Low-performing Hospitals Research Articles

Hospital strategies in commercial episode-based reimbursement.

To understand hospitals' approaches to spending reduction in commercial episode-based payment programs and inform incentive design. Qualitative arm of an explanatory sequential mixed-methods study involving semistructured interviews with hospital leaders participating in a statewide quality improvement collaborative with novel episode-based incentive payments introduced by the state's largest commercial payer. We recruited 21 leaders from 8 purposively selected, diverse hospitals with both high and low performance. Video teleconference-based interviews followed a standardized protocol and addressed 4 domains: choice of clinical condition for evaluation, strategies for episode spending reduction, best practices for success in earning incentives, and barriers to achievement. Rapid qualitative analysis with purposeful data reduction was employed to generate a matrix of key themes within the study domains. Strategies were similar between high- and low-performing hospitals. When selecting conditions, some hospitals focused on areas of underperformance, aiming for improvement opportunities, whereas others chose conditions already achieving highest efficiency. Many tried to synergize with other ongoing improvement initiatives and clinical areas with established leaders and champions. Key strategies included data-driven improvement, care standardization, and protocol dissemination. Best practices for success included readmission prevention and postacute care spending containment. The findings highlighted hospitals' most common strategies and approaches, providing several insights into optimal design of commercial episode-based incentives: They must be lucrative enough to earn attention or consistent with larger federal programs; hospitals need opportunities to succeed through both improved performance and sustained excellence; and programs may incur malalignment between hospitals and credentialed physicians.

Trends in HCAHPS Survey Scores, 2008-2019: A Quality Improvement Perspective.

HCAHPS' 2008 initial public reporting, 2012 inclusion in the Hospital Value-Based Purchasing Program (HVBP), and 2015 inclusion in Hospital Star Ratings were intended to improve patient experiences. Characterize pre-COVID-19 (2008-2019) trends in hospital consumer assessment of healthcare providers and systems (HCAHPS) scores. Describe HCAHPS score trends overall, by phase: (1) initial public reporting period (2008-2013), (2) first 2 years of HVBP (2013-2015), and (3) initial HCAHPS Star Ratings reporting (2015-2019); and by hospital characteristics (HCAHPS decile, ownership, size, teaching affiliation, and urban/rural). A total of 3909 HCAHPS-participating US hospitals. HCAHPS summary score (HCAHPS-SS) and 9 measures. The mean 2007-2019 HCAHPS-SS improvement in most-positive-category ("top-box") responses was +5.2 percentage points/pp across all hospitals (where differences of 5pp, 3pp, and 1pp are "large," "medium," and "small"). Improvement rate was largest in phase 1 (+0.8/pp/year vs. +0.2pp/year and +0.1pp/year for phases 2 and 3, respectively). Improvement was largest for Overall Rating of Hospital (+8.5pp), Discharge Information (+7.3pp), and Nurse Communication (+6.5pp), smallest for Doctor Communication (+0.8pp). Some measures improved notably through phases 2 and 3 (Nurse Communication, Staff Responsiveness, Overall Rating of Hospital), but others slowed or reversed in Phase 3 (Communication about Medicines, Quietness). Bottom-decile hospitals improved more than other hospitals for all measures. All HCAHPS measures improved rapidly 2008-2013, especially among low-performing (bottom-decile) hospitals, narrowing the range of performance and improving scores overall. This initial improvement may reflect widespread, general quality improvement (QI) efforts in lower-performing hospitals. Subsequent slower improvement following the introduction of HVBP and Star Ratings may have reflected targeted, resource-intensive QI in higher-performing hospitals.

