Chief Quality Officers Research Articles

Approaches to Design an Efficient, Predictable Global Post-approval Change Management System that Facilitates Continual Improvement and Drug Product Availability.

The complexity and inter-connectedness of operating in a global world for drug product supply has become an undeniable reality, further underscored by the COVID-19 pandemic. For Post-Approval Changes (PACs) that are an inevitable part of a product's commercial life, the impact of the growing global regulatory complexity and related drug shortages has brought the Global PAC ManagementSystem to an inflection point in particular for companies that have their products marketed in many countries.This paper illustrates through data analyzed for the first time from 145,000 + PACs for 156 countries, collected by 18 global pharma companies over a 3-year period (2019-2021), how severe the problem of global regulatory complexity is. Only PACs requiring national regulatory agency (NRA) approval prior to implementation were included in the data set. 1 of the 156 country NRAs approved all submitted PACs within a period of 6months. The 6-month timeline was chosen because it is the recommended review timeline for major changes in the WHO guidance for vaccines and biotherapeutic products. 10 out of the 156 (6%) countries had no more than 10% of the PACs reviewed and approved in > 6 months. In 33 (22%) countries more than half of the PACs took > 6 months for approval. It is rare that the same PAC is approved globally within 6 months as individual NRAs take from a few months to years (in some cases > 5 years) for their review.The global PAC management complexity has steadily grown over the past 20years. Attempts thus far to solve this problem have not made any meaningful difference. Senior leaders and decision-makers across the interdependent components of the complex Global PAC Management System (industry and regulators) must come together and collaboratively manage the problem holistically with the objective of ensuring global drug product availability instead of continuing with distinct stakeholder or country-focused solutions, which can tend to worsen the problem.In this paper, the Chief Quality Officers (CQOs) from 18 of the largest innovator pharma companies (see Acknowledgements) are speaking with One-Voice-of-Quality for PACs (1VQ for PACs Initiative). They are recommending a set of 8 approaches to activate a holistic transformation of the Global PAC Management System. This article presents their view on the problem of global regulatory complexity for managing PACs, it's impact on continual improvement and the risk to drug product supply, as well as approaches that can help alleviate the problem.

Perceptions of Chinese hospital leaders on joint commission international accreditation: a qualitative study.

Joint Commission International (JCI) accreditation plays a significant role in improving the quality of care and patient safety worldwide. Hospital leadership is critical in making international accreditation happen with successful implementation. Little is known about how Chinese hospital leaders experienced and perceived the impact of JCI accreditation. This paper is the first study to explore the perceptions of hospital leaders toward JCI accreditation in China. Qualitative semi-structured interviews were used to explore the perceptions of the chief operating officers, the chief medical officers, and the chief quality officers in five JCI-accredited hospitals in China. Thematic analysis was used to analyze the interview transcripts and identify the main themes. Fifteen hospital leaders participated in the interviews. Three themes emerged from the analysis, namely the motivations, challenges, and benefits related to pursuing and implementing JCI accreditation. The qualitative study found that eight factors influenced hospital leadership to pursue JCI accreditation, five challenges were identified with implementing JCI standards, and eight benefits emerged from the leadership perspective. Pursuing JCI accreditation is a discretionary decision by the hospital leadership. Participants were motivated by prevalent perceptions that JCI requirements would be used as a management tool to improve the quality of care and patient safety in their hospitals. These same organizational leaders identified challenges associated with implementing and sustaining JCI accreditation. The significant challenges were a clear understanding of the foreign accreditation standards, making staff actively participate in JCI processes, and changing staff behaviors accordingly. The top 5 perceived benefits to JCI accreditation from the leaders' perspective were improved leadership and hospital safety, improvements in the care processes, and the quality of care and the learning culture improved. Other perceived benefits include enhanced reputation, better cost containment, and a sense of pride in the staff in JCI-accredited hospitals.

