics to government and independent health care rating organizations, but the annual cost to acute care hospitals of measuring and reporting quality metric data, independent of resources spent on quality interventions, is not well known. Objective: To evaluate externally reported inpatient quality metrics for adult patients and estimate the cost of data collection and reporting, independent of quality-improvement efforts. Design, Setting, and Participants: Retrospective time-driven activity-based costing study at the Johns Hopkins Hospital (Baltimore, Maryland) with hospital personnel involved in quality metric reporting processes interviewed between January 1, 2019, and June 30, 2019, about quality reporting activities in the 2018 calendar year. Main Outcomes and Measures: Outcomes included the number of metrics, annual person-hours per metric type, and annual personnel cost per metric type. Results: A total of 162 unique metrics were identified, of which 96 (59.3%) were claims-based, 107 (66.0%) were outcome metrics, and 101 (62.3%) were related to patient safety. Preparing and reporting data for these metrics required an estimated 108 478 person-hours, with an estimated personnel cost of $5 038 218.28 (2022 USD) plus an additional $602 730.66 in vendor fees. Claims-based (96 metrics; $37 553.58 per metric per year) and chart-abstracted (26 metrics; $33 871.30 per metric per year) metrics used the most resources per metric, while electronic metrics consumed far less (4 metrics; $1901.58 per metric per year). Conclusions and Relevance: Significant resources are expended exclusively for quality reporting, and some methods of quality assessment are far more expensive than others. Claims-based metrics were unexpectedly found to be the most resource intensive of all metric types. Policy makers should consider reducing the number of metrics and shifting to electronic metrics, when possible, to optimize resources spent in the overall pursuit of higher quality.

Improving Patient Experience in Radiology: Impact of a Multifaceted Intervention on National Ranking.

Purpose To assess the impact of a patient experience improvement program on national ranking in patient experience in a large academic radiology department. Materials and Methods This Health Insurance Portability and Accountability Act-compliant study was exempted from institutional review board approval. After initiating an electronic patient experience survey, 26 210 surveys and 22 213 comments were received from May 2017 to April 2018. During the study period, a multifaceted quality improvement initiative was instituted, focused on improving patient experience in the radiology department. The primary outcome was national percentile ranking as measured with the survey. Secondary outcome was the change in departmental percentile ranking compared with the overall hospital ranking for patient experience measured with a similar survey. Results The overall raw score for the department increased from 92.8 to 93.6 of 100 (P < .001), and the national ranking improved from the 35th to 50th percentile (P = .001). Improvements in raw scores related to personnel were primarily responsible for the increase in overall raw score and ranking. Of the 22 213 comments received, 3458 (15.6%) were negative. The percentage of negative comments was highly correlated with lower monthly percentile ranking (Pearson correlation coefficient of -0.69; P = .01). Conclusion It is feasible to develop a large-scale electronic survey to assess patient experience in the radiology department, to identify improvement opportunities, and to measurably improve patient experience. Changes in the percentage of negative comments were correlated with changes in a practice's national percentile rank in patient experience. © RSNA, 2019 Online supplemental material is available for this article. See also the editorial by Kruskal and Sarwar in this issue.

A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality.

BACKGROUND: The opioid overdose crisis now claims more than 40,000 lives in the United States every year, and many hospitals and health systems are responding with opioid-related initiatives, but how best to coordinate hospital or health system-wide strategy and approach remains a challenge. METHODS: An organizational opioid stewardship program (OSP) was created to reduce opioid-related morbidity and mortality in order to provide an efficient, comprehensive, multidisciplinary approach to address the epidemic in one health system. An executive committee of hospital leaders was convened to empower and launch the program. To measure progress, metrics related to care of patients on opioids and those with opioid use disorder (OUD) were evaluated. RESULTS: The OSP created a holistic, health system-wide program that addressed opioid prescribing, treatment of OUD, education, and information technology tools. After implementation, the number of opioid prescriptions decreased (-73.5/month; p < 0.001), mean morphine milligram equivalents (MME) per prescription decreased (-0.4/month; p < 0.001), the number of unique patients receiving an opioid decreased (-52.6/month; p < 0.001), and the number of prescriptions ≥ 90 MME decreased (-48.1/month; p < 0.001). Prescriptions and providers for buprenorphine increased (+6.0 prescriptions/month and +0.4 providers/month; both p < 0.001). Visits for opioid overdose did not change (-0.2 overdoses/month; p = 0.29). CONCLUSION: This paper describes a framework for a new health system-wide OSP. Successful implementation required strong executive sponsorship, ensuring that the program is not housed in any one clinical department in the health system, creating an environment that empowers cross-disciplinary collaboration and inclusion, as well as the development of measures to guide efforts.

