Improvements In Quality Metrics Research Articles

Effect of implementing an integrated oncology dashboard on clinical and operational quality in a community-based cancer network.

420 Background: MaineHealth Cancer Care Network (MHCCN) encompasses nine regional cancer centers and one affiliate cancer center located in rural south-central Maine and New Hampshire. MHCCN developed an integrated operational dashboard to improve clinical and operational performance. In this report, we detail improvements in a variety of quality metrics after implementation of the dashboard. Methods: Extracts from various non-interoperable data sources were integrated using a MS Power BI platform to create the dashboard. Divided into pages— summary, growth, service excellence, innovation and transformation —the dashboard provides searchable and regularly updated snapshots of numerous relevant metrics in these domains. Access to the dashboard was extended to all clinical and operational staff, with data reviewed bi-monthly in provider and operational meetings. The dashboard played a pivotal role in identifying MHCCN’s 2023 key performance indicator, specifically the electronic health record (EHR)-based TNM staging, along with notable care gaps such as underutilization of the NCCN distress thermometer (DT) for psychosocial distress assessment. Bottlenecks to timely care delivery were similarly identified by leveraging time to treatment data in the service excellence page. Targeted quality improvement initiatives were devised to address the gaps. Results: EHR-based structured TNM staging by providers improved from 29% in Fiscal Year (FY) 2022 to 47% in FY 2023 and 64% in FY 2024 year-to-date (YTD). Use of the NCCN DT improved from 1.1% in FY 2022 to 30.9% in FY 2023 and 49.9% in FY 2024 YTD. Process changes resulting from identifying delayed scheduling of PET scans as a bottleneck reduced the lead time from scan ordering to scan appointment from 18 days (January-July 2023) to 9 days (January-April 2024). Leveraging access to monthly productivity data through the dashboard, provider compensation reform incorporating production-based incentives was launched in July 2023, improving throughput and access as well as provider recruitment and retention. Information transparency from a freely accessible dashboard contributed to a 0.67-point gain in the 2023 Gallup provider core engagement CE3 score, reaching 3.45 (on a five-point scale). Conclusions: Clinical and operational metrics are often fragmented across different platforms, leading to inefficiencies and limited insights. Creating a system-wide integrated quality dashboard improved data visibility, provider engagement and led to measurable improvement in quality metrics across various domains.

Electronic health record modification and dashboard development to improve clinical care in pediatric rheumatology.

This report describes our experience in electronic health record (EHR) note modification and creation of an external dashboard to create a local learning health system that contributes to quality improvement and patient care within our pediatric rheumatology clinic. We applied quality improvement methodology to develop a more reliable and accurate system to identify patients with juvenile idiopathic arthritis and track important measures that aide in improving patient care and performance outcomes. From 2019 to 2021, we iteratively modified our outpatient clinic EHR note to include structured data elements to improve longitudinal monitoring. We then validated data transferred to an electronic dashboard external to the EHR and demonstrated utility for identifying an accurate patient population and tracking quality improvement initiatives. Creation of the structured data elements improved the identification of patients with JIA with >99% accuracy and without requiring manual review of the chart. Using the dashboard to monitor performance, we improved documentation of critical disease activity measures that resulted in improvement in those scores across the local population of patients with JIA. The structured data elements also enabled us to automate electronic data transfer to a multicenter learning network registry. The structured data element modifications made to our outpatient EHR note populate a local dashboard that allows real time access to critical information for patient care, population management, and improvement in quality metrics. The collection and monitoring of structured data can be scaled to other quality improvement initiatives in our clinic and shared with other centers.

Predicting FDG-PET Images From Multi-Contrast MRI Using Deep Learning in Patients With Brain Neoplasms.