Evolution of the Chief Medical Officer Role in Teaching Hospitals and Health Systems.

Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today. The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions. Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians. This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.

Testing Hospital Quality Strategic Determinants

Hospital administrators are motivated to improve hospital quality in the eyes of their patients, healthcare quality regulators, and accrediting organizations. This study empirically tests the importance of some strategic determinants of hospital quality by collecting data using an emailed questionnaire filled by 258 chief quality officers. The results supported the importance of competitive intelligence, strategic leadership, management of technology, specific characteristics of the change process, and organization culture as major determinants of hospital quality. Based on the results, the report makes recommendations on where to direct their efforts, including understanding how to measure these important factors. The important model tested here has not been proposed before and provides several research opportunities for perhaps expanding the model and account for unexplained variance in hospital quality, including other constructs potentially being moderators and mediators for the hypothesized relationships.

Industry One-Voice-of-Quality Solutions Management Review of Post-Approval Changes Guide.

Post-approval changes (PACs) are inevitable and necessary throughout the life of a drug product. Because many PACs require prior approval by individual regulatory agencies each having their own reporting requirements and approval timelines, this results in companies having to manage several versions of a manufacturing process at the same time. The global regulatory complexity increases risk of drug shortages. Chief quality officers and heads of quality from more than 20 global pharmaceutical companies have come together to speak with One-Voice-of-Quality (1VQ) and develop solutions to this problem by developing a science and risk-based approach to manage more PACs in the pharmaceutical quality system (PQS) rather than submitting these as prior approval supplements. Pharmaceutical companies already conduct management review (MR) according to the International Conference on Harmonization (ICH) Q10. This One-Voice-Of-Quality paper is a practical guide on how companies can expand the MR to also evaluate and demonstrate the effectiveness of their PQS in specifically managing PACs to achieve regulatory flexibility as stated in ICH Q10, Annex 1. Examples of PQS key performance indicators (KPIs) that may be used to assess, plan, implement, and monitor PACs are described. The intent is to provide assurance through MR that PACs can be managed effectively in the PQS, thereby resulting in a reduced need for regulatory prior approval of certain low risk changes that enhance product availability, reduce the risk of drug shortages, and/or facilitate timely innovation and continual improvement in the pharmaceutical industry. This document is endorsed by 1VQ chief quality officers and heads of quality.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Picking Up the Pieces: Healthcare Quality in a Post-COVID-19 World.

Solving the Global Continual Improvement and Innovation Challenge: How an Effective Pharmaceutical Quality System Can Transform Post-Approval Change Management.

Post-approval changes are inevitable and necessary throughout the life of a drug product-to implement new knowledge, maintain a state of control, and drive continual improvement. Many of these post-approval changes require regulatory agency approval by individual countries before implementation. Because of the global regulatory complexity, individual post-approval changes usually take years for full worldwide approval even when they reduce patient risk, improve compliance, or enhance the manufacturing process or test methods. This global complexity slows down continual improvement and innovation and can cause drug shortages and current good manufacturing practices compliance issues. Manufacturers that market products globally experience the greatest challenge and risks in their daily operations because of this post-approval change complexity. A global problem needs a global solution. Quality leaders speaking globally with "One Voice of Quality" are essential for solving this difficult problem. This concept paper has been developed under the sponsorship of a group of Chief Quality Officers (Heads of Quality) from >25 global pharmaceutical companies and has been endorsed by the Parenteral Drug Association. The intent of this concept paper is to develop and implement aligned, standard solutions within the industry, leveraging the core foundation of the pharmaceutical quality system, such that a transformational shift can be achieved with faster implementation of new knowledge, continual improvement, and innovation through post-approval changes.LAY ABSTRACT: Pharmaceutical manufacturers must make changes to their products and manufacturing processes over time as they incorporate new technology and new information. Because drug products are highly regulated in every country, the manufacturer must often contact national drug regulators before making these changes, even if the manufacturer is confident, based on testing and process controls, that the change will not have a negative impact on product quality or patient safety. For a product that is globally marketed, the manufacturer may have to contact dozens of regulators before making a change. This paper suggests that industry work together to identify ways to demonstrate to regulators that product and process knowledge as well as pharmaceutical quality systems are strong enough that the manufacturers should be allowed to manage some post-approval changes themselves.

