To be or not to be compliant? Hospitals' initial strategic responses to the federal price transparency rule.

OBJECTIVE: To understand US hospitals' initial strategic responses to the federal price transparency rule that took effect January 2021. DATA SOURCES AND STUDY SETTING: Primary interview data collected from 12 not-for-profit hospital organizations in six US metropolitan markets. All but one organization were multihospital systems; the 12 organizations represent a total of 81 hospitals. STUDY DESIGN: Exploratory, cross-sectional, qualitative interview study of a convenience sample of hospital organizations across six geographically and compliance diverse markets. DATA COLLECTION/EXTRACTION METHODS: In-depth, semi-structured, qualitative interviews with 16 key informants across sampled organizations between November 2021 and March 2022. Interviews solicited data about internal organizational factors and external market factors affecting strategic responses. Transcribed interviews were de-identified, coded, and analyzed using the constant comparative method. PRINCIPAL FINDINGS: Hospitals' strategic responses were influenced internally by the degree of the regulation's alignment with organizational values and goals, and task complexity vis-a-vis available resources. We found extensive variation in organizational capabilities to comply, and all but one organization relied on consultants and vendors to some degree. Key external factors driving strategic responses were hospitals' variable perceptions about how available price information would affect their competitive position, bottom line, and reputation. Organizations with more confidence in their interpretation of the environment, including how peers or purchasers would behave, and greater clarity in their own organization's position and goals, had more definitive initial strategic responses. In the first year, organizations' strategic responses skewed toward compliance, especially for the rule's consumer shopping requirements. CONCLUSIONS: A deeper understanding of the realities of operationalizing price transparency policy for hospitals is needed to improve its impact.

Better outcomes through patient - Provider therapeutic connections? An exploratory study of proposed mediating variables.

BACKGROUND: Patient-provider therapeutic connections (TCs) have been theorized to enhance patient outcomes as well as care provider job satisfaction and to reduce burnout. High-quality TCs may result in better matching of health care to patient needs, and thus, better care quality and patient outcomes. For care providers, work environments that enable high-quality TCs may make the work more motivating and facilitate resilience. METHOD: We surveyed patients (n = 346) and care providers (n = 341) about their experiences of TCs, and how TCs related to outcomes. We tested parallel mediation models to examine relations. RESULTS: TCs predicted better patient health status, mental health status, and satisfaction, and predicted greater care provider job satisfaction and lower burnout. TCs were theorized to operate through two sets of mechanisms (health self-efficacy and activation for patients; meaningfulness of work and psychological safety for providers). Results revealed significant indirect associations between TCs and outcomes for both groups. CONCLUSIONS: TCs are associated with patient and provider outcomes; however, these relations appear to be explained by several mediating variables. It appears that TCs are associated with better outcomes for patients through health self-efficacy and activation, and TCs are associated with better outcomes for care providers through meaningfulness of work and psychological safety.

Patient-provider therapeutic connections to improve health care: Conceptual development and systematic review of patient measures.

BACKGROUND: The Triple Aim (improved population health, improved patient experiences, and lower costs) has influenced U.S. health care since it was introduced in 2008. With it, value-based purchasing has brought unprecedented focus on patient experience measurement. Despite having devoted extensive resources toward improving patient experiences, inconsistent improvements suggest there are some dimensions not yet being widely measured or addressed. Furthermore, a renewed focus on health disparities calls for stronger patient-provider connections in order to reduce health care inequities. PURPOSE: The aim of this study was to articulate the concept of therapeutic connections (TCs) in health care and examine existing survey measures, from the patient perspective, to learn whether they capture the TC construct. METHOD: We interviewed subject matter experts ( n = 24) and patients ( n = 22) about measuring TCs and then conducted a systematic review of quantitative measures from three databases using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and COSMIN (COnsensus-based Standards for the selection of health Measurement INstruments) criteria. RESULTS: Of 31 unique measures, none captured all of the theorized TC dimensions. Most were measures of collaboration and shared decision-making or caring. DISCUSSION: Focusing on the nature of patient-provider connections is vital because they are the backbone of most delivery models seeking to achieve the Triple Aim . Further development of the TC concept and measures is warranted to facilitate organizational and financing policies that meaningfully support widespread improvement. PRACTICE IMPLICATIONS: A focus on barriers and facilitators of TCs is needed. Without advancing our understanding of the role TCs play in care, policymakers and practitioners will be limited in their ability to make impactful changes.

