Quality Tools in Practice
Physician Connectedness Improves Quality
A population-based cohort study was used to determine if patient-physician connectedness affects measures of clinical performance. Based on a validated algorithm, 59.3 percent of the 155,580 assessed patients were connected to a specific physician, 34.5 percent were connected only to a specific practice, and 6.2 percent could not be connected to a physician or practice. The authors found that physician-connected patients were significantly more likely than practice-connected patients to receive guideline-consistent care. S. J. Atlas, R. W. Grant, T. G. Ferris et al., Patient–Physician Connectedness and Quality of Primary Care, Annals of Internal Medicine, March 3, 2009 150(5):325–35.
EMRs, Not Other Technology, Associated with Quality
This perspective sought to build on the evidence demonstrating a correlation between health information technology (IT) and clinical quality. To do this, the authors evaluated four years of Medicare patient data (1999-2002) to determine whether changes in patient safety correlated with hospitals' health IT investments. They found that the use of electronic medical records (EMRs) is associated with reduced infections, an effect that grew with time. However, EMRs were the only health IT application that had a clear and statistically significant effect on patient safety. S. T. Parente and J. S. McCullough, Health Information Technology and Patient Safety: Evidence from Panel Data, Health Affairs, March/April 2009 28(2):357–60.
Automated Medication Reconciliation Reduces Discrepancies, Nursing Time
The Portland, Ore., Department of Veterans Affairs developed a standardized medication reconciliation process to reduce discrepancies in medication documentation at its chemotherapy administration unit. Called the automated patient history intake device, this computer terminal kiosk is accessed by patients in the clinic lobby and simultaneously checks them in for appointments and gathers a medication-adherence history. The new process identified medication discrepancies, including some that were clinically significant or potentially lethal, and reduced nursing time dedicated to reconciliation activities without an apparent loss in data accuracy. B. Lesselroth, S. Adams, R. Felder et al., Using Consumer-Based Kiosk Technology to Improve and Standardize Medication Reconciliation in a Specialty Care Setting, Joint Commission Journal on Quality and Patient Safety, May 2009 35(5):264–71.
Outpatient Medication Reconciliation Reduces Errors
This study followed the implementation of a medication reconciliation process by PeaceHealth Medical Group, a multispecialty physician group in Eugene, Ore., in 2005. PeaceHealth developed a standardized approach to: (1) review and reconcile the medication list for every patient at each office visit and (2) report on the results obtained within its clinics. The process resulted in a substantial increase in the number of accurate medication lists, with fewer discrepancies between the medications a patient is taking and those recorded in the electronic medical record. R. Stock, J. Scott, and S. Gurtel, Using an Electronic Prescribing System to Ensure Accurate Medication Lists in a Large Multidisciplinary Medical Group, Joint Commission Journal on Quality and Patient Safety, May 2009 35(5):271–9.
Financial Incentives for Quality
Study: P4P Value Limited
The authors interviewed key stakeholders involved in the California Integrated Healthcare Association's statewide pay-for-performance (P4P) program to assess whether P4P changes physician behavior, ultimately leading to improved quality of care. They found that, three years into the program, California physician organizations had made changes in response to P4P, but that "these changes did not translate into the breakthrough improvements in quality desired by plans and purchasers." C. L. Damberg, K. Raube, S. S. Teleki et al., Taking Stock of Pay-For-Performance: A Candid Assessment from the Front Lines, Health Affairs, March/April 2009 28(2):517–25.
P4P Measures Need Validation
This study analyzed hospital performance data from the Centers for Medicare and Medicaid Services/Premier Hospital Quality Initiative Demonstration and compared them with publicly available outcomes data. The authors found that hospital quality measures do not correlate with patient outcomes. They conclude that such measures should not be tied to payments until they have been validated. T. Bhattacharyya, A. A. Freiberg, P. Mehta et al., Measuring the Report Card: The Validity of Pay-for-Performance Metrics in Orthopedic Surgery, Health Affairs, March/April 28(2):526–32.
Survey: Financial Incentives Increase IT Use
A national survey of all U.S. medical groups and independent practice associations with 20 or more physicians in 2006-07 was used to assess the role of external incentives on physician use of clinical information technology (IT). The study, with a response rate of 60.3 percent, found IT use varied across these groups. However, physician organizations evaluated by external entities for pay-for-performance and public reporting purposes, and those participating in quality improvement initiatives, had higher levels of adoption. J. C. Robinson, L. P. Casalino, R. R. Gillies et al., Financial Incentives, Quality Improvement Programs, and the Adoption of Clinical Information Technology, Medical Care, April 2009 47(4):411–17.