Quality improvement strategies and tools: A comparative analysis between Italy and the United States.

Italian and American hospitals, in two different periods, have been urged by external circumstances to extensively redesign their quality improvement strategies. This paper, through the use of a survey administered to chief quality officers in both countries, aims to identify commonalities and differences between the two systems and to understand which approaches are effective in improving quality of care. In both countries chief quality officers report quality improvement has become a strategic priority, clinical governance approaches, and tools-such as disease-specific quality improvement projects and clinical pathways-are commonly used, and there is widespread awareness that clinical decision making must be supported by protocols and guidelines. Furthermore, the study clearly outlines the critical importance of adopting a system-wide approach to quality improvement. To this extent Italy seems lagging behind compared to US in fact: (i) responsibilities for different dimensions of quality are spread across different organizational units; (ii) quality improvement strategies do not typically involve administrative staff; and (iii) quality performance measures are not disseminated widely within the organization but are reported primarily to top management. On the other hand, in Italy chief quality officers perceive that the typical hospital organizational structure, which is based on clinical directories, allows better coordination between clinical specialties than in the United States. In both countries, the results of the study show that it is not the single methodology/model that makes the difference but how the different quality improvement strategies and tools interact to each other and how they are coherently embedded with the overall organizational strategy.

Virtual quality: the failure of public reporting and pay-for-performance programs.