Abstract TP107: Quantifying Hospital Opportunities to Increase Thrombolysis

Introduction: Emergency-department-based implementation strategies to increase thrombolysis are promising. We sought to quantify the number of hospitals with opportunities to increase thrombolysis under various tPA treatment thresholds. Methods: We used data from the 2018 State Inpatient Databases (SID) from 17 states. The study population was limited to ischemic stroke patients admitted to the hospital. The primary outcome was the sum of patients receiving stroke thrombolysis (tPA) at each facility (DRG 61-63, ICD-10 procedure code 3E03317, ICD-10 diagnosis code Z92.82). The primary exposure was hospital stroke volume categorized into quartiles (1 st Quartile [Low]: 1-7, 2 nd Quartile: 8-53, 3 rd Quartile: 54-178, 4 th Quartile [High]: 179-1431). To estimate the number of additional patients treated if hospitals improve their thrombolysis rates across various thresholds, we calculated the expected number of thrombolysis treatments (tPA thresholds multiplied by hospital stroke volume and subtracted by the number of patients receiving tPA at each facility). Results: We identified 203,843 hospital admissions with a primary ischemic stroke diagnosis from 1608 hospitals. On average, 13.3% of patients received tPA. The proportion of stroke patients receiving tPA was higher in higher stroke volume hospitals (Table 1). Black people were more likely to receive care at high-stroke volume hospitals. Among 1608 hospitals, 1131 (70%) had tPA rates below 10%. If these 1131 hospitals improve their tPA rates to 10%, 2655 (2.3 patients/hospital/year) additional stroke patients would be treated with tPA. Conclusions: Low stroke volume hospitals have the lowest thrombolytic treatment rates, but interventions at these hospitals will have limited population benefits and may not be an efficient use of hospital resources. Intervening at high-volume, low-performing hospitals offers the largest opportunity to increase thrombolysis and will promote stroke racial equity.

What is a star worth to Medicare beneficiaries? A discrete choice experiment of hospital quality ratings.

Hospital quality ratings are widely available to help Medicare beneficiaries make an informed choice about where to receive care. However, how beneficiaries' trade-off between different quality domains (clinical outcomes, patient experience, safety, efficiency) and other considerations (out-of-pocket cost, travel distance) is not well understood. We sought to study how beneficiaries make trade-offs when choosing a hypothetical hospital. We administered an online survey that included a discrete choice experiment to a nationally representative sample of 1025 Medicare beneficiaries. On average, beneficiaries were willing to pay $1698 more for a hospital with a 1-star higher rating on clinical outcomes. This was over twice the value of the patient experience ($691) and safety ($615) domains and nearly 8 times the value of the efficiency domain ($218). We also found that the value of a 1-star improvement depends not only on the quality domain but also the baseline level of performance of the hospital. Generally, it is more valuable for low-performing hospitals to achieve average performance than for average hospitals to achieve excellence.

Excellence in Antibiotic Stewardship: A Mixed-Methods Study Comparing High-, Medium-, and Low-Performing Hospitals.

Despite antibiotic stewardship programs existing in most acute care hospitals, there continues to be variation in appropriate antibiotic use. While existing research examines individual prescriber behavior, contextual reasons for variation are poorly understood. We conducted an explanatory, sequential mixed-methods study of a purposeful sample of 7 hospitals with varying discharge antibiotic overuse. For each hospital, we conducted surveys, document analysis, and semi-structured interviews with antibiotic stewardship and clinical stakeholders. Data were analyzed separately and mixed during the interpretation phase, where each hospital was examined as a case, with findings organized across cases using a strengths, weaknesses, opportunities, and threats framework to identify factors accounting for differences in antibiotic overuse across hospitals. Surveys included 85 respondents. Interviews included 90 respondents (31 hospitalists, 33 clinical pharmacists, 14 stewardship leaders, 12 hospital leaders). On surveys, clinical pharmacists at hospitals with lower antibiotic overuse were more likely to report feeling: respected by hospitalist colleagues (P = .001), considered valuable team members (P = .001), and comfortable recommending antibiotic changes (P = .02). Based on mixed-methods analysis, hospitals with low antibiotic overuse had 4 distinguishing characteristics: (1) robust knowledge of and access to antibiotic stewardship guidance; (2) high-quality clinical pharmacist-physician relationships; (3) tools and infrastructure to support stewardship; and (4) highly engaged infectious diseases physicians who advocated stewardship principles. This mixed-methods study demonstrates the importance of organizational context for high performance in stewardship and suggests that improving antimicrobial stewardship requires attention to knowledge, interactions, and relationships between clinical teams and infrastructure that supports stewardship and team interactions.