Addressing the Lack of Competition in Generic Drugs to Improve Healthcare Quality and Safety.

A lack of access to critical drugs in the USA, either due to exorbitant prices or shortages, has become a troubling norm that threatens the quality and safety of healthcare. In 2017, there were shortages of 146 commonly used drugs including electrolytes, chemotherapy, cardiovascular, and antibiotic agents. For example, there currently exists a shortage in intravenous fluids and injectable opioids (both in chronic short supply for years) that has been respectively ascribed to disruptions in pharmaceutical manufacturing by Hurricane Maria and manufacturing delays. These explanations, however, mask a more fundamental and avoidable cause: a lack of healthy competition in the generic drug market which is likely contributing to price hikes and shortages. By understanding this underlying cause, we hope to illuminate a pathway from our current state of complacency, where drug price hikes and shortages are routine, to a future state of effective action, where patients have reliable access to vital drugs. This article outlines a roadmap to influence incentives, regulations, new drug development, and ultimately stakeholder (i.e., patients, providers, and drug makers) behavior to enhance competition, with the ultimate aim of improving the quality and safety of healthcare for our patients.

Improving Clinician Well-being and Patient Safety Through Human-Centered Design.

This Viewpoint discusses the need for clinicians to be involved in every stage of the development of patient safety interventions in order to not only improve patient care, but also maximize the interventions' effectiveness and ensure clinician well-being and buy-in.

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.

Excessive diagnostic testing in acute kidney injury.

BACKGROUND: The patterns, performance characteristics, and yield of diagnostic tests ordered for the evaluation of acute kidney injury (AKI) have not been rigorously evaluated. METHODS: We characterized the frequency of AKI diagnostic testing for urine, blood, radiology, and pathology tests in all adult inpatients who were admitted with or developed AKI (N = 4903 patients with 5731 AKI episodes) during a single calendar year. We assessed the frequency of abnormal test results overall and by AKI stage. We manually reviewed electronic medical records to evaluate the diagnostic yield of selected urine, blood, and radiology tests. Diagnostic yield of urine and blood tests was determined based on whether an abnormal test affected AKI diagnosis or management, whereas diagnostic yield of radiology tests was based on whether an abnormal test resulted in a procedural intervention. In sensitivity analyses we also evaluated appropriateness of testing using prespecified criteria. RESULTS: Frequency of testing increased with higher AKI stage for nearly all diagnostic tests, whereas frequency of detecting an abnormal result increased for some, but not all, tests. Frequency of detecting an abnormal result was highly variable across tests, ranging from 0 % for anti-glomerular basement membrane testing to 71 % for urine protein testing. Many of the tests evaluated had low diagnostic yield. In particular, selected urine and blood tests were unlikely to impact AKI diagnosis or management, whereas radiology tests had greater clinical utility. CONCLUSIONS: In patients with AKI, many of the diagnostic tests performed, even when positive or abnormal, may have limited clinical utility.

Ambulatory Medication Reconciliation: Using a Collaborative Approach to Process Improvement at an Academic Medical Center.