Is there too much focus on measuring and reporting quality rather thanontheconditionsneededfor improving it?TheCenters for Medicare & Medicaid Services (CMS) and other organizations require physicians and hospitals to publicly report performance on quality measures, and the CMS and privatepayersare tyingreimbursementpartly todata fromsuch measures in pay-for-performance programs. However, as the director of an intensive care unit performance improvement program, I know that it is difficult—and sometimes counterproductive—to try to improve a complex systemsimply by rewarding or penalizing the results. Holdinghealthcareprofessionalsand institutionsaccountable for qualitymetrics can backfire. For example, because reported qualitymeasures are limited in number and reflect national rather thanlocalpriorities, theymaydivertattentionfrom other, perhaps more important, problems in individual hospitals—a formof teaching to the test.Efforts to improveperformancecanalso leadtogaming, throughchanges indocumentation and coding, or even changes in clinical practice. As examples, health care professionals and institutions may avoid high-riskornonadherentpatients,1basetriagedecisionsontheir effectonperformancemeasures (suchaschoosingnot toadmit patientswhoare likely tobereadmittedfromtheemergencydepartment to reduce readmission rates), or omit screening that might identify conditions, such as hospital-acquired venous thromboembolism, that could reflect poorly onperformance.2 What is less frequently discussed, but just as important, is thatpublic reportingandpay-for-performance systems shift the focus of quality improvement todocumentation. In sodoing, these efforts take quality improvement out of the hands of clinicians anduncouplemeasurement from its clinical context. The hope is that the required measurements will jumpstart a cycle of continuousquality improvement inwhichdata areused tohonepractice.However, there is no guarantee that datawill be soused. Indeed, the tasks ofmeasurement and reporting fully occupymany hospital quality improvement departments, leaving fewresources for actually improvingmedicalpractice.Toensurestandardization,eachmeasuregenerally requires aheftymanual to specifymethods and sometimes its own information technology and specialized staff. This bureaucraticwork usually falls to nonclinical (or nonpracticing) staff; theymayhave little understandingof, or authority over, processes on the wards. In practice, such staff may deal almost entirely with improvements based on building documentation into the flow of work or modifying coding, creating the illusion of improved performance. Hospitalhallwaysarefullofdisplaysofchartsshowingprogress on various qualitymeasures; hospital leadersmeet to discuss qualitymetrics, and administrators sendnewsletters that congratulate staff on accomplishing quality goals.However, in many hospitals, patient care is largely unaffected. Busy physiciansandnursesrushbyhallwaydisplaysanddonotreadnewsletters thatreportqualitymetrics.Whentheypayattention, they tend to regard the data with skepticism: after all, they do not perceive much change save perhaps for some additional requirements for documentation. Few clinicians sit on quality committees, andstill fewerhavea role in theactual implementation of quality improvement projects. The findings of a study3 presented in this issue of JAMA InternalMedicine reinforceconcernsabout theunintendedconsequencesofpublic reportingandpay forperformanceandalso suggest a gapbetweenquality improvement activities andpatient care. Lindenauer et al3 surveyed hospital leaders (chief executiveofficersandexecutives responsible forquality) about publicly reported quality measures required by the CMS. Althoughmost respondents said that theyused themeasures extensively, more than half were concerned that the measures encouraged teaching to the test, and almost half reported trying to maximize performance primarily through changes in documentationandcoding.Also important is thathalf ormore believed that the CMSmeasures did notmeaningfully distinguishamonghospitalsoraccurately reflectqualityofcare,even for conditions specifically targeted by themeasures. In short, the study findings suggest that many hospital leaders doubt theclinical relevanceof thesemeasures.This skepticismisconsistentwithnational data: studies of public reporting andpayfor-performance programs in the United States have failed to demonstrate a clear connection to improved quality.4,5 Howcan these results beexplained?The respondentsmay haveunderstood that althoughpublicly reportedmeasuresare highly influential,muchof their effect doesnot reach thebedside. Thismaybeclearest to thosemost closely involved in the mechanics ofmeasurement and reporting. Executives specifically responsible for quality (eg, chief quality officers) were more than twice as likely as chief executive officers to believe that hospitals attempted to maximize performance on mortality and readmissionsmeasuresprimarily by changingdocumentation and coding andmuch less likely to believe that the measureswere clinicallymeaningful fordifferentiatingamong hospitals. Therewas generally less skepticismabout the clinical relevance of measures of process and patient experience, such as use of venous thromboembolism prophylaxis and patient satisfaction, than about outcome measures, such as mortalRelated article page 1904 Research Original Investigation Health Care Quality Attitudes

Attitudes of hospital leaders toward publicly reported measures of health care quality.

Public reporting of quality is considered a key strategy for stimulating improvement efforts at US hospitals; however, little is known about the attitudes of hospital leaders toward existing quality measures. To describe US hospital leaders' attitudes toward hospital quality measures found on the Centers for Medicare & Medicaid Services' Hospital Compare website, assess use of these measures for quality improvement, and examine the association between leaders' attitudes and hospital quality performance. We mailed a 21-item questionnaire from January 1 through September 31, 2012, to senior hospital leaders from a stratified random sample of 630 US hospitals, including equal numbers with better-than-expected, as-expected, and worse-than-expected performance on mortality and readmission measures. We assessed levels of agreement with statements concerning quality measures, examined use of measures for improvement activities, and analyzed the association between leaders' attitudes and hospital performance. Of 630 hospitals surveyed, 380 (60.3%) responded. For each of the mortality, readmission, process, and patient experience measures, more than 70% of hospitals agreed with the statement that "public reporting stimulates quality improvement activity at my institution"; agreement for measures of cost and volume was 65.2% and 53.3%, respectively. A similar pattern was observed for the statement that "our hospital is able to influence performance on this measure"; agreement for processes of care and patient experience measures was 96.4% and 94.2%, respectively. A total of 89.7% of hospitals agreed that the hospital's reputation was influenced by patient experience measures; agreement was 77.4% for mortality, 69.9% for readmission, 76.3% for process measures, 66.1% for cost measures, and 54.0% for volume measures. A total of 87.1% of hospitals reported incorporating performance on publicly reported measures into their hospital's annual goals, whereas 90.2% reported regularly reviewing the results with the hospital's board of trustees and 94.3% with senior clinical and administrative leaders. When compared with chief executive officers and chief medical officers, respondents who identified themselves as chief quality officers or vice presidents of quality were less likely to agree that public reporting stimulates quality improvement and that measured differences are large enough to differentiate among hospitals. Hospital leaders indicated that the measures reported on the Hospital Compare website exert strong influence over local planning and improvement efforts. However, they expressed concerns about the clinical meaningfulness, unintended consequences, and methods of public reporting.

