Quality Improvement Organizations Research Articles

A risk-adjusted, composite outcomes score and resource utilization metrics for very low-birth-weight infants.

It is difficult for neonatal intensive care units (NICUs) to determine the overall efficacy of multiple continuous quality improvement (CQI) projects aimed at reducing very low-birth-weight (VLBW) infant morbidities. It is challenging to know whether a NICU is becoming more proficient, and it is not usually apparent whether concurrent resource use is changing. To develop a risk-adjusted composite score of the major morbidities in VLBW infants and a companion metric that accounts for resource use to enhance the ability to measure overall progress in CQI and to identify proficient NICUs. This retrospective investigation used individual patient-level demographic and outcomes data from 8 NICUs who were long term CQI collaborators within the Vermont Oxford Network, a large international quality improvement organization dedicated to improving the care of premature infants. Study participants were infants who weighed 401 to 1500 g born from January 1, 2000, through December 31, 2011, at each of the 8 participating NICUs. Risk-adjusted, composite VLBW infant morbidity and resource utilization score. A total of 15,961 infants (mean [SD] gestational age, 28.2 [3.0] weeks; mean [SD] birth weight, 1020 [306] g) were analyzed. Concurrent with multiple shared CQI projects over 12 years, the group benefit metric improved 38% from 80 in 2000 to 110 in 2011 (P < .001). The entire member VON benefit metric improved 28% from 72 in 2000 to 92 in 2011 (P < .001). The group value metric improved 25% from 1.2 in 2000 to 1.5 in 2011 (P < .001). The entire member VON value metric improved 18% from 1.1 in 2000 to 1.3 in 2011 (P < .001). Significant inter-NICU variation in both composite scores was noted in the 8 member CQI group. Hospital length of stay increased in the 8 NICUs 64 to 71 days (P <.001), and a similar increase was noted in the entire member VON, 65 to 68 days (P < .001). We have created the first, to our knowledge, web-based tool for NICUs to calculate their own composite morbidity and resource utilization scores that estimate NICU CQI proficiency. In our structured group CQI over 12 years, both metrics revealed significant improvement, but increases in length of stay (resource use) blunted value improvement. Why some NICUs improve their scores more successfully than others remains a crucial challenge. Future CQI efforts should explore strategies that cost-efficiently reduce intertwined VLBW infant morbidities, emphasizing whole cultures of proficient care rather than the traditional emphasis on single-morbidity reduction.

Process Evaluation of a Quality Improvement Project to Decrease Hospital Readmissions From Skilled Nursing Facilities

ObjectiveTo describe and evaluate the impact of quality improvement (QI) support provided to skilled nursing facilities (SNFs) by a Quality Improvement Organization (QIO). DesignRetrospective, mixed-method, process evaluation of a QI project intended to decrease preventable hospital readmissions from SNFs. SettingFive SNFs in Connecticut. ParticipantsSNF Administrators, Directors of Nursing, Assistant Directors of Nursing, Admissions Coordinators, Registered Nurses, Certified Nursing Assistants, Receptionists, QIO Quality Improvement Consultant. InterventionQIO staff provided training and technical assistance to SNF administrative and clinical staff to establish or enhance QI infrastructure and implement an established set of QI tools [Interventions to Reduce Acute Care Transfers (INTERACT) tools]. MeasurementsBaseline SNF demographic, staffing, and hospital readmission data; baseline and follow-up SNF QI structure (QI Committee), processes (general and use of INTERACT tools), and outcome (30-day all-cause hospital readmission rates); details of QIO-provided training and technical assistance; QIO-perceived barriers to quality improvement; SNF leadership-perceived barriers, accomplishments, and suggestions for improvement of QIO support. ResultsSuccess occurred in establishing QI Committees and targeting preventable hospital readmissions, as well as implementing INTERACT tools in all SNFs; however, hospital readmission rates decreased in only 2 facilities. QIO staff and SNF leaders noted the ongoing challenge of engaging already busy SNF staff and leadership in QI activities. SNF leaders reported that they appreciated the training and technical assistance that their institutions received, although most noted that additional support was needed to bring about improvement in readmission rates. ConclusionThis process evaluation documented mixed clinical results but successfully identified opportunities to improve recruitment of and provision of technical support to participating SNFs. Recommendations are offered for others who wish to conduct similar projects.