Do Hospital Characteristics Predict Racial-and-Ethnic Disparities in Patient Experience? National Results From the HCAHPS Survey.

Assess whether hospital characteristics associated with better patient experiences overall are also associated with smaller racial-and-ethnic disparities in inpatient experience. Hospitals that are smaller, non-profit, and serve high proportions of White patients tend to be high-performing overall, but it is not known whether these hospitals also have smaller racial-and-ethnic disparities in care. We used linear mixed-effect regression models to predict a summary measure that averaged eight Hospital CAHPS (HCAHPS) measures (Nurse Communication, Doctor Communication, Staff Responsiveness, Communication about Medicines, Discharge Information, Care Coordination, Hospital Cleanliness, and Quietness) from patient race-and-ethnicity, hospital characteristics (size, ownership, racial-and-ethnic patient-mix), and interactions of race-and-ethnicity with hospital characteristics. Inpatients discharged from 4,365 hospitals in 2021 who completed an HCAHPS survey ( N =2,288,862). While hospitals serving larger proportions of Black and Hispanic patients scored lower on all measures, racial-and-ethnic disparities were generally smaller for Black and Hispanic patients who received care from hospitals serving higher proportions of patients in their racial-and-ethnic group. Experiences overall were better in smaller and non-profit hospitals, but racial-and-ethnic differences were slightly larger. Large, for-profit hospitals and hospitals serving higher proportions of Black and Hispanic patients tend to be lower performing overall but have smaller disparities in patient experience. High-performing hospitals might look at low-performing hospitals for how to provide less disparate care whereas low-performing hospitals may look to high-performing hospitals for how to improve patient experience overall.

Addressing knowledge gaps in Surgical Safety Checklist use: statistical process control analysis of a surgical quality improvement programme in Ethiopia.

The WHO Surgical Safety Checklist reduces morbidity and mortality after surgery, but uptake remains challenging. In particular, low-income countries have been found to have lower rates of checklist use compared with high-income countries. The aim of this study was to determine the impact of educational workshops on Surgical Safety Checklist use implemented as part of a quality improvement initiative in five hospitals in Ethiopia that had variable experience with the Surgical Safety Checklist. From April 2019 to September 2020, each hospital implemented a 6-month surgical quality improvement programme, which included a Surgical Safety Checklist workshop. Statistical process control methodology was used to understand the variation in Surgical Safety Checklist compliance before and after workshops and a time-series analysis was performed using population-averaged generalized estimating equation Poisson regression. Checklist compliance was defined as correctly completing a sign in, timeout, and sign out. Incidence rate ratios of correct checklist use pre- and post-intervention were calculated and the change in mean weekly compliance was predicted. Checklist compliance data were obtained from 2767 operations (1940 (70 per cent) pre-intervention and 827 (30 per cent) post-intervention). Mean weekly checklist compliance improved from 27.3 to 41.2 per cent (mean difference 13.9 per cent, P = 0.001; incidence rate ratio 1.51, P = 0.001). Hospitals with higher checklist compliance at baseline had the greatest overall improvements in compliance, more than 50 per cent over pre-intervention, while low-performing hospitals showed no improvement. Surgical Safety Checklist workshops improved checklist compliance in hospitals with some experience with its use. Workshops had little effect in hospitals unfamiliar with the Surgical Safety Checklist, emphasizing the importance of multifactorial interventions and culture-change approaches. In receptive facilities, short workshops can accelerate behaviour change.

Patient healthcare experiences of cancer hospitals in China: A multilevel modeling analysis based on a national survey.