18 F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is valuable for determining presence of viable tumor, but is limited by geographical restrictions, radiation exposure, and high cost. To generate diagnostic-quality PET equivalent imaging for patients with brain neoplasms by deep learning with multi-contrast MRI. Retrospective. Patients (59 studies from 51 subjects; age 56 ± 13 years; 29 males) who underwent 18 F-FDG PET and MRI for determining recurrent brain tumor. 3T; 3D GRE T1, 3D GRE T1c, 3D FSE T2-FLAIR, and 3D FSE ASL, 18 F-FDG PET imaging. Convolutional neural networks were trained using four MRIs as inputs and acquired FDG PET images as output. The agreement between the acquired and synthesized PET was evaluated by quality metrics and Bland-Altman plots for standardized uptake value ratio. Three physicians scored image quality on a 5-point scale, with score ≥3 as high-quality. They assessed the lesions on a 5-point scale, which was binarized to analyze diagnostic consistency of the synthesized PET compared to the acquired PET. The agreement in ratings between the acquired and synthesized PET were tested with Gwet's AC and exact Bowker test of symmetry. Agreement of the readers was assessed by Gwet's AC. P = 0.05 was used as the cutoff for statistical significance. The synthesized PET visually resembled the acquired PET and showed significant improvement in quality metrics (+21.7% on PSNR, +22.2% on SSIM, -31.8% on RSME) compared with ASL. A total of 49.7% of the synthesized PET were considered as high-quality compared to 73.4% of the acquired PET which was statistically significant, but with distinct variability between readers. For the positive/negative lesion assessment, the synthesized PET had an accuracy of 87% but had a tendency to overcall. The proposed deep learning model has the potential of synthesizing diagnostic quality FDG PET images without the use of radiotracers. 3 TECHNICAL EFFICACY: Stage 2.

Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly

BackgroundOur institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends. MethodsQuality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data. ResultsDespite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient—a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities. ConclusionThe benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

Quality metrics in adult spinal deformity surgery over the last decade: a combined analysis of the largest prospective multicenter data sets.

The reported rate of complications and cost of adult spinal deformity (ASD) surgery, associated with an exponential increase in the number of surgeries, cause alarm among healthcare payers and providers worldwide. The authors conjointly analyzed the largest prospective available ASD data sets to define trends in quality-of-care indicators (complications, reinterventions, and health-related quality of life [HRQOL] outcomes) since 2010. This is an observational prospective longitudinal cohort study. Patients underwent surgery between January 2010 and December 2016, with > 2 years of follow-up data. Demographic, surgical, radiological, and HRQOL (i.e., Oswestry Disability Index, SF-36, Scoliosis Research Society-22r) data obtained preoperatively and at 3, 6, 12, and 24 months after surgery were evaluated. Trends and changes in indicators were analyzed using local regression (i.e., locally estimated scatterplot smoothing [LOESS]) and adjusted odds ratio (OR). Of the 2286 patients included in the 2 registries, 1520 underwent surgery between 2010 and 2016. A total of 1151 (75.7%) patients who were treated surgically at 23 centers in 5 countries met inclusion criteria. Patient recruitment increased progressively (2010-2011 vs 2015-2016: OR 1.64, p < 0.01), whereas baseline clinical characteristics (age, American Society of Anesthesiologists class, HRQOL scores, sagittal deformity) did not change. Since 2010 there has been a sustained reduction in major and minor postoperative complications observed at 90 days (major: OR 0.59; minor: OR 0.65; p < 0.01); at 1 year (major: OR 0.52; minor: 0.75; p < 0.01); and at 2 years of follow-up (major: OR 0.4; minor: 0.80; p < 0.01) as well as in the 2-year reintervention rate (OR 0.41, p < 0.01). Simultaneously, there has been a slight improvement in the correction of sagittal deformity (i.e., pelvic incidence-lumbar lordosis mismatch: OR 1.11, p = 0.19) and a greater gain in quality of life (i.e., Oswestry Disability Index 26% vs 40%, p = 0.02; Scoliosis Research Society-22r, self-image domain OR 1.16, p = 0.13), and these are associated with a progressive reduction of surgical aggressiveness (number of fused segments: OR 0.81, p < 0.01; percent pelvic fixation: OR 0.66, p < 0.01; percent 3-column osteotomies: OR 0.63, p < 0.01). The best available data show a robust global improvement in quality metrics in ASD surgery over the last decade. Surgical complications and reoperations have been reduced by half, while improvement in disability increased and correction rates were maintained, in patients with similar baseline characteristics.

Integrated Care Management to Improve Diabetes Outcomes in Refugee and Immigrant Patients (I-Care).

