Holding Providers Accountable for Health Care Outcomes.

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

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

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

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

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

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

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

Improving the quality of health care: what's taking so long?

Nearly fourteen years ago the Institute of Medicine's report, To Err Is Human: Building a Safer Health System, triggered a national movement to improve patient safety. Despite the substantial and concentrated efforts that followed, quality and safety problems in health care continue to routinely result in harm to patients. Desired progress will not be achieved unless substantial changes are made to the way in which quality improvement is conducted. Alongside important efforts to eliminate preventable complications of care, there must also be an effort to seriously address the widespread overuse of health services. That overuse, which places patients at risk of harm and wastes resources at the same time, has been almost entirely left out of recent quality improvement endeavors. Newer and much more effective strategies and tools are needed to address the complex quality challenges confronting health care. Tools such as Lean, Six Sigma, and change management are proving highly effective in tackling problems as difficult as hand-off communication failures and patient falls. Finally, the organizational culture of most American hospitals and other health care organizations must change. To create a culture of safety, leaders must eliminate intimidating behaviors that suppress the reporting of errors and unsafe conditions. Leaders must also hold everyone accountable for adherence to safe practices.

High-reliability health care: getting there from here.

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

Quality of care: how good is good enough?

Israel has made impressive progress in improving performance on key measures of the quality of health care in the community in recent years. These achievements are all the more notable given Israel's modest overall spending on health care and because they have accrued to virtually the entire population of the country.Health care systems in most developed nations around the world find themselves in a similar position today with respect to health care quality. Despite significantly increased improvement efforts over the past decade, routine safety processes, such as hand hygiene and medication administration, fail routinely at rates of 30% to 50%. People with chronic diseases experience preventable episodes of acute illness that require hospitalization due to medication mix-ups and other failures of outpatient management. Patients continue to be harmed by preventable adverse events, such as surgery on the wrong part of the body and fires in operating theaters. Health care around the world is not nearly as safe as other industries, such as commercial aviation, that have mastered highly effective ways to manage serious hazards.Health care organizations will have to undertake three interrelated changes to get substantially closer to the superlative safety records of other industries: leadership commitment to zero major quality failures, widespread implementation of highly effective process improvement methods, and the adoption of all facets of a culture of safety. Each of these changes represents a major challenge to the way today's health care organizations plan and carry out their daily work. The Israeli health system is in an enviable position to implement these changes. Universal health insurance coverage, the enrolment of the entire population in a small number of health plans, and the widespread use of electronic health records provide advantages available to few other countries.Achieving and sustaining levels of safety comparable to, say, commercial aviation will be a long journey for health care--one we should begin promptly.This is a commentary on http://www.ijhpr.org/content/1/1/3/

Hospital performance trends on national quality measures and the association with Joint Commission accreditation.

BACKGROUND: Evaluations of the impact of hospital accreditation have been previously hampered by the lack of nationally standardized data. One way to assess this impact is to compare accreditation status with other evidence-based measures of quality, such as the process measures now publicly reported by The Joint Commission and the Centers for Medicare and Medicaid Services (CMS). OBJECTIVES: To examine the association between Joint Commission accreditation status and both absolute measures of, and trends in, hospital performance on publicly reported quality measures for common diseases. DESIGN, SETTING, AND PATIENTS: Performance data for 2004 and 2008 from U.S. acute care and critical access hospitals were obtained using publicly available CMS Hospital Compare data augmented with Joint Commission performance data. MEASUREMENTS: Changes in hospital performance between 2004 and 2008, and percent of hospitals with 2008 performance exceeding 90% for 16 measures of quality-of-care and 4 summary scores. RESULTS: Hospitals accredited by The Joint Commission tended to have better baseline performance in 2004 than non-accredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores. CONCLUSIONS: While Joint Commission-accredited hospitals already outperformed non-accredited hospitals on publicly reported quality measures in the early days of public reporting, these differences became significantly more pronounced over 5 years of observation. Future research should examine whether accreditation actually promotes improved performance or is a marker for other hospital characteristics associated with such performance. Journal of Hospital Medicine 2011;6:458-465. © 2011 Society of Hospital Medicine.

The ongoing quality improvement journey: next stop, high reliability.

Quality improvement in health care has a long history that includes such epic figures as Ignaz Semmelweis, the nineteenth-century obstetrician who introduced hand washing to medical care, and Florence Nightingale, the English nurse who determined that poor living conditions were a leading cause of the deaths of soldiers at army hospitals. Systematic and sustained improvement in clinical quality in particular has a more brief and less heroic trajectory. Over the past fifty years, a variety of approaches have been tried, with only limited success. More recently, some health care organizations began to adopt the lessons of high-reliability science, which studies organizations such as those in the commercial aviation industry, which manage great hazard extremely well. We review the evolution of quality improvement in US health care and propose a framework that hospitals and other organizations can use to move toward high reliability.

What the United States could learn from Israel about improving the quality of health care.

In 1999 Israel began to implement a system for monitoring quality of care in its health plans. That system was based largely on a similar system in the United States that, until recently, was associated with steady improvements in performance. However, in recent years health plan quality in the United States appears to have reached a plateau. In contrast, health plans in Israel have continued to show improvements on many of the same measures. Between 2005 and 2007 they achieved a gain of 6.7 percent in nine measures of primary care quality, while US performance on these measures declined. These gains were achieved, in part, through intense cooperation among health plans and physicians. Israel is a much smaller country and differs greatly from the United States in how it finances health care. Nonetheless, we suggest that the Israeli experience could help the United States accelerate the move toward quality improvement-for example, through increased coordination among US employers, health plans, physicians, and physician groups.

Controlling healthcare costs by removing waste: what American doctors can do now.

Healthcare costs are unsustainable. The authors propose a solution to control costs without rationing (deliberate withholding of effective care) or payment reductions to doctors and hospitals. Three physician-led strategies comprise this solution: reduce (1) overuse of health services, (2) preventable complications and (3) waste within healthcare processes. These challenges know no borders.

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

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

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

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