Patient satisfaction is a crucial indicator for assessing quality of care in healthcare settings. However, patient satisfaction benchmark for cancer hospitals in China is not established. To examine patient satisfaction levels in tertiary cancer hospitals in China, and inter-hospital variations after case-mix adjustment. A nationwide cross-sectional hospital performance survey conducted from January to March 2021. At 30 tertiary cancer hospitals in China. A total of 4,847 adult inpatients consecutively recruited at 30 tertiary cancer hospitals were included. Patient characteristics included demographic characteristics (sex, age, education, and annual family income), clinical characteristics (cancer type, cancer stage, self-reported health status, and length of stay), and actual respondents of questionnaire. Patient satisfaction was measured using 23 items covering five aspects, administrative process, hospital environment, medical care, symptom management, and overall satisfaction. Responses to each item were recorded using a 5-point Likert scale. Patient satisfaction level for each aspect was described at individual and hospital levels. Using multilevel logistic regression, patient characteristics associated with patient satisfaction were examined as case-mix adjusters and inter-hospital variation were determined. The satisfaction rates for symptom management, administrative process, hospital environment, overall satisfaction, and medical care aspects were 74.56, 81.70, 84.18, 84.26, and 90.86% with a cut-off value of 4, respectively. Significant predictors of patient satisfaction included sex, age, cancer type, cancer stage, self-reported health status, and actual respondent (representative or patient) (all P < 0.05). The ranking of the hospitals' performance in satisfaction was altered after the case-mix adjustment was made. But even after the adjustment, significant variation in satisfaction among hospitals remained. This study pointed to symptom management as a special area, to which a keen attention should be paid by policymakers and hospital administrators. Significant variation in satisfaction among hospitals remained, implying that future studies should examine major factors affecting the variation. In review, target interventions are needed in low-performing hospitals.

Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality

To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM). Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters. The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics. Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

Proven Impact of an Advanced Air Purification System in the Reduction of Infectious Airborne and Surface Pathogens, Concomitant Reduction of Hospital-acquired Infections and Length of Stay, and Improvement in Health-care Economics.

Proven Impact of an Advanced Air Purification System in the Reduction of Infectious Airborne and Surface Pathogens, Concomitant Reduction of Hospital-acquired Infections and Length of Stay, and Improvement in Health-care Economics.

High-Performing and Low-Performing Hospitals Across Medicare Value-Based Payment Programs

This cross-sectional study examines the number and characteristics of hospitals that performed well or poorly across 3 Medicare value-based programs in fiscal year 2020.

Distinguishing High-Performing From Low-Performing Hospitals for Severe Maternal Morbidity: A Focus on Quality and Equity.

To investigate which organizational factors, policies, and practices distinguish hospitals with high compared with low risk-adjusted rates of severe maternal morbidity (SMM). Using a positive deviance approach, this qualitative study included 50 semistructured interviews with health care professionals (obstetrics and gynecology chairs, labor and delivery medical directors, nurse managers, frontline nurses, physicians or nurses responsible for quality and safety, and chief medical officers) in four low-performing and four high-performing hospitals in New York City. Hospital performance was based on risk-adjusted morbidity metrics from previous research. Major topics explored were structural characteristics (eg, staffing, credentialing), organizational characteristics (eg, culture, leadership, communication, use of data), labor and delivery practices (eg, use of standardized, evidence-based practices, teamwork), and racial and ethnic disparities in SMM. All interviews were audiotaped, professionally transcribed, and coded using NVivo software. Researchers blinded to group assignment conducted qualitative content analysis. Researchers wrote analytic memos to identify key themes and patterns emerging from the interviews, highlight illustrative quotes, and draw qualitative comparisons between the two hospital clusters with different (but unrevealed) performance levels. Six themes distinguished high-performing from low-performing hospitals. High-performing hospitals were more likely to have: 1) senior leadership involved in day-to-day quality activities and dedicated to quality improvement, 2) a strong focus on standards and standardized care, 3) strong nurse-physician communication and teamwork, 4) adequate physician and nurse staffing and supervision, 5) sharing of performance data with nurses and other frontline clinicians, and 6) explicit awareness that racial and ethnic disparities exist and that racism and bias in the hospital can lead to differential treatment. Organizational factors, policies, and practices at multiple levels distinguish high-performing from low-performing hospitals for SMM. Findings illustrate the potential for targeted quality initiatives to improve maternal health and reduce obstetric disparities arising from delivery in low-performing hospitals.