Purpose: Refugee and immigrant patients face significant barriers to health care and are more likely to have poorly controlled chronic disease than the general U.S. population. I-Care aims to improve health equity for refugees and immigrants who face a disproportionate burden of chronic disease.Methods: Refugees and immigrants with uncontrolled diabetes and associated cardiovascular risk factors were enrolled in a care management program within an academic adult medicine clinic. The program utilized a care manager to coordinate care and services between designated primary care providers, affiliated clinical teams, and community partners. Health literacy, chronic disease parameters, and care utilization were assessed at enrollment and 8–12 months later.Results: A total of 50 refugees and immigrants were followed for 8 to 12 months. Clinical parameters found a reduced mean HbA1c from 9.32 to 8.60 (p=0.05) and reduced low-density lipoprotein mean from 96.22 to 86.60 (p=0.01). The frequency of normal blood pressures was 9 (18%) at enrollment and 16 (32%) at 1 year. The cumulative frequency of emergency room visits decreased from 66% to 36% and hospitalizations from 22% to 8%. Rates of comprehensive care monitoring, including monofilament testing and one-time ophthalmology visits, increased from 60% to 82% and from 32% to 42%, respectively. Cumulative frequency of interdisciplinary support engagement with pharmacy and nutrition visits increased from 58% to 78% and from 26% to 38%, respectively.Conclusion: This program highlights the importance of a multidisciplinary community-engaged care model that has demonstrated improvement in quality metrics and health care costs for refugees and immigrants.

BC tree-based spectral sampling for big complex network visualization

Graph sampling methods have been used to reduce the size and complexity of big complex networks for graph mining and visualization. However, existing graph sampling methods often fail to preserve the connectivity and important structures of the original graph. This paper introduces a new divide and conquer approach to spectral graph sampling based on graph connectivity, called the BC Tree (i.e., decomposition of a connected graph into biconnected components) and spectral sparsification. Specifically, we present two methods, spectral vertex sampling BC_SV and spectral edge sampling BC_SS by computing effective resistance values of vertices and edges for each connected component. Furthermore, we present DBC_SS and DBC_GD, graph connectivity-based distributed algorithms for spectral sparsification and graph drawing respectively, aiming to further improve the runtime efficiency of spectral sparsification and graph drawing by integrating connectivity-based graph decomposition and distributed computing. Experimental results demonstrate that BC_SV and BC_SS are significantly faster than previous spectral graph sampling methods while preserving the same sampling quality. DBC_SS and DBC_GD obtain further significant runtime improvement over sequential approaches, and DBC_GD further achieves significant improvements in quality metrics over sequential graph drawing layouts.

Pediatric Tracheostomy Outcomes After Development of a Multidisciplinary Airway Team: A Quality Improvement Initiative

ObjectivesTo analyze a multidisciplinary tracheostomy team’s effect on length of stay and cost.MethodsAn airway management program using a balanced scorecard was created to track key performance measures. Interventions included weekly rounding, standardized placement, postoperative care, and caregiver education. Process measures included time to first education, speech-language pathology consultation rates, and pretracheostomy consultations. Outcome measures focused on the total length of stay, 30-day revisit rates after discharge, accidental decannulation rate, and standardized cost. Regression analysis was used to predict the program’s effect on length of stay and total cost.ResultsIn total, 239 children met inclusion. The mean time to first education class was reduced from 13.7 to 1.9 days (P < .001). The speech-language pathology consultation rate increased from 68% to 95% (P < .001), and the presurgical consultation rate with the tracheostomy team increased from 14% to 93% (P < .001). The length of stay decreased from 133 to 96 days (P = .006). Total costs were lower for short admissions but higher for prolonged admissions. Revisits within 30 days remained stable over time (18%).DiscussionEstablishing a multidisciplinary tracheostomy team results in improvements in quality metrics when caring for children with tracheostomies. Controlling for associated factors showed the mean length of stay decreased significantly in the first full year of program implementation. Cost analysis estimated significant reductions for tracheostomy patients spending less time in the hospital.Implications for PracticeA airway management program can positively affect tracheostomy processes and outcomes.