Abstract 186: Understanding Readmissions at Minority-Serving Hospitals

Objective: The Affordable Care Act requires that the Centers for Medicare and Medicaid Services (CMS) reduce payments to hospitals with high readmission rates starting in 2013. Minority-serving institutions have higher rates of readmissions, and are therefore likely to be financially penalized as a result of this policy. Our objective was to better understand the characteristics, settings, and strategies that differentiate strong and poor performing minority-serving hospitals. Methods: We conducted case studies at six U.S. hospitals with a patient population over 50% black, choosing sites based on either strong or poor performance on readmissions in 2008-2009. Chief Medical Officers, Chief Executive Officers, Chief Quality Officers, Case Managers, and other key staff at each site each participated in hour-long semi-structured interviews where questions about hospital and patient characteristics, priorities, strategies to reduce readmissions, and general impressions about CMS’s policies were asked. Detailed notes were collected and supplemented by a review of audio tapes. Themes and intensity of comments were coded and prepared as a matrix. Results: Nearly all of the case study respondents felt that the readmission rate was an important quality metric for CMS to assess, and most respondents felt their hospitals could do better to reduce readmissions. However, few respondents knew if they were going to be penalized by CMS. The majority of respondents reported implementing new programs or procedures to try to reduce readmissions regardless of whether they were going to be penalized. Hospitals that had a low proportion of self-pay patients, high occupancy rates, and high margins had more programmatic efforts around reducing readmissions and improving transitions of care. Some strategies employed were the implementation of call centers, focused attention on discharge planning, and availability of local external resources to support program staff. Nevertheless, nearly all respondents felt that they were unable to reduce readmission rates to the level they wished because of patient and community factors, including difficulties with paying for and managing medications, literacy, housing stability, and income. Respondents also identified significant challenges in terms of infrastructure, including inadequate staffing and expertise in this area to implement potentially beneficial programs. Conclusions: Minority-serving hospitals in our case studies faced substantial challenges to reducing readmissions, including their own financial health as well as community and patient-level factors. Better understanding the strategies and approaches that work in resource-poor settings, or accounting for the poverty of the underlying patient population, are two potential strategies for ensuring that CMS’s readmissions policies do not inadvertently worsen disparities.

Reporting Information on Emergency Department Crowding to the Hospital Board and Delivery of Time-Sensitive Care

Hospital governing boards influence the quality of care that hospitals provide by holding senior leaders and managers accountable. A study was conducted to determine whether reporting data on emergency department (ED) crowding to hospital boards was associated with better performance on a time-sensitive quality measure for patients with acute myocardial infarction (AMI): Primary PCI [percutaneous intervention] Within 90 Minutes of Hospital Arrival. In a survey, hospital chief quality officers were asked whether the following data were reported to the hospital governing board: ED wait times, the percentage of ED patients who left without being seen (LWBS), and the percentage of admitted ED patients who are boarded in the ED. Responses were paired with Centers for Medicare & Medicaid Services (CMS) data on the percentage of eligible AMI patients who received PCI within 90 minutes of arrival, which served as the hospitals' PCI score. In the sample of 261 hospitals, 133 (51%) of hospital governing boards received data on wait times, 125 (48%) received data on LWBS, and 63 (24%) received data on ED boarding. After hospital characteristics were controlled for, hospitals that reported data on ED boarding to the governing board had PCI scores that were 5.5 percentage points higher (that is, better); p < .05. There was no association between reporting wait times or LWBS to the board and PCI scores. Reporting data on the incidence of ED boarding to hospital governing boards was associated with better performance for PCI. More research is needed to explore the direction of this relationship, but the results suggest that hospitals should consider reporting data on ED boarding to their boards as a low/no-cost quality improvement activity.