Expert-Identified Practices for Achieving Measurable Performance Improvements With Lean Implementation.

Despite the rapid spread of Lean management in health care, few organizations have achieved measurable overall performance improvements with Lean. What differentiates these organizations from those that struggle with realizing the potential benefits of Lean management is unclear. In this qualitative study we explore measuring the impact of Lean and the recommended practices for achieving measurable performance improvements with Lean in health care organizations. Informed by preliminary quantitative results from analyses of high- and low-performing Lean hospitals, we conducted 17 semi-structured interviews with Lean health care experts on the Lean principles and practices associated with better performance. We conducted qualitative content analyses of the interview transcripts based on grounded theory and linking to core principles and practices of the Lean management system. The qualitative data revealed 3 categories of metrics for measuring the impact of Lean: currently used institutional measures, measures tailored to Lean initiatives, and population-level measures. Leadership engagement/commitment and clear organizational focus/prioritization/alignment had the highest weighted averages of success factors. The lack of these 2 factors had the highest weighted averages of biggest barriers for achieving measurable performance improvements with Lean implementation. Leadership engagement and organizational focus can facilitate achieving the organization's performance improvement goals, whereas their absence can considerably hinder performance improvement efforts. Many different approaches have been used to quantify the impact of Lean, but currently used institutional performance measures are preferred by the majority of Lean experts.

Hospital performance comparison of inpatient fall rates; the impact of risk adjusting for patient-related factors: a multicentre cross-sectional survey

BackgroundComparing inpatient fall rates can serve as a benchmark for quality improvement. To improve the comparability of performance between hospitals, adjustments for patient-related fall risk factors that are not modifiable by care are recommended. Thereafter, the remaining variability in risk-adjusted fall rates can be attributed to differences in quality of care provided by a hospital. Research on risk-adjusted fall rates and their impact on hospital comparisons is currently sparse. Therefore, the aims of this study were to develop an inpatient fall risk adjustment model based on patient-related fall risk factors, and to analyse the impact of applying this model on comparisons of inpatient fall rates in acute care hospitals in Switzerland.MethodsData on inpatient falls in Swiss acute care hospitals were collected on one day in 2017, 2018 and 2019, as part of an annual multicentre cross-sectional survey. After excluding maternity and outpatient wards, all inpatients older than 18 years were included. Two-level logistic regression models were used to construct unadjusted and risk-adjusted caterpillar plots to compare inter-hospital variability in inpatient fall rates.ResultsOne hundred thirty eight hospitals and 35,998 patients were included in the analysis. Risk adjustment showed that the following factors were associated with a higher risk of falling: increasing care dependency (to a great extent care dependent, odds ratio 3.43, 95% confidence interval 2.78–4.23), a fall in the last 12 months (OR 2.14, CI 1.89–2.42), the intake of sedative and or psychotropic medications (OR 1.74, CI 1.54–1.98), mental and behavioural disorders (OR 1.55, CI 1.36–1.77) and higher age (OR 1.01, CI 1.01–1.02). With odds ratios between 1.26 and 0.67, eight further ICD-10 diagnosis groups were included. Female sex (OR 0.78, CI 0.70–0.88) and postoperative patients (OR 0.83, CI 0.73–0.95) were associated with a lower risk of falling. Unadjusted caterpillar plots identified 20 low- and 3 high-performing hospitals. After risk adjustment, 2 low-performing hospitals remained.ConclusionsRisk adjustment of inpatient fall rates could reduce misclassification of hospital performance and enables a fairer basis for decision-making and quality improvement measures. Patient-related fall risk factors such as care dependency, history of falls and cognitive impairment should be routinely assessed.

Risk-Adjusted Mortality Rates as a Quality Proxy Outperform Volume in Surgical Oncology-A New Perspective on Hospital Centralization Using National Population-Based Data.