Quality Reporting
Public Reporting Might Widen Gap Between High- and Low-Quality Facilities
This study examined how public reporting affects the quality of care in clinical areas for which performance data are not being reported. It focused on non-targeted care in skilled nursing facilities, using the nursing home Minimum Data Set from 1999 to 2005 for all postacute care admissions. (Public reporting was initiated by the Centers for Medicare and Medicaid Services on their Nursing Home Compare Web site in 2002.) The authors found that public reporting had mixed effects on non-targeted care, improving it in high-ranking facilities but worsening it in low-ranking facilities. R. M. Werner, R. T. Konetzka, and G. B. Kruse, Impact of Public Reporting on Unreported Quality of Care, Health Services Research, April 2009 44(2):379–98.
Leapfrog Group Ranking and Mortality Rates
The Leapfrog Group allows hospitals to self-report the steps they have taken toward implementing the Safe Practices for Better Healthcare as part of its Hospital Survey, and then ranks hospital performance by quartiles and posts this information on its Web site. This observation analysis sought to determine the relationship between a hospital's Safe Practices Score and risk-adjusted inpatient mortality rates. The study found no significant association. L. P. Kernisan, S. J. Lee, W. J. Boscardin et al., Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality, Journal of the American Medical Association, April 1, 2009 301(13):1341–48.
Hospital Quality Alliance Data Used to Assess Individual Care Quality
A retrospective analysis of Hospital Quality Alliance patient-level data was used to assess the quality of care provided to patients hospitalized for acute myocardial infarction (AMI), heart failure, or pneumonia. Variations in quality by patient and hospital characteristics, and the sensitivity of all-or-none performance to the number and type of processes, were assessed. The authors found that 82.8 percent of AMI patients, 57.3 percent of heart failure patients, and 41.7 percent of pneumonia patients received all recommended care during their hospitalizations. C. Vogeli, R. Kang, M. B. Landrum, Quality of Care Provided to Individual Patients in U.S. Hospitals: Results from an Analysis of National Hospital Quality Alliance Data, Medical Care, May 2009 47(5):591–99.
Health Care System Performance
Hospital Safety Events Increase Readmission Rate
This study examined the effects of adverse safety events on readmissions among a population of almost 1.5 million adult surgery patients, initially treated in 1,088 short-stay hospitals, who are at risk for at least one of nine types of patient safety events. It found the one-month readmission rate was 11 percent for those with no safety events and 16 percent when a safety event was recorded. The three-month readmission rates were about 17 percent and 25 percent, respectively. B. Friedman, W. Encinosa, H. J. Jiang et al., Do Patient Safety Events Increase Readmissions? Medical Care, May 2009 47(5):583–90.
Teaching Residents About QI
This perspective reviews the challenges to teaching quality improvement—defined as methods of improving the processes of clinical care—to medical residents and then makes recommendations on how to overcome them. Among the authors' suggestions are setting learner objectives; providing training over an extended period of time; obtaining support from faculty who teach clinical medicine; and showing the connection between evidence-based medicine and systems improvement. G. Mosser, K. K. Frisch, P. K. Skarda et al., Addressing the Challenges in Teaching Quality Improvement, American Journal of Medicine, May 2009 122 (5):487–91.
Physician Connectedness Improves Quality
A population-based cohort study was used to determine if patient-physician connectedness affects measures of clinical performance. Based on a validated algorithm, 59.3 percent of the 155,580 assessed patients were connected to a specific physician, 34.5 percent were connected only to a specific practice, and 6.2 percent could not be connected to a physician or practice. The authors found that physician-connected patients were significantly more likely than practice-connected patients to receive guideline-consistent care. S. J. Atlas, R. W. Grant, T. G. Ferris et al., Patient–Physician Connectedness and Quality of Primary Care, Annals of Internal Medicine, March 3, 2009 150(5):325–35.
EMRs, Not Other Technology, Associated with Quality
This perspective sought to build on the evidence demonstrating a correlation between health information technology (IT) and clinical quality. To do this, the authors evaluated four years of Medicare patient data (1999-2002) to determine whether changes in patient safety correlated with hospitals' health IT investments. They found that the use of electronic medical records (EMRs) is associated with reduced infections, an effect that grew with time. However, EMRs were the only health IT application that had a clear and statistically significant effect on patient safety. S. T. Parente and J. S. McCullough, Health Information Technology and Patient Safety: Evidence from Panel Data, Health Affairs, March/April 2009 28(2):357–60.