13 Quality Improvement Strategies and the Link to Performance on Percutaneous Intervention for Acute Myocardial Infarction

In an effort to encourage quality improvement in emergency care, a number of organizations (eg, Institute of Medicine, Joint Commission, American College of Emergency Physicians) have recommended that hospitals adopt various improvement practices and technologies including patient flow improvement, emergency department (ED) dashboards, and 5-level triage systems. These quality improvement strategies have been shown to be beneficial in single-site evaluations, but to our knowledge, they have not been evaluated in multisite studies. Our study explores the relationship between use of these 3 quality improvement strategies and hospital performance on receipt of percutaneous intervention within 90 minutes for acute myocardial infarction patients. In 2009, we administered a survey on quality improvement activities to chief quality officers at 1,988 hospitals; 28.8% (n=572) responded. The survey asked respondents about the use of ED dashboards and whether patient flow strategies were used widely or hospital-wide. We obtained data from the 2009 American Hospital Association (AHA) Annual Survey on hospitals' ED triage systems. We paired these data with 2008 and 2009 Hospital Quality Alliance data on the percentage of acute myocardial infarction patients with a percutaneous coronary intervention time under 90 minutes. After excluding hospitals with less than 25 cases, data were available for 271 hospitals. T-tests were used to detect differences in percutaneous coronary intervention performance scores based on whether hospitals used patient flow strategies, an ED dashboard, and a 5-level triage system. Linear regression models were used to adjust for hospital characteristics (bed size, region, ownership, network affiliation, and teaching status) obtained from the AHA Survey. Forty-four percent of respondents reported using patient flow strategies widely or hospital-wide, 46% reported using an ED dashboard, and 55% reported using a 5-level triage system. In comparison to hospitals that did not use the practice or technology, percutaneous coronary intervention performance scores were significantly (p<.05) better at hospitals that used patient flow strategies (83.9% versus 80.4%), ED dashboards (83.7% versus 80.0%) and 5-level triage systems (83.7% versus 78.4%). Even after controlling for hospital characteristics, percutaneous coronary intervention performance scores were 3.5 (p<.03) percentage points higher (ie, better) for hospitals that used patient flow strategies and 6.2 (p<.01) percentage points higher for hospitals that used a 5-level triage system. percutaneous coronary intervention performance scores were 5.2 (p<.01) percentage points higher at hospitals with 2 quality improvement strategies in place and 7.6 (p<.01) percentage points higher at hospitals with 3 quality improvement strategies in place. Use of multiple quality improvement strategies was associated with significantly and sizably better percutaneous coronary intervention performance scores, and the biggest difference in percutaneous coronary intervention scores was between hospitals that do and do not use 5-level triage. Our findings suggest that hospitals should consider adopting these quality improvement strategies.

Medicare’s Payment Policy for Hospital-Acquired Conditions

In 2008, Medicare implemented a policy limiting reimbursement to hospitals for treating avoidable hospital-acquired conditions (HACs). Although the policy will expand nationally to Medicaid programs in 2011, little is known about the impact on safety net hospitals. The authors conducted interviews with 60 chief quality officers and 55 chief financial officers from safety net hospitals to explore the impact of Medicare's HACs policy during its first year. Despite the predicted small financial impact, the authors found that the policy gained the attention of hospital leaders and many governing boards. Although the policy reportedly provided additional motivation to reduce HACs, few hospitals implemented new care practices and instead focused on documenting conditions that are present for patients on admission. The findings also illustrate the need for Centers for Medicare & Medicaid Services to provide more guidance to the industry when this type of policy is introduced.