Seven years after Meaningful Use: Physicians' and nurses' experiences with electronic health records.

Although the federal government's Meaningful Use electronic health record (EHR) implementation program resulted in some successes, there have been many challenges. The purpose of this study was to obtain detailed empirical data to better understand physicians' and nurses' experiences with EHRs. We conducted in-depth interviews with 30 physicians and nurses from two large health systems that were focused on attaining Stage 3 Meaningful Use criteria. Thematic framework analysis identified themes related to perceived benefits and challenges with EHR use. Participants appreciated benefits such as real-time patient data and easier access to information. Challenges included lack of interoperability across units, and this seemed to underlie many other noted challenges such as increased workload, insufficient training, and the perceived need for workarounds. Two key findings included mixed messages about trust in the EHR's information and its interference with interpersonal relationships. Results suggest that conservation of resources theory may be a useful strategy for understanding behaviors that enhance or undermine effective EHR use. Implications for policy and practice are discussed.

Patient-centered communication in the era of electronic health records: What does the evidence say?

OBJECTIVE: Patient-physician communication is essential for patient-centered health care. Physicians are concerned that electronic health records (EHRs) negatively affect communication with patients. This study identified a framework for understanding communication functions that influence patient outcomes. We then conducted a systematic review of the literature and organized it within the framework to better understand what is known. METHOD: A comprehensive search of three databases (CINAHL, Medline, PsycINFO) yielded 41 articles for analysis. RESULTS: Results indicated that EHR use improves capture and sharing of certain biomedical information. However, it may interfere with collection of psychosocial and emotional information, and therefore may interfere with development of supportive, healing relationships. Patient access to the EHR and messaging functions may improve communication, patient empowerment, engagement, and self-management. CONCLUSION: More rigorous examination of EHR impacts on communication functions and their influences on patient outcomes is imperative for achieving patient-centered care. By focusing on the role of communication functions on patient outcomes, future EHRs can be developed to facilitate care. PRACTICE IMPLICATIONS: Training alone is likely to be insufficient to address disruptions to communication processes. Processes must be improved, and EHRs must be developed to capture useful data without interfering with physicians' and patients' abilities to effectively communicate.

Patient-physician role relationships and patient activation: the moderating effects of race and ethnicity.

The goals of this article were to empirically describe how racial and ethnic minorities compare with Whites in terms of their role relationships with physicians and examine how differences in those relationships are associated (positively or negatively) with patient activation for minority groups, relative to Whites. Based on analysis of survey data collected from a random sample of 8,140 individuals with chronic illness, we found that both Blacks and Hispanics generally perceive their role relationships with physicians to be less equitable than do Whites and that the benefits to minorities from more equitable role relationships with physicians are not uniform across dimensions of patient-physician relationships or racial and ethnic subgroups. Based on these findings, we submit that race and ethnicity should be considered in the development and assessment of tailored interventions to improve activation.

Why and how six aligning forces for quality communities have focused on reducing disparities.

Public reports on provider performance can help guide consumers' health care decisions, yet consumer awareness and use of public reports is low and may be even lower among racial/ethnic minorities. In this qualitative research article, we describe activities implemented by multi-stakeholder alliances in six U.S. communities to increase minorities' awareness of public reports. We also describe alliances' motivation for deliberately targeting greater awareness among minorities. We found that alliances' decision was influenced by the proportion of minorities and perceptions of race-based disparities in care in the community. To raise awareness, alliances collaborated with minority-serving organizations to (a) advertise their web-based public report using ethnic media outlets, (b) present their public reporting website during health education outreach events held in minority communities, and (c) translate their public report into multiple languages. We conclude that community partnerships are a promising mechanism for targeting efforts to increase awareness of public reports in minority communities.

The importance of clinical severity in the measurement of hospital readmission rates for Medicare beneficiaries, 1997-2007.

In the coming years, assessing the impact of efforts to reduce hospital readmissions will be important to policy makers and hospitals. To inform such assessments, we sought to define preexisting trends in readmission rates for patients by level of clinical severity using a difference-in-differences analysis of Medicare inpatient claims data from 1997, 2002, and 2007 for patients with acute myocardial infarction and congestive heart failure. We also examined trends in length of stay, in-hospital mortality, and postdischarge mortality by severity level to provide additional context for interpreting readmission rate trends. From 1997 to 2007, the difference in readmission rates between the highest and lowest severity quartiles increased. Length of stay and in-hospital mortality decreased for all patients; however, postdischarge mortality increased for the highest-severity patients and decreased for the lowest-severity patients. Assessments of recent policy reforms and quality improvement programs should account for underlying differential trends in readmission rates based on patient severity.