From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs

BackgroundThe Bundled Payments for Care Improvement (BPCI) initiative improved quality and reduced costs following total hip (THA) and knee arthroplasty (TKA). In October 2018, the BPCI-Advanced program was implemented. The purpose of this study is to compare the quality metrics and performance between our institution’s participation in the BPCI program with the BPCI-Advanced initiative. MethodsWe reviewed a consecutive series of Medicare primary THA and TKA patients. Demographics, medical comorbidities, discharge disposition, readmission, and complication rates were compared between BPCI and BPCI-Advanced groups. Medicare claims data were used to compare episode-of-care costs, target price, and margin per patient between the cohorts. ResultsCompared to BPCI patients (n = 9222), BPCI-Advanced patients (n = 2430) had lower rates of readmission (5.8% vs 3.8%, P = .001) and higher rate of discharge to home (72% vs 78%, P < .001) with similar rates of complications (4% vs 4%, P = .216). Medical comorbidities were similar between groups. BPCI-Advanced patients had higher episode-of-care costs ($22,044 vs $18,440, P < .001) and a higher mean target price ($21,154 vs $20,277, P < .001). BPCI-Advanced patients had a reduced per-patient margin compared to BPCI ($890 loss vs $1459 gain, P < .001), resulting in a $2,138,670 loss in the first three-quarters of program participation. ConclusionDespite marked improvements in quality metrics, our institution suffered a substantial loss through BPCI-Advanced secondary to methodological changes within the program, such as the exclusion of outpatient TKAs, facility-specific target pricing, and the elimination of different risk tracks for institutions. Medicare should consider adjustments to this program to keep surgeons participating in alternative payment models.

797 Estimated Blood Loss in Burns: A Quality Metric That Defies Measurement?

Abstract Introduction There are a handful of publications over the past 3 decades evaluating single institution blood loss during excision and grafting procedures (E/G) for thermal injuries. The average estimated blood loss (EBL) reported ranges from 0.75ml/cm2 excised to 9.2% total blood volume/1% E/G, with disparate standard deviations. EBL should be benchmarked and evaluated for improvement in quality metrics. Methods We performed a retrospective evaluation of 66 burn E/G cases. They were analyzed for blood loss at 24 and 72 hours post procedure, accounting for any intra-operative or immediate post-operative transfusions using the Mercuriali formula. Each unit of transfused blood was estimated to increase hemoglobin 1g/dL. Results Means and standard deviations for calculated EBL, taking into account transfused blood and ongoing donor site bleeding up to 72 hours is depicted in Table 1. EBL in &amp;lt; 20% TBSA and &amp;gt;20% TBSA cases were compared as well as those with and without tourniquet use. Means and standard deviations for calculated EBL, taking into account transfused blood and ongoing donor site bleeding up to 72 hours is depicted in Table 1. EBL in &amp;lt; 20% TBSA and &amp;gt;20% TBSA cases were compared as well as those with and without tourniquet use. Conclusions Benchmark quality measures for burn should include EBL. These preliminary data suggest that results could guide intraoperative transfusion decisions if enough cases are analyzed (data collection is ongoing). Evaluation of EBL may also provide insight for transfusion ratios for coagulopathy of burn. Applicability of Research to Practice Evaluation of blood loss during surgical treatment of thermal injuries is an important benchmark and its study may lead to improvements in care.

Improvement in Quality Metrics using Clinical Decision Support: Incorporating the Process in the Military Practice

Improvement in Quality Metrics using Clinical Decision Support: Incorporating the Process in the Military Practice

Shifting Implementation Science Theory to Empower Primary Care Practices.

Observers of the past 10 to 15 years have witnessed the simultaneous growth of dramatic changes in the practice of primary care and the emergence of a new field of dissemination and implementation science (D&I). Most current implementation science research in primary care assumes practices are not meeting externally derived standards and need external support to meet these demands. After a decade of initiatives, many stakeholders now question the return on their investments. Overall improvements in quality metrics, utilization cost savings, and patient experience have been less than anticipated. While recently conducting a research project in primary care practices, we unexpectedly discovered 3 practices that profoundly shifted our thinking about the sources and directionality of practice change and the underlying assumptions of D&I. Inspired by these practices-along with systems thinking, complexity theory, action research, and the collaborative approaches of community-based participatory research-we propose a reimagining of D&I theory to empower practices. We shift the emphasis regarding the source and direction of change from outside-in to inside-out Such a shift has the potential to open a new frontier in the science of dissemination and implementation and inform better health policy.

Centers for Disease Control and Prevention 2017 Guidelines for Prevention of Surgical Site Infections: Review and Relevant Recommendations.