Interrelationships among knowledge management, organisational learning and innovation

This study aims to describe the interrelationships among knowledge management, organisational learning and innovation. This description potentially helps a company’s preparation for the application of the quality management award. The Thailand Quality Award highlights the interrelationships among knowledge management, workforce focus and leadership as they contribute to learning and innovation, continuous performance improvement and organisational competitiveness. A total of 35 manufacturing firms completed and returned the survey. The interviews with chief quality officers were also conducted to help interpret the survey’s findings. The results show that effective knowledge management will lead to better learning and subsequently more innovativeness in an organisation. These results also indicate the importance of leadership in establishing supportive cultures and working environment for effective knowledge management.

How Well Can We Identify the High-Performing Hospital?

Sharing lessons from high-performing hospitals facilitates quality improvement. High-performing hospitals have usually been identified using a small number of performance measures. The objective was to analyze how well 1,006 hospitals performed across a broader range of measures. Five measures were developed from publicly available data: adherence to processes of care, 30-day readmission rates, in-hospital mortality, efficiency, and patient satisfaction. For a subset of hospitals, the authors included two survey-based assessments of patient care quality, one by chief quality officers and one by frontline clinicians. In general, there was little correlation among the publicly available measures (r ≤ .10), though there was notable correlation between objective measures and survey-based measures (r = .23). Hospitals that performed well on a composite measure calculated from the publicly available measures were often not in the top quintile on most individual measures. This highlights the challenge in identifying high-performing hospitals to learn organizational-level best practices.

279: Reporting Patient Flow Measures to the Hospital Board and Performance on Percutaneous Intervention for Acute Myocardial Infarction: Is There an Association?

Hospital boards may influence the quality of care that hospitals provide by holding clinicians and managers accountable. Our study 1) explores whether emergency department (ED) patient flow measures are reported to hospital boards, and 2) investigates the relationship between this reporting and hospital performance on receipt of percutaneous intervention (PCI) within 90 minutes for acute myocardial infarction (AMI) patients. In 2009, we administered a survey on quality improvement activities to chief quality officers at 1,319 urban hospitals; 30% (n=397) responded. The survey included questions on the collection and reporting of three ED patient flow measures: wait times, boarding times, and the percent of patients who left without being seen (LWBS). We paired survey responses with 2008 Hospital Quality Alliance data on the percentage of AMI patients with a PCI time under 90 minutes. Data were available for 292 of the hospitals. T-tests were used to detect differences in PCI scores based on whether hospitals reported the patient flow measures to their boards. Linear regression models were used to adjust for hospital characteristics (bed size, annual number of ED visits, ownership, and teaching and safety net status) obtained from the 2007 American Hospital Association Annual Survey. Twenty-six percent of respondents said that boarding times were collected and reported to the board, compared to 48.3% each for LWBS and wait times. In comparison to hospitals that either did not collect the measure, or collected the measure but did not report the results to the board or senior management, PCI scores were significantly (p<.05) better at hospitals that collected and reported wait times (80.4% versus 74.0%) and patient boarding times (83.0% versus 76.2%) to the board. Even after controlling for hospital characteristics, PCI scores were 5.6% (p<.03) better for hospitals that reported wait times to the board, and 5.8% (p<.02) better for hospitals that reported boarding times. Collecting and reporting ED patient wait times and boarding times to hospital boards was associated with higher performance for PCI. A possible explanation is the influential role that boards play in holding hospitals accountable for the quality of their care. Hospitals should consider reporting measures of patient flow to their boards.

Using Hospital Standardized Mortality Ratios for Public Reporting: A Comment by the Consortium of Chief Quality Officers

Using Hospital Standardized Mortality Ratios for Public Reporting: A Comment by the Consortium of Chief Quality Officers