Limits of readmission rates in measuring hospital quality suggest the need for added metrics.

Recent national policies use risk-standardized readmission rates to measure hospital performance on the theory that readmissions reflect dimensions of the quality of patient care that are influenced by hospitals. In this article our objective was to assess readmission rates as a hospital quality measure. First we compared quartile rankings of hospitals based on readmission rates in 2009 and 2011 to see whether hospitals maintained their relative performance or whether shifts occurred that suggested either changes in quality or random variation. Next we examined the relationship between readmission rates and several commonly used hospital quality indicators, including risk-standardized mortality rates, volume, teaching status, and process-measure performance. We found that quartile rankings fluctuated and that readmission rates for lower-performing hospitals in 2009 tended to improve by 2011, while readmission rates for higher-performing hospitals tended to worsen. Regression to the mean (a form of statistical noise) accounted for a portion of the changes in hospital performance. We also found that readmission rates were higher in teaching hospitals and were weakly correlated with the other indicators of hospital quality. Policy makers should consider augmenting the use of readmission rates with other measures of hospital performance during care transitions and should build on current efforts that take a communitywide approach to the readmissions issue.

Making sense of "consumer engagement" initiatives to improve health and health care: a conceptual framework to guide policy and practice.

CONTEXT: Policymakers and practitioners continue to pursue initiatives designed to engage individuals in their health and health care despite discordant views and mixed evidence regarding the ability to cultivate greater individual engagement that improves Americans' health and well-being and helps manage health care costs. There is limited and mixed evidence regarding the value of different interventions. METHODS: Based on our involvement in evaluating various community-based consumer engagement initiatives and a targeted literature review of models of behavior change, we identified the need for a framework to classify the universe of consumer engagement initiatives toward advancing policymakers' and practitioners' knowledge of their value and fit in various contexts. We developed a framework that expanded our conceptualization of consumer engagement, building on elements of two common models, the individually focused transtheoretical model of behavior and the broader, multilevel social ecological model. Finally, we applied this framework to one community's existing consumer engagement program. FINDINGS: Consumer engagement in health and health care refers to the performance of specific behaviors ("engaged behaviors") and/or an individual's capacity and motivation to perform these behaviors ("activation"). These two dimensions are related but distinct and thus should be differentiated. The framework creates four classification schemas, by (1) targeted behavior types (self-management, health care encounter, shopping, and health behaviors) and by (2) individual, (3) group, and (4) community dimensions. Our example illustrates that the framework can systematically classify a variety of consumer engagement programs, and that this exercise and resulting characterization can provide a structured way to consider the program and how its components fit program goals both individually and collectively. CONCLUSIONS: Applying the framework could help advance the field by making policymakers and practitioners aware of the wide range of approaches, providing a structured way to organize and characterize interventions retrospectively, and helping them consider how they can meet the program's goals both individually and collectively.

Turning readmission reduction policies into results: some lessons from a multistate initiative to reduce readmissions.

Efforts are under way nationally to reduce avoidable hospital readmissions by changing payments to hospitals, but it is unclear how well or how quickly these policy changes will produce widespread reductions in hospital readmissions. To examine some of the challenges to implementing such approaches, the authors analyzed the early experiences of 3 statewide programs to reduce preventable readmissions that began in 2009. Based on interviews with program participants in 2011, the authors identified 3 key obstacles to progress: the difficulty of developing collaborative relationships across care settings, gaps in evidence for effective interventions, and deficits in quality improvement capabilities among some organizations. These findings underscore the uncertainty of success of current readmissions policies and suggest that immediate improvement in readmission rates through a change in reimbursement may be unlikely unless these other obstacles are addressed expeditiously. In particular, cultivation of productive collaboration across care settings will be critical because these kinds of relationships are not well established or naturally occurring in most communities.

Patient-physician role relationships and patient activation among individuals with chronic illness.

OBJECTIVE: To examine whether chronically ill patients' perceptions of their role relationships with their physicians are associated with levels of patient activation. DATA SOURCES: Random digit dial survey of 8,140 chronically ill patients and the Area Resource File. STUDY DESIGN: Cross-sectional, multivariate analysis of the relationship between dimensions of patient-physician role relationships and level of patient activation. The study controlled for variables related to patient demographics, socioeconomic status, health status, and market and family context. PRINCIPAL FINDINGS: Higher perceived quality of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians were associated with higher levels of patient activation. Treatment goal setting was not significantly associated with patient activation. CONCLUSION: Patient-physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.