The associated patient morbidity and resource-intensive nature of managing surgical site infections (SSI) has focused attention toward not only improving treatment protocols but also enhancing preventative measures. The purpose of this review was to summarize the relevant updated CDC guidelines for the prevention of SSI that were released in 2017. The CDC recommends the integration of the guidelines for improvement in quality metrics, reportable outcomes, and patient safety. The updated guidelines include generalized recommendations for parenteral antimicrobial prophylaxis, non-parenteral antimicrobial prophylaxis, glycemic control, normothermia, oxygenation, and antiseptic prophylaxis. The arthroplasty section includes recommendations for blood transfusion, systemic immunosuppressive therapy, and antibiotics during drain use. There was low-quality evidence precluding recommendations for preoperative intra-articular corticosteroid injections, orthopedic surgical space suits, and biofilm management. The recommendations provided throughout this review, including more recent guidelines from other organizations such as the AAOS and ACR, should assist clinicians in developing and/or refining surgical site prevention protocols for their patients undergoing total joint arthroplasty procedures.

The “TRAUMA LIFE” initiative: The impact of a multidisciplinary checklist process on outcomes and communication in a Trauma Intensive Care Unit

BackgroundChecklists have been advocated to improve quality outcomes/communication in the critical care setting, but results have been mixed. A new checklist process, “TRAUMA LIFE”, was implemented in our Trauma Intensive Care Unit (TICU) to replace prior checklists. The purpose of this study was to evaluate the impact of the “TRAUMA LIFE” process implementation on quality metrics and on patient/family communication in the TICU. Methods“TRAUMA LIFE” was considered maturely implemented by 2016. Multiple quality metrics, including restraint order compliance, were compared between 2013 and 2016 (pre- and post-implementation). Compliance with the “Family Message” (FM), a part of the “TRAUMA LIFE” communication process, was analyzed in 2016. ResultsImprovement was seen in CAUTI, VAE, and IUCU; CLABSI rates increased. Restraint order compliance increased significantly. FM delivery compliance was inconsistent; improvement was noted in concordance between update content and FM documented in Electronic Medical Record. ConclusionImplementation of “TRAUMA LIFE” was well integrated into the rounding process and was associated with some improvement in quality metrics and communication. Additional evaluation is required to assess sustainability.

Improvement in Quality Metrics by the UPMC Enhanced Care Program: A Novel Super-Utilizer Program.

The aim was to evaluate pre-post quality of care measures among super-utilizer patients enrolled in the Enhanced Care Program (ECP), a primary care intensive care program. A pre-post analysis of metrics of quality of care for diabetes, hypertension, cancer screenings, and connection to mental health care for participants in the ECP was conducted for patients enrolled in ECP for 6 or more months. Patients enrolled in ECP showed statistically significant improvements in hemoglobin A1c, retinal exams, blood pressure measurements, and screenings for colon cancer, and trends toward improvement in diabetic foot exams and screenings for cervical and breast cancer. There was a significant increase in connecting patients to mental health care. This study shows that super-utilizer patients enrolled in the ECP had significant improvements in quality metrics from those prior to enrollment in ECP.

Serial improvement of quality metrics in pediatric thoracoscopic lobectomy for congenital lung malformation: an analysis of learning curve.

Video-assisted thoracic surgery (VATS) pulmonary resection in children is a technically demanding procedure that requires a relatively long learning period. This study aimed to evaluate the serial improvement of quality metrics according to case volume experience in pediatric VATS pulmonary resection of congenital lung malformation (CLM). Methods VATS anatomical resection in CLM was attempted in 200 consecutive patients. The learning curve for the operative time was modeled by cumulative sum analysis. Quality metrics were used to measure technical achievement and efficiency outcomes. Results The median operative time was 95min. The median length of hospital stay and chest tube indwelling time was 4 and 2 days, respectively. The improvement of operation time was observed persistently until 200 cases. However, two cut-off points, the 50th case and 110th case, were identified in the learning curve for operative time, and the 110th case was the turning point for stable outcomes with short operation time. Significant reduction of length of hospital stay and chest tube indwelling time was observed after 50 cases (p = .002 and p = .021, respectively). The complication rate decreased but continued at a low rate for entire study period and the interval decrease was not statistically significant. Conversion rate decreased significantly (p = .001), and technically challenging procedures were performed more frequently in later cases. Conclusions Improvements of quality metrics in operation time, conversion rate, length of hospital stay, and chest tube indwelling time were observed in proportion to case volume. Minimum experience of 50 is necessary for stable outcomes of pediatric VATS pulmonary resection.

Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative.

The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.