Quality Improvement and Patient Safety Organizations in Anesthesiology

Quality Improvement and Patient Safety Organizations in Anesthesiology

Quality improvement and patient safety organizations in anesthesiology.

The Anesthesiology Quality Institute contributes both to local quality improvement in the practice of anesthesiology through data collection and establishment of benchmarks and to patient safety in partnership with the Anesthesia Patient Safety Foundation.

Using a Small Workgroup to Jump-start a Community-Wide Coalition to Reduce Preventable Hospital Readmissions.

Unplanned hospital readmissions are common and often preventable. A review of Medicare discharge data identified a geographical area with higher than expected readmission rates. The state Medicare quality improvement organization (QIO) used community organizing techniques to assess provider engagement and hypothesized that a small workgroup of high impact providers could address some root causes for preventable readmissions, achieve quick wins, and reinvigorate the broader community-wide coalition. Seven of the eight facilities targeted by the QIO actively engaged and began rapid cycle initiatives to improve the patient transfer process between providers. Monthly, 2-hr structured meetings were supplemented by additional ad hoc meetings convened by participants. Effectiveness of the intervention was measured by workgroup functioning, the implementation of multiple initiatives spread from the small workgroup to the broader provider coalition, and reductions in readmissions to the anchor hospital system from the participating skilled nursing facilities. The community impact of the workgroup initiative is shown by a decline in community readmission rates for Medicare beneficiaries.

PATH: A Grassroots Initiative in Arizona

PATH: A Grassroots Initiative in Arizona

Is audit and feedback associated with increased hospital adherence to standards for communication during patient care transitions?

Guidelines to enhance communication during patient care transitions between healthcare settings have the potential to improve patient outcomes and satisfaction, as well as to decrease overall costs. In 2009, Healthcentric Advisors, the Medicare Quality Improvement Organization (QIO) for New England, collaborated with Rhode Island providers and stakeholders to develop communitywide standards for hospitals, the Safe Transitions Best Practice Measures for Hospitals and then implemented a hospital quality improvement intervention. As part of this intervention, 10 of the state’s 11 acute-care hospitals collected quarterly data and Healthcentric Advisors provided audit and feedback reports showing each facility’s progress and the state’s average performance. Using hospital-reported data on four best practice measures and Medicare claims data for Q2 2011-Q1 2013, we performed descriptive analyses of (1) inpatient-to-outpatient communication for all patients at the 10 participating hospitals, as measured by four best practice measures, and (2) state-wide all-cause, 30-day readmission rates per 1,000 fee-for-service (FFS) beneficiaries. Aggregate performance for the four best practice process measures increased by 5.5% to 217.6% for all patients who met eligibility criteria (p ≤ .001 for each measure) and the readmission rate decreased by 18.4% from 14.12 to 11.52 per 1,000 eligible FFS Medicare beneficiaries (p ≤ .001). These findings suggest that communitywide standards, such as the Safe Transitions Best Practice Measures for Hospitals, and audit and feedback interventions can successfully improve hospitals’ communication during patient care transitions between healthcare settings.