Fostering change within organizational participants of multisectoral health care alliances.

BACKGROUND: A touted advantage of multisectoral health care alliances is their ability to coordinate diverse constituencies and pursue community health goals in ways that allow them to make greater progress than each constituency could independently. However, participating organizations may have goals that do not entirely overlap or necessarily align with the alliance's goals, which can weaken or undermine an alliance's efforts. Fostering changes within participating organizations in ways that are consistent with the alliance's goals (i.e., alliance-oriented change) may be one mechanism by which alliances can coordinate diverse activities and improve care in their local communities. PURPOSE: We examined whether alliance-oriented change within participating organizations is associated with alliance decision-making and conflict management style, level of participation, perceptions of alliance participation benefits and costs, and awareness of alliance activities within participating organizations. METHODOLOGY: The study used two rounds of survey data collected from organizational participants of 14 alliances participating in the Robert Wood Johnson Foundation's Aligning Forces for Quality program. FINDINGS: Alliance participants generally reported low levels of alliance-oriented change within their organizations as a result of the alliance and its activities. However, participants reporting higher levels of internal change in response to alliance activities had more positive perceptions of alliance decision-making style, higher levels of participation in alliance activities, more positive perceptions of alliance participation benefits relative to costs, and greater awareness of alliance activities across multiple levels of their respective organizations. PRACTICE IMPLICATIONS: Despite relatively low levels of alliance-oriented change within participating organizations, alliances may still have the means to align the goal orientations of a diverse membership and foster change that may extend the reach of the alliance in the community.

Community-level interventions to collect race/ethnicity and language data to reduce disparities.

OBJECTIVE: The systematic collection and use of race/ethnicity and language (REL) data by healthcare organizations has long been recognized as a critical step to reducing healthcare disparities locally and nationally. We seek to identify the challenges and opportunities in implementing community-level interventions to collect REL data for detecting and reducing disparities in care in the 14 multi-stakeholder communities participating in the Aligning Forces for Quality initiative. STUDY DESIGN: This was a cross-sectional descriptive qualitative study. METHODS: We conducted 1-hour, face-to-face, semi-structured interviews with identified key informants during 2-day visits to each of the 14 communities in 2010, and supplemented this information with 2 rounds of semi-structured telephone interviews. Data were analyzed using a qualitative analysis software program, which assists with organizing and analyzing large quantities of interview data through creation of analytic units. We used deductive and inductive qualitative methods to analyze the data. RESULTS: Communities found it challenging to implement a community-level intervention to collect standardized REL data because addressing disparities is complex, the utility of having individual healthcare organizations collect these data is difficult to communicate, and perceptions of disparities in the community vary across stakeholders. Opportunities include working with credible "early adopters" in the community and leveraging federal or state mandates to encourage providers to collect this information. CONCLUSIONS: Community-level efforts to collect REL data require securing buy-in from organizational leadership, developing a dialogue across the community, and generating awareness across key players about disparities-reduction efforts, especially REL data collection, without alienating patients, communities, and providers.

Barriers and strategies to align stakeholders in healthcare alliances.

OBJECTIVE: To identify barriers to stakeholder alignment and strategies used by 14 multi-stakeholder alliances participating in the Aligning Forces for Quality initiative to overcome these barriers. STUDY DESIGN: The study used a mixed method, comparative case study design. METHODS: Alliances were categorized as more or less highly aligned based on an alignment index constructed from survey responses. Six alliances (top and bottom quartile) were selected for more in-depth qualitative analysis. Semi-structured interviews of key informants were used to identify factors that distinguished more highly aligned alliances from less highly aligned alliances. RESULTS: Market context was one of the most important factors differentiating alliances. More highly aligned alliances had more extensive histories of collaboration, established more credibility in the local community, and were more effective at balancing collaborative initiatives against competitive interests. More highly aligned alliances also took more active approaches to build consensus among stakeholders regarding alliance initiatives, and were able to successfully utilize small decision-making bodies to foster this consensus. In contrast, leadership credibility, leadership stability, and trust were important facilitators of alignment for all alliances, regardless of the level of alignment. These factors intersect and overlap in a multitude of ways to influence stakeholder alignment. CONCLUSIONS: Alignment in an alliance context is critical for leveraging the unique knowledge, skills, and abilities of stakeholders in ways that can build capacity to improve the health of the community in ways that cannot be achieved independently by stakeholders. The findings highlight the need for multifaceted approaches to promote stakeholder alignment.