BACKGROUND: Incomplete medication reconciliation has been identified as a source of adverse drug events and a threat to patient safety. How best to measure and improve rates of medication reconciliation in ambulatory care remains unknown. METHODS: An institutional collaborative improvement effort to develop and implement medication reconciliation processes was designed and facilitated across all 148 Brigham and Women's Hospital (Boston) ambulatory specialty practices: 63 underwent a more rigorous approach, a modified approach was undertaken in another 71 specialty practices, and a less intensive approach took place in the 14 primary care practices. The level of intervention varied on the basis of preexisting improvement infrastructure and practice prescription rates. Two electronically measured metrics were created to evaluate ambulatory visits to a provider in which there was a medication change: (1) Measure 1: the percentage of active medications prescribed by that provider that were reconciled; and (2) Measure 2: how often all the medications prescribed by that provider were reconciled. After the collaborative was completed, performance data were routinely shared with frontline staff and hospital leadership, and medication reconciliation rates became part of an institutional financial incentive program. RESULTS: For Measure 1, specialty practices improved from 71% to 90% (September 2012-August 2014; 24-month period). Primary care practice performance improved from 62% to 91% (December 2012-August 2014; 20-month period). For Measure 2, overall performance across all ambulatory practices increased from 81% to 90% during the first 12 months of the financial incentive program (October 2013- September 2014). CONCLUSION: A collaborative model of process improvement paired with financial incentives can successfully increase rates of ambulatory medication reconciliation.

Overuse of testing in preoperative evaluation and syncope: a survey of hospitalists.

BACKGROUND: Health care reform efforts and initiatives seek to improve quality and reduce costs by eliminating unnecessary care. However, little is known about overuse and its drivers, especially in hospitals. OBJECTIVE: To assess the extent of and factors associated with overuse of testing in U.S. hospitals. DESIGN: National survey of practice patterns for 2 common clinical vignettes: preoperative evaluation and syncope. Respondents were randomly selected and randomly provided 1 of 4 versions of each vignette. Each version contained identical clinical information but varied in factors that could change physician behavior. Respondents were asked to identify what they believed most hospitalists at their institution would recommend in each vignette. SETTING: Mailed survey conducted from June through October 2011. PARTICIPANTS: Physicians practicing adult hospital medicine in the United States. MEASUREMENTS: Responses indicating overuse (more testing than recommended by American College of Cardiology/American Heart Association guidelines). RESULTS: 68% (1020 of 1500) of hospitalists responded. They reported overuse in 52% to 65% of the preoperative evaluation vignettes and 82% to 85% of the syncope vignettes. Overuse more frequently resulted from a physician's desire to reassure patients or themselves than an incorrect belief that it was clinically indicated (preoperative evaluation, 63% vs. 37%; syncope, 69% vs. 31%; P < 0.001 for each). LIMITATION: Survey responses may not represent actual clinical choices. CONCLUSION: Physicians reported substantial overuse in 2 common clinical situations in the hospital. Improving provider knowledge of guidelines may help reduce overuse, but despite awareness of the guidelines, physicians often deviate from them to reassure patients or themselves. PRIMARY FUNDING SOURCE: Blue Cross Blue Shield of Michigan Foundation, Department of Veterans Affairs Center for Clinical Management Research, University of Michigan Specialist-Hospitalist Allied Research Program, and Ann Arbor Veterans Affairs/University of Michigan Patient Safety Enhancement Program.

Implementation of Measures to Improve SCIP Perioperative Beta-Blocker Compliance: Quality and Financial Implications.

INTRODUCTION: The Surgical Care Improvement Project (SCIP) was launched in 2005. One of the SCIP metrics includes perioperative beta-blocker guideline (CARD-2), which measures the percentage of patients on a pre-operative beta-blocker with continued use in the perioperative period. Compliance is intended to decrease rates of acute myocardial infarction (AMI) and cardiac mortality among high-risk patients. We desired to create low cost, standardized processes on an institutional level to improve compliance with the SCIP CARD-2 metric. METHODS: We assessed the impact of interventions on provider compliance with the SCIP CARD-2 metric and on simulated impact on institutional cost. RESULTS: We were able to improve CARD-2 compliance at one hospital within a year of intervention implementation. The hospital decreased its losses due to noncompliance in FY 2014 by $27 273. DISCUSSION: A relatively low cost intervention, aimed at educating providers that utilized existing infrastructure resulted in improved SCIP beta-blocker compliance. Changes in the reimbursement system made at the time of publication demonstrate that reimbursement measures are constantly in flux; tailored interventions based upon our successes may still produce similar results.