Despite a long-known association between annual hospital volume and outcome, little progress has been made in shifting high-risk surgery to safer hospitals. This study investigates whether the risk-standardized mortality rate (RSMR) could serve as a stronger proxy for surgical quality than volume. We included all patients who underwent complex oncologic surgeries in Germany between 2010 and 2018 for any of five major cancer types, splitting the data into training (2010-2015) and validation sets (2016-2018). For each surgical group, we calculated annual volume and RSMR quintiles in the training set and applied these thresholds to the validation set. We studied the overlap between the two systems, modeled a market exit of low-performing hospitals, and compared effectiveness and efficiency of volume- and RSMR-based rankings. We compared travel distance or time that would be required to reallocate patients to the nearest hospital with low-mortality ranking for the specific procedure. Between 2016 and 2018, 158,079 patients were treated in 974 hospitals. At least 50% of high-volume hospitals were not ranked in the low-mortality group according to RSMR grouping. In an RSMR centralization model, an average of 32 patients undergoing complex oncologic surgery would need to relocate to a low-mortality hospital to save one life, whereas 47 would need to relocate to a high-volume hospital. Mean difference in travel times between the nearest hospital to the hospital that performed surgery ranged from 10 minutes for colorectal cancer to 24 minutes for pancreatic cancer. Centralization on the basis of RSMR compared with volume would ensure lower median travel times for all cancer types, and these times would be lower than those observed. RSMR is a promising proxy for measuring surgical quality. It outperforms volume in effectiveness, efficiency, and hospital availability for patients.

Barriers and facilitators of CT scan reduction in the workup of pediatric appendicitis: A pediatric surgical quality collaborative qualitative study

IntroductionDespite ongoing efforts to decrease ionizing radiation exposure from computed tomography (CT) use in pediatric appendicitis, high CT utilization rates are still observed across many hospitals. This study aims to identify factors influencing CT use and facilitators and barriers to quality improvement efforts. MethodsThe Pediatric Surgery Quality Collaborative is a voluntary consortium of 42 children's hospitals participating in the National Surgical Quality Improvement Project - Pediatric. Hospitals were compared based on CT utilization from January 1, 2019, to December 31, 2019. Semi-structured interviews were conducted with surgeons, radiologists, emergency medicine physicians, and clinical data abstractors from 7 hospitals with low CT use rates (high performers) and 6 hospitals with high CT use rates (low performers). A mixed deductive and inductive coding approach for analysis of the interview transcripts was used to develop a codebook based on the Theoretical Domains Framework and subsequently identify prominent barriers and facilitators to CT reduction. ResultsThematic saturation was achieved after 13 interviews. We identified four factors that distinguish high-performing from low-performing hospitals: (1) consistent availability of resources such as ultrasound technicians, pediatric radiologists, and magnetic resonance imaging (MRI); (2) presence of and adherence to protocols guiding imaging modality decision making and imaging execution; (3) culture of inter-departmental collaboration; and (4) presence of a radiation reduction champion. ConclusionsSignificant barriers to reducing the use of CT in pediatric appendicitis exist. Our findings highlight that future quality improvement efforts should target resource availability, protocol adherence, collaborative culture, and radiation reduction champions. Levels of EvidenceLevel III

Quality of Care for Gallstone Pancreatitis—the Impact of the Acute Care Surgery Model and Hospital-Level Operative Resources

BackgroundIndex cholecystectomy is the standard of care for gallstone pancreatitis. Hospital-level operative resources and implementation of an acute care surgery (ACS) model may impact the ability to perform index cholecystectomy. We aimed to determine the influence of structure and process measures related to operating room access on achieving index cholecystectomy for gallstone pancreatitis. MethodsIn 2015, we surveyed 2811 US hospitals on ACS practices, including infrastructure for operative access. A total of 1690 hospitals (60%) responded. We anonymously linked survey data to 2015 State Inpatient Databases from 17 states using American Hospital Association identifiers. We identified patients ≥ 18 years who were admitted with gallstone pancreatitis. Patients transferred from another facility were excluded. Univariate and multivariable regression analyses, clustered by hospital and adjusted for patient factors, were performed to examine multiple structure and process variables related to achieving an index cholecystectomy rate of ≥ 75% (high performers). ResultsOver the study period, 5656 patients were admitted with gallstone pancreatitis and 70% had an index cholecystectomy. High-performing hospitals achieved an index cholecystectomy rate of 84.1% compared to 58.5% at low-performing hospitals. On multivariable regression analysis, only teaching vs. non-teaching hospital (OR 2.91, 95% CI 1.11–7.70) and access to dedicated, daytime operative resources (i.e., block time) vs. no/little access (OR 1.93, 95% CI 1.11–3.37) were associated with high-performing hospitals. ConclusionsAccess to dedicated, daytime operative resources is associated with high quality of care for gallstone pancreatitis. Health systems should consider the addition of dedicated, daytime operative resources for acute care surgery service lines to improve patient care.