Evaluating a community-based program to improve healthcare quality: research design for the Aligning Forces for Quality initiative.

OBJECTIVE: The Aligning Forces for Quality (AF4Q) initiative is the Robert Wood Johnson Foundation's (RWJF's) signature effort to increase the overall quality of healthcare in targeted communities throughout the country. In addition to sponsoring this 16-site, complex program, the RWJF funds an independent scientific evaluation to support objective research on the initiative's effectiveness and contributions to basic knowledge in 5 core programmatic areas. The research design, data, and challenges faced in the evaluation of this 10-year initiative are discussed. STUDY DESIGN: A descriptive overview of the evaluation research design for a multi-site, community based, healthcare quality improvement initiative is provided. METHODS: The multiphase research design employed by the evaluation team is discussed. RESULTS: Evaluation provides formative feedback to the RWJF, participants, and other interested audiences in real time; develops approaches to assess innovative and under-studied interventions; furthers the analysis and understanding of effective community-based collaborative work in healthcare; and helps to differentiate the various facilitators, barriers, and contextual dimensions that affect the implementation and outcomes of community-based health interventions. CONCLUSIONS: The AF4Q initiative is arguably the largest community-level healthcare improvement demonstration in the United States to date; it is being implemented at a time of rapid change in national healthcare policy. The implementation of large-scale, multi-site initiatives is becoming an increasingly common approach for addressing problems in healthcare. The evaluation research design for the AF4Q initiative, and the lessons learned from its approach, may be valuable to others tasked with evaluating similar community-based initiatives.

Using websites to engage consumers in managing their health and healthcare.

OBJECTIVE: This study provides insight into the potential of local community health information websites to cultivate and support consumer engagement through website positioning and content choices. STUDY DESIGN: This descriptive study compared health-related websites maintained by 16 multi-stakeholder community alliances charged with improving consumer engagement and public reporting of provider performance data. METHODS: We systematically assessed website messaging, content, and the presence of explicit connections among information and tools related to consumer engagement behaviors for 32 websites maintained by alliances as of November 2011. These findings were triangulated with information about alliances' public reporting activities from key informant interviews (2007-2011) with stakeholders in 14 alliances. RESULTS: A total of 25 of the 32 alliance websites contained information for consumers, and 14 of those included information related to at least 3 of 4 consumer engagement behaviors: shopping for high-quality providers or treatments, self-advocacy in healthcare encounters, self-management of illness, and partaking in general healthy behaviors. Positioning strategies and tactics to attract consumers varied widely across alliances. Some targeted specific conditions or behaviors; others took a broader community approach. Two alliances had strong alignment between website messaging and consumer engagement content, 7 had moderate alignment, and 7 had limited alignment. CONCLUSIONS: Although alliances have been experimenting with a wide array of website approaches, their promise as a tool to improve consumer engagement is still uncertain. Further research that addresses the comparative value of different website approaches is needed.

Midterm observations and recommendations from the evaluation of the AF4Q initiative.

OBJECTIVE: To offer midterm observations and recommendations based on how Aligning Forces for Quality (AF4Q) alliances are faring in their journey toward improving healthcare quality at the community level. STUDY DESIGN: This study used a mixed method design. METHODS: Longitudinal evaluation data to date were analyzed, including results from multiple surveys, qualitative analysis of key informant interviews, review of secondary documents and analysis of secondary data, and ongoing tracking of the activities of the 16 participating alliances. The observations and recommendations are based on consensus achieved by the AF4Q evaluation team investigators after in-depth iterative discussions. RESULTS: Six formative observations are identified and discussed: (1) stakeholder support and participation has been maintained despite changes in economic and political environments; (2) progress on program goals has been slow; (3) the "alignment" in the AF4Q initiative has been slow to materialize; (4) the AF4Q initiative has established a productive network of peer communities; (5) the impact of the AF4Q initiative, and the time to observe impact, vary by community, based on history and context; and (6) sustainability is the major future challenge for the AF4Q initiative. CONCLUSIONS: Multi-stakeholder alliances' efforts to improve quality should be viewed as "pieces of the health reform puzzle" rather than stand-alone solutions. As healthcare reform is challenged politically, alliances can practice the bipartisanship that focuses conversation on what is good for the community and how best to achieve community goals amid a potential sea of change in both federal and state policy and funding.