Automated Medication Reconciliation Reduces Discrepancies, Nursing Time
The Portland, Ore., Department of Veterans Affairs developed a standardized medication reconciliation process to reduce discrepancies in medication documentation at its chemotherapy administration unit. Called the automated patient history intake device, this computer terminal kiosk is accessed by patients in the clinic lobby and simultaneously checks them in for appointments and gathers a medication-adherence history. The new process identified medication discrepancies, including some that were clinically significant or potentially lethal, and reduced nursing time dedicated to reconciliation activities without an apparent loss in data accuracy. B. Lesselroth, S. Adams, R. Felder et al., Using Consumer-Based Kiosk Technology to Improve and Standardize Medication Reconciliation in a Specialty Care Setting, Joint Commission Journal on Quality and Patient Safety, May 2009 35(5):264–71.
Outpatient Medication Reconciliation Reduces Errors
This study followed the implementation of a medication reconciliation process by PeaceHealth Medical Group, a multispecialty physician group in Eugene, Ore., in 2005. PeaceHealth developed a standardized approach to: (1) review and reconcile the medication list for every patient at each office visit and (2) report on the results obtained within its clinics. The process resulted in a substantial increase in the number of accurate medication lists, with fewer discrepancies between the medications a patient is taking and those recorded in the electronic medical record. R. Stock, J. Scott, and S. Gurtel, Using an Electronic Prescribing System to Ensure Accurate Medication Lists in a Large Multidisciplinary Medical Group, Joint Commission Journal on Quality and Patient Safety, May 2009 35(5):271–9.
Financial Incentives for Quality
Study: P4P Value Limited
The authors interviewed key stakeholders involved in the California Integrated Healthcare Association's statewide pay-for-performance (P4P) program to assess whether P4P changes physician behavior, ultimately leading to improved quality of care. They found that, three years into the program, California physician organizations had made changes in response to P4P, but that "these changes did not translate into the breakthrough improvements in quality desired by plans and purchasers." C. L. Damberg, K. Raube, S. S. Teleki et al., Taking Stock of Pay-For-Performance: A Candid Assessment from the Front Lines, Health Affairs, March/April 2009 28(2):517–25.
P4P Measures Need Validation
This study analyzed hospital performance data from the Centers for Medicare and Medicaid Services/Premier Hospital Quality Initiative Demonstration and compared them with publicly available outcomes data. The authors found that hospital quality measures do not correlate with patient outcomes. They conclude that such measures should not be tied to payments until they have been validated. T. Bhattacharyya, A. A. Freiberg, P. Mehta et al., Measuring the Report Card: The Validity of Pay-for-Performance Metrics in Orthopedic Surgery, Health Affairs, March/April 28(2):526–32.
Survey: Financial Incentives Increase IT Use
A national survey of all U.S. medical groups and independent practice associations with 20 or more physicians in 2006-07 was used to assess the role of external incentives on physician use of clinical information technology (IT). The study, with a response rate of 60.3 percent, found IT use varied across these groups. However, physician organizations evaluated by external entities for pay-for-performance and public reporting purposes, and those participating in quality improvement initiatives, had higher levels of adoption. J. C. Robinson, L. P. Casalino, R. R. Gillies et al., Financial Incentives, Quality Improvement Programs, and the Adoption of Clinical Information Technology, Medical Care, April 2009 47(4):411–17.
Quality Reporting
Public Reporting Might Widen Gap Between High- and Low-Quality Facilities
This study examined how public reporting affects the quality of care in clinical areas for which performance data are not being reported. It focused on non-targeted care in skilled nursing facilities, using the nursing home Minimum Data Set from 1999 to 2005 for all postacute care admissions. (Public reporting was initiated by the Centers for Medicare and Medicaid Services on their Nursing Home Compare Web site in 2002.) The authors found that public reporting had mixed effects on non-targeted care, improving it in high-ranking facilities but worsening it in low-ranking facilities. R. M. Werner, R. T. Konetzka, and G. B. Kruse, Impact of Public Reporting on Unreported Quality of Care, Health Services Research, April 2009 44(2):379–98.
Leapfrog Group Ranking and Mortality Rates
The Leapfrog Group allows hospitals to self-report the steps they have taken toward implementing the Safe Practices for Better Healthcare as part of its Hospital Survey, and then ranks hospital performance by quartiles and posts this information on its Web site. This observation analysis sought to determine the relationship between a hospital's Safe Practices Score and risk-adjusted inpatient mortality rates. The study