Annual Surgeon Volume and Patient Outcomes Following Laparoscopic Totally Extraperitoneal Inguinal Hernia Repairs.

Data on laparoscopic totally extraperitoneal inguinal hernia repairs (TEP-IHRs) suggest that approximately 250 operations are needed to gain mastery, but the annual volume required to maintain high-quality outcomes is unknown. A retrospective review was performed of every patient undergoing a TEP-IHR at the Mayo Clinic (Rochester, MN) from 1995 to 2011. Analysis focused on the annual volume of 21 staff surgeons and their specific patient outcomes broken up into three groups: Group 1 (G1) (n = 1 surgeon) performed >30 repairs per year; Group 2 (G2) (n = 3 surgeons), 15-30 repairs; and Group 3 (G3) (n = 17), <15 repairs. In total, 1601 patients underwent 2410 TEP-IHRs, with no significant patient demographic differences among groups. Greater annual surgeon volume (G1 > G2 > G3) was associated with improved outcomes as shown by the respective rates for intra- (1%, 2.6%, and 5.6%) and postoperative (13%, 27%, and 36%) complications, need for overnight stay (17%, 23%, and 29%), and hernia recurrence (1%, 4%, and 4.3%) (all P < .05). Surgeons with greater annual operative volumes were more likely to operate on patients with bilateral and recurrent hernias. Surgeons performing at least 15 repairs per year (G1 and G2) showed improvements in quality metrics over time. Annual operative volumes of >30 repairs per year are associated with the highest quality outcomes for TEP-IHR. Operative volumes of at least 15 repairs per year are associated with improvements in quality metrics over time. Mentorship and operative assistance of low-volume TEP-IHR surgeons may be useful in improving patient outcomes.

Large performance incentives had the greatest impact on providers whose quality metrics were lowest at baseline.

This study examined the impact of Fairview Health Services' primary care provider compensation model, in which 40 percent of compensation was based on clinic-level quality outcomes. Fairview Health Services is a Pioneer accountable care organization in Minnesota. Using publicly reported performance data from 2010 and 2012, we found that Fairview's improvement in quality metrics was not greater than the improvement in other comparable Minnesota medical groups. An analysis of Fairview's administrative data found that the largest predictor of improvement over the first two years of the compensation model was primary care providers' baseline quality performance. Providers whose baseline performance was in the lowest tertile improved three times more, on average, across the three quality metrics studied than those in the middle tertile, and almost six times more than those in the top tertile. As a result, there was a narrowing of variation in performance across all primary care providers at Fairview and a narrowing of the gap in quality between providers who treated the highest-income patient panels and those who treated the lowest-income panels. The large quality incentive fell short of its overall quality improvement aim. However, the results suggest that payment reform may help narrow variation in primary care provider performance, which can translate into narrowing socioeconomic disparities.

Development of Smilow's EPIC ambulatory dashboard and the impact on bar code scanning compliance at care centers.

166 Background: Barcode scanning of patient wristbands is a critical stop-gap to prevent administration errors. After EPIC go-live and the implementation of barcode scanning, we created 10 EPIC-based metric reports including scanning compliance. Prior to having reports, our clinical leadership relied on variable qualitative feedback on scanning rates. Our AIM was to reach 90% patient barcode scanning compliance by Feb, 2014 and 95% by Aug, 2014 across Smilow Cancer Hospital Care Centers of Yale-New Haven Hospital. Methods: To engage staff, we shared data on the importance of barcode scanning, compliance and related adverse event reports. Staff reported challenges with scanning patients. We engaged pharmacy leadership to rectify barcode mapping errors. Leadership shared the expectation that all patients would be scanned, that there would be spot checks to prevent workarounds, that staff would be accountable for their own performance and that of their peers, remediation plans for areas &lt;90% compliant and use of a dashboard for employee and medication specific reports. Results: Monitoring, feedback, competition, and improved scanning equipment led to compliance increasing form 89% to 99%. Conclusions: Staff input, detailed reports and workflow review were needed for successful barcode scanning implementation. Staff knowledge that compliance was monitored, communicating improvement, and competition were required for incentive to change practice. Leaders encouraged a culture of safety by ensuring staff feedback was addressed and issues were resolved.Interdisciplinary teamwork between nursing, pharmacy, education and products was necessary to improve barcoding capability.EPIC-based metric reports can drive awareness of and improvement in quality metrics to ensure safe patient-care. [Table: see text]