Success in the Face of Reform

We hear repeatedly that health reform will dramatically affect the way postacute and long-term care (PA/LTC) will participate in the U.S. health care system. New models of care delivery include accountable care organization, medical homes, and demonstration projects that combine Medicare and Medicaid dollars. All have core principles of accountability, integration of care, emphasis on long-term health outcomes, and better transitions. So, where do physicians look for guidance in the postreform world? Many of us immediately think of innovative centers such as the Cleveland Clinic and the Mayo Clinics. There is certainly much to learn from them, but how transferable are their practices? How dependent are their models on concentrated populations and resources? What do they offer to rural or suburban practices? At the same time, some independent physician practices are trying to chart their own paths through the changing environment without sacrificing physician leadership. One such model is Chappel Health and Wellness in central Florida. It's led by Chris Chappel, MD, CMD, and includes three other physicians and six physician assistants. They operate three clinics and provide medical direction to 25 PA/LTC facilities in the three counties around Orlando. What makes Dr. Chappel's practice model unusual is that it incorporates “discharge clinics” in cooperation with local hospitals. These clinics streamline transitions from the acute setting by giving patients on-site access to a pharmacy, a home health agency, and a durable medical equipment provider. The discharge clinics also set the immediate follow-up appointments with primary care physicians and specialists. The pharmacy's presence alone mitigates what is a major contributor to hospital readmissions, medication errors. Each Chappell clinic also has a wellness program incorporating diet and exercise coaching in a 5,500 square-foot gym. In a final twist, Chappel Health and Wellness has a clinical research arm staffed by a pharmacist and two physicians. Dr. Chappel has been working with Florida's Quality Improvement Organization on a project to reduce hospital readmissions. The collaboration includes four nursing homes, two home health agencies, and a patient-advocacy and coaching organization. The project targets seven of the leading readmission diagnoses, including heart failure, chronic obstructive pulmonary disease, and sepsis. The linchpins of the project are two: immediately offering a health coach to a patient at hospital discharge and use of the Interventions to Reduce Acute Care Transfers (INTERACT) program for improving long-term care transitions. The results have been dramatic. Nursing homes have become more comfortable treating patients with complex diagnoses and talking with family members about care-setting choice. Hospital admission rates of residents in the four nursing homes have decreased from 26% to 17% and are still falling. Thus, Chappel Health and Wellness is firmly planted in both community-based and facility-based long-term care. Dr. Chappel describes the model as a medical village concept within a clinic. He and his colleagues strive to follow the Institute of Medicine's advice on how to give appropriate and affordable care: “Deliver the right care at the right time by the right provider in the right setting.” Is Dr. Chappel naïve in trying to go it alone in the post–health reform world? He says that he is striving to let primary care do what it does best and eliminate or reduce the need for the administrative middle man of an accountable care organization (ACO), for instance. “I think we are years away from bundled payments for physician services in the outpatient world. If it happens sooner, our concept will be ready for it and will have a track record, especially when it comes to decreasing 30-day readmits,” Dr. Chappel said. Maybe he's not naïve. He says that physician groups partnering with hospitals, nursing homes, insurance companies, and other entities is inevitable. “We are starting small to work out the bugs, then expanding in whatever direction it takes us.” The handwriting is on the wall. Governmental payers, employers, and health insurance companies are all pushing for more integrated health care systems, where physicians and hospitals are held accountable for the overall cost and quality of care. It is likely that all physicians will need to participate in systems requiring more communication, care coordination, and quality-data reporting. The Chappel Health and Wellness model strives for coordinated services that are rooted deeply in a profound respect for patients. In Dr. Chappel's view, hospitals, LTC facilities, and physicians' practices can and must work together effectively.

Making quality improvement programs more effective.

In the past 25 years, and as recent as 2011, all external evaluations of the Quality Improvement Organization (QIO) Program have found its impact to be small or difficult to discern. The QIO program costs about $200 million on average to administer each year to improve quality of healthcare for people of 65 years or older. The program was created to address questionable quality of care. QIOs review how care is provided based on performance measures. The paper aims to discuss these issues. In 2012, the author supported the production of quarterly reports and reviewed internal monitoring and evaluation protocols of the program. The task also required reviewing all previous program evaluations. The task involved many conversations about the complexities of the program, why impact is difficult to discern and possible ways for eventual improvement. Process flow charts were created to simulate the data life cycle and discrete event models were created based on the sequence of data collection and reporting to identify gaps in data flow. The internal evaluation uncovered data gaps within the program. The need for a system of specification rules for data conceptualization, collection, distribution, discovery, analysis and repurposing is clear. There were data inconsistencies and difficulty of integrating data from one instance of measurement to the next. The lack of good and reliable data makes it difficult to discern true impact. The prescription is for a formal data policy or data governance structure to integrate and document all aspects of the data life cycle. The specification rules for governance are exemplified by the Data Documentation Initiative and the requirements published by the Data Governance Institute. The elements are all in place for a solid foundation of the data governance structure. These recommendations will increase the value of program data. The model specifies which agency units must be included in the governance authority and the data team. The model prescribes in detail a data governance model to address gaps in the life cycle. These prescriptive measures will allow the program to integrate all of its data. Without this formal data governance structure, the QIO program will be undetermined by the persistent lack of good data for monitoring and evaluation.

Determinants of Survivorship Care Plan Use in US Cancer Programs

Cancer programs are increasingly required to use survivorship care plans (SCPs). Compliance with SCP use requirements will be evaluated at the cancer program level. Cancer program-level determinants of SCP use may suggest strategies for compliance. The objective of this study was to describe SCP use and identify its cancer program-level determinants. We surveyed employees knowledgeable about survivorship practices in cancer programs throughout the USA with a wide range of annual incident cancers, program types, and cancer care quality improvement organization memberships (81/100 response rate). We used descriptive statistics to describe SCP use and bivariate statistics to identify its cancer program-level determinants. Most respondents (56 %) reported that SCPs were not used. In programs reporting use, SCP use is restricted primarily to breast (82 %) and colorectal (55 %) cancer survivors, and few providers use SCPs. When developed, SCPs seldom reach survivors and their primary care providers. Most respondents (78 %) reported beginning to use SCPs because of requirements. Frequently cited barriers included insufficient resources (76 %), perceived difficulty using SCPs (29 %), and lack of advocacy for SCP use from influential people (24 %). SCP use was positively associated with academic program type (p = .009) and membership in the National Cancer Institute's Community Cancer Centers Program (p = .009) and negatively associated with freestanding program type (p = .02). SCP use in the US cancer programs is highly inconsistent. Many cancer programs plan to implement SCPs to comply with SCP use requirements. Support specifically intended to facilitate SCP use may be more effective than non-specific resources.

Pharmacists provide care

Pharmacists provide care

Following Through: The Consistency of Survivorship Care Plan Use in United States Cancer Programs

The Institute of Medicine suggests that consistent survivorship care plan (SCP) use involves developing and delivering SCPs to all cancer survivors and their primary care providers (PCPs). We describe the consistency of SCP use in US cancer programs and assess its relationship with cancer-program-level determinants. We surveyed employees knowledgeable about survivorship practices in cancer programs reporting current SCP use (n = 36, 81 % response rate). We operationalized consistent SCP use as whether SCPs were (1) developed for ≥75 % survivors, (2) delivered to ≥75 % survivors, (3) delivered to ≥75 % PCPs, and (4) all of the above. We use descriptive statistics to report SCP use consistency and evaluate associations using Fisher's exact and Wilcoxon rank sum tests. SCPs were developed for ≥75 % survivors in five programs (15 %), eight (25 %) delivered ≥75 % SCPs to survivors, seven (23 %) delivered ≥75 % SCPs to PCPs, and only one program (4 %) met all three criteria. We found relationships between SCP use consistency and geographic region (p = .05), initiating SCP use in response to survivors' requests (p = .03), and membership in the National Cancer Institute's National Community Cancer Centers Program (p = .01). SCP use is highly inconsistent. Survivors and cancer care quality improvement organizations may play a key role in improving the consistency of SCP use in US cancer programs. Survivors can initiate SCP use. Cancer care quality improvement organizations can specify how cancer programs' compliance with SCP guidelines will be assessed. Future research should identify mechanisms underlying the relationships that we found.

Gaining momentum: Pharmacists recognized for health care contributions

Gaining momentum: Pharmacists recognized for health care contributions

Hospitals Seek to Better Understand Nursing Facilities

Hospitals Seek to Better Understand Nursing Facilities

Implementation of a statewide quality assessment program for rectal cancer.

4 Background: The quality of surgical care for rectal cancer (RC) has been extensively studied in Europe; however, efforts in the United States are limited by the lack of detail about surgical care in available registries. We describe a unique quality assessment program for RC designed within the Michigan Surgical Quality Collaborative (MSQC), a collaborative quality improvement organization that includes community and academic medical centers. Methods: 10 MSQC hospitals contributed to this retrospective cohort study (2007-2012). Experienced nurse reviewers were trained to abstract cancer surgery-specific data from hospital medical records and local tumor registries. Five RC surgery-specific quality measures were designed based on literature review and current guidelines: adequate lymph node (LN) procurement (&gt;=12); use of mesorectal excision; rate of margin positivity; use of neoadjuvant therapy for clinical stage II/III; and sphincter preservation rate for mid/upper RC. Results: 353 RC cases were studied (333 radical surgery, 20 local surgery). Participating hospitals varied in size (5 &lt;400 beds), teaching status (6 major teaching, 2 minor teaching, 2 non-teaching), and urban/rural location (9 urban). Challenges encountered in the data abstraction training process included overcoming technical jargon in pathology and operative reports. Regular conference calls, access to a specialist for questions, and modifications to definitions helped overcome difficulties; 9 of 10 abstractors scored &gt;90% correct on test cases. Analysis reveals wide variation between hospitals on quality measures. 75% of cases had adequate LN procurement (range by hospital 64-100%); mesorectal excision was performed in 76% of cases (38-97%); 9% had positive margins (0-17%); 94% of clinical stage II/III cases had neoadjuvant therapy (67-100%); and 86% of eligible cases had sphincter preservation (62-100%). Conclusions: A program designed to provide salient feedback to surgeons regarding RC treatment is feasible, and reveals that high-quality processes of care are not consistently used. These data suggest opportunities for process improvement. The program will be disseminated statewide for prospective data feedback and quality assessment.

Synthesizing Lessons Learned From Get With The Guidelines

The American Heart Association/American Stroke Association (AHA/ASA) is a trusted source of scientific information in cardiovascular medicine. The AHA/ASA has a longstanding commitment to support state-of-the-art scientific research in cardiovascular disease and stroke. The AHA/ASA has also developed a leadership role in translating cardiovascular science into internationally respected guidelines. In 2000, however, the AHA/ASA concluded that, to provide maximal benefit for patients with cardiovascular disease and those at risk, it needed to develop a rigorous approach to translating its guidelines into clinical practice. The result was a comprehensive suite of programs collectively called Get With The Guidelines (GWTG). Modeled in part on the University of California, Los Angeles Cardiovascular Hospitalization Atherosclerosis Management Program (CHAMP),1,2 GWTG was successfully piloted by the AHA in Massachusetts.3 Based on the success of the Massachusetts pilot, the AHA committed significant human and financial resources to extend the program across the United States. This commitment included the development of a national steering committee composed of AHA/ASA volunteers, and the addition of multiple modules including hospital-based management of coronary artery disease, heart failure, stroke, and resuscitation after in-hospital cardiac arrest. The scientific foundation of the program is the best evidence from the latest American College of Cardiology/AHA/ASA guidelines. GWTG staff work with participating hospitals to implement these guidelines by using AHA/ASA quality improvement professional consultation, workshops, and Webinars. In addition, the AHA developed sophisticated clinical databases (registries) through which hospitals and physicians collect information in real time for the assessment of quality, regional, and national benchmarking, national recognition, and the generation of new science. The AHA underwrites a portion of the costs associated with the technology platform and data collection tools to reduce the financial burden on participating sites. From the 4 GWTG disease-specific registries, >200 articles have been published in peer-reviewed journals. …

Assessment of Public Health Perspectives on Responding to an Emerging Pathogen

Public health has an important and critical role in responding to emerging multidrug-resistant organisms, such as carbapenem-resistant Enterobacteriaceae. The Centers for Disease Control and Prevention developed a survey as a tool for state health departments to determine carbapenem-resistant Enterobacteriaceae prevalence within their region. This report summarizes an assessment of the health department experience with the survey, their perceived roles and responsibilities in responding to an emerging health care-associated pathogen, and potential barriers to public health engagement of acute care facilities in response activities. Key informant interviews consisting of open-ended and 5-point Likert scale questions were conducted. Interviewees represented state health departments that administered the survey and select states that did not. Of 11 states interviewed, 7 (64%) had administered the survey to acute care facilities. Despite similar competing priorities and concerns about administering the survey, different perspectives emerged among the 11 states; those that administered the survey regarded it as a learning opportunity, whereas other states emphasized concerns about survey logistics and other public health demands. All 11 states perceived the prevention of an emerging pathogen to be a public health priority, but the degree of their action depended on availability of resources and existing relationships with infection preventionists. Health departments had less interaction with other hospital personnel (eg, facility leadership) and limited knowledge of the roles and associated responsibilities of other health care partners (eg, Quality Improvement Organizations). Although considered a public health priority, response efforts to emerging pathogens were reported to vary among state health departments. A better understanding is needed of the factors that motivate and facilitate state health departments to engage in a public health activity despite the challenges of competing priorities and limited resources. Efforts should also focus on improving the relationship between health departments and hospital leadership and other health care partners.

Pharmacy innovation across the nation

Pharmacy innovation across the nation

Medicare Hospitalizations, Readmissions Drop in Transitions Project

Hospitalizations and 30-day readmissions fell for Medicare patients in 14 communities when providers there worked with local quality improvement organizations (QIOs)to smooth and coordinate transitions between care settings, researchers from the Colorado Foundation for Medical Care and the Centers for Medicare & Medicaid Services reported in JAMA.The communities that participated in the 2-year CMS project saw mean reductions of 5.74% in hospitalizations and 5.70% in 30-day readmissions per 1,000 Medicare fee-for-service patients during 2009-2010. Fifty control communities saw smaller reductions: 3.17% in hospitalizations and 2.05% in readmissions (JAMA 2013;309:381-91).“Our results provide evidence of a … significant association between care transitions improvement interventions initiated by 14 [QIOs] and reductions in rehospitalizations and hospitalizations” as well as “evidence of a background national decline in hospitalizations and rehospitalizations for Medicare beneficiaries since 2008,” the researchers said.CMS left it up to each community to decide how best to improve transitions. QIOs guided the efforts and worked with local health care facilities and providers to improve a range of areas, including discharge standardization, medication reconciliation, chronic disease care planning, palliative care counseling, elder care services, and patient self-management. “Local community context was clearly relevant,” the investigators said.Each community used three or more evidence-based approaches such as Interventions to Reduce Acute Care Transfers, Re-Engineered Discharges, Transitional Care Nursing, the Care Transitions Program, and the Best Practices Intervention Packages on transitional care. The agency spent on average about $12 million annually to support the QIOs' efforts to coordinate improved care transitions.“Attempts to optimize care transitions will need to recognize that there is no single solution to address all the issues contributing to patient rehospitalization,” wrote Dr. Mark V. Williams, chief of the division of medicine–hospital medicine at the Northwestern University, Chicago, in an editorial (JAMA 2013;309:394-6). Hospitalizations and 30-day readmissions fell for Medicare patients in 14 communities when providers there worked with local quality improvement organizations (QIOs)to smooth and coordinate transitions between care settings, researchers from the Colorado Foundation for Medical Care and the Centers for Medicare & Medicaid Services reported in JAMA. The communities that participated in the 2-year CMS project saw mean reductions of 5.74% in hospitalizations and 5.70% in 30-day readmissions per 1,000 Medicare fee-for-service patients during 2009-2010. Fifty control communities saw smaller reductions: 3.17% in hospitalizations and 2.05% in readmissions (JAMA 2013;309:381-91). “Our results provide evidence of a … significant association between care transitions improvement interventions initiated by 14 [QIOs] and reductions in rehospitalizations and hospitalizations” as well as “evidence of a background national decline in hospitalizations and rehospitalizations for Medicare beneficiaries since 2008,” the researchers said. CMS left it up to each community to decide how best to improve transitions. QIOs guided the efforts and worked with local health care facilities and providers to improve a range of areas, including discharge standardization, medication reconciliation, chronic disease care planning, palliative care counseling, elder care services, and patient self-management. “Local community context was clearly relevant,” the investigators said. Each community used three or more evidence-based approaches such as Interventions to Reduce Acute Care Transfers, Re-Engineered Discharges, Transitional Care Nursing, the Care Transitions Program, and the Best Practices Intervention Packages on transitional care. The agency spent on average about $12 million annually to support the QIOs' efforts to coordinate improved care transitions. “Attempts to optimize care transitions will need to recognize that there is no single solution to address all the issues contributing to patient rehospitalization,” wrote Dr. Mark V. Williams, chief of the division of medicine–hospital medicine at the Northwestern University, Chicago, in an editorial (JAMA 2013;309:394-6).

The Centers for Medicare &amp; Medicaid Services Diabetes Health Disparities Reduction Program

The Centers for Medicare & Medicaid Services has implemented 3 prevention interventions programs to bring diabetes self-management education to vulnerable populations via Medicare's Quality Improvement Organizations. The programs and the lessons derived from a Federal initiative geared to closing the health disparities gap are described.