Influence of Context as a Key Ingredient for High Performance on Skilled Nursing Facility Readmissions

Improving hospital discharge processes and reducing adverse outcomes post discharge has become a topic of national importance, especially for older patients transitioning to skilled nursing facilities (SNFs). The substantial variation in rehospitalization outcomes suggests contextual factors may play a role in performance. We conducted rapid ethnography with opportunistic interviews (148 hours of observations, 30 clinicians) at hospitals that were high (n=2) or low (n=2)- performing in terms of their readmission rates from SNF, as well as 5 associated SNFs, to understand how contextual differences influenced performance variation. We used thematic analysis to categorize contextual factors and compare differences across high and low perfoming sites. We found three main contextual factors that differed across high- and low-performing hospitals and SNFs: team dynamics, patient characteristics, and organizational context. First, we observed high-quality communication, situational awareness, and shared mental models among team members in high-performing sites. Second, patients at high-performing hospitals had better insurance coverage that made it feasible for clinicians to place patients in SNFs based on their needs instead of financial abilities. Third, staff at high-performing hospitals were more engaged in the transitions process and rapport building with SNFs thereby facilitating smooth transitions of care from hospitals to SNFs. For example, clinicians at high- performing sites were actively engaged in directing the discharge process, but this was not observed in low-performing sites where a lack of clinician engagement lead to delays. Understanding how context affects transitions could be used to target organizational, policy, and staff level interventions to reduce adverse outcomes.

Hospital variation in downstream secondary preventive medication uptake: implications for quality and outcomes

Abstract Background Adherence to guideline recommended therapy improves outcomes in patients with myocardial infarction. We sought to appraise between-hospital variation in downstream adherence to secondary preventive medication and hypothesised that discharge from high-adherence hospitals was associated with improved long-term outcomes. Methods We included 7,624 patients hospitalised because of myocardial infarction in 14 hospitals between 2015 and 2017 in Slovenia (nation-wide sample). Using indirect identifiers, we linked routinely collected data on patients from the i) Hospital Discharge Statistics Database, ii) the National Mortality Registry and iii) the Medication Reimbursement Database. We used random intercept logistic regression modelling for prediction of secondary prevention medication uptake 30 to 90 days after discharge, adjusting for case-mix, hospital size and percutaneous coronary intervention (PCI) availability. We classified hospitals into high- and low adherence (i.e., above and below the national median adjusted odds) and assessed the association between hospital performance, and death or re-infarction with multivariate Cox proportional hazards modelling. Results Secondary preventive medication uptake ranged from 30.7% to 87.3% in high- and low-performing hospitals, respectively. Discharge from high-adherence hospitals were associated with significantly lower all-cause mortality and re-infarction rates (hazard ratio 0.82; 95% confidence interval 0.69–0.98) when compared to hospitals with secondary preventive medication uptake below the national median, after adjusting for case-mix and hospital characteristics. Conclusions Downstream secondary preventive medication uptake vary across hospitals. Although case-mix and hospital characteristics explain some of the variation, discharge from a hospital with good downstream secondary preventive medication uptake is associated with lower risk of death or re-infarction. Event rates, low- vs. high-adhererence Funding Acknowledgement Type of funding source: None

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach

BackgroundDespite the increased focus on improving patient’s postacute care outcomes, best practices for reducing readmissions from skilled nursing facilities (SNFs) are unclear. The objective of this study was to observe...