A Single-Center Multidisciplinary Initiative to Reduce Catheter-Associated Urinary Tract Infection Rates: Quality and Financial Implications.

INTRODUCTION: Catheter-associated urinary tract infection (CAUTI) is an important patient safety issue that is responsible for an estimated 449334 annual infections, with an average direct cost of $790-$1200 per infection. In total, the cost associated with CAUTI is estimated to be $115 million to $1.82 billion annually. METHODS: We conducted an internal revenue analysis with a standard sensitivity analysis to assess the impact of a low-cost CAUTI reduction program on direct costs to the hospital over four years. The interventions included the formation of a multidisciplinary CAUTI reduction task force, formal data collection in all ICUs, staff education, and new electronic order sets with decision support. RESULTS: During the initial intervention period, the infection rate per 1000 catheter days decreased from 5.4 to 1.5. In the second year of the program, the infection rate increased to 4.6. After additional interventions were launched, infection rates decreased to 2.2. Cost savings per 1000 catheter days (±20%) during the initial intervention were $4501 ($3600-$5401). DISCUSSION: Our intervention demonstrated that provider education and electronic documentation prompts were followed by a significant decrease in catheter utilization, that in turn was followed by lower infection rates. Decreased emphasis on intervention goals were followed by an increase in CAUTI rates. Our subsequent interventions suggest that upward trends may be reversible.

Increasing pneumococcal vaccination for immunosuppressed patients: a cluster quality improvement trial.

OBJECTIVE: Pneumococcal vaccination is important for patients taking immunosuppressive medications, but prior studies suggest that most patients do not undergo vaccination. The aim of this study was to evaluate the effects of a point-of-care paper reminder form as a quality improvement (QI) strategy to increase the numbers of immunosuppressed patients being kept up-to-date with pneumococcal vaccination in a rheumatology practice. METHODS: Selected rheumatologists at 5 ambulatory practice sites received a point-of-care paper reminder form to be applied to patients who were not up-to-date with pneumococcal vaccination. Interrupted time-series analyses were used to measure the effect of the intervention on the pneumococcal vaccination rates among patients, comparing the rates in the intervention group with those in a control group of rheumatologists who did not receive the intervention. Adjusted Cox proportional hazards models were examined to identify independent predictors of being up-to-date with pneumococcal vaccination. RESULTS: We evaluated a total of 3,717 patients (66.0% with rheumatoid arthritis) who were taking immunosuppressive medications (74.1% women, mean age 53.7 years). Rheumatologists who received the intervention had a significant increase in the rate of patients who were up-to-date with pneumococcal vaccination, from 67.6% to 80.0% (P=0.006), in the time period following the intervention, compared to a rate that remained stable, from 52.3% to 52.0% (P=0.90), among patients in the nonintervention control group during this same time period. In regression models, positive predictors of being up-to-date with pneumococcal vaccination at the patient level included the following: having received the intervention (hazard ratio [HR] 3.58, 95% confidence interval [95% CI] 2.46-5.20), having a primary care physician affiliated with Brigham and Women's Hospital (HR 1.68, 95% CI 1.44-1.97), having a diagnosis of diabetes mellitus (HR 1.57, 95% CI 1.02-2.41), and being age 56-65 years at baseline, compared to age≤45 years (HR 1.24, 95% CI 1.01-1.51). CONCLUSION: A QI strategy involving a simple point-of-care paper reminder form significantly increased the rate of being up-to-date with pneumococcal vaccination among patients receiving immunosuppressive medications in our rheumatology practices over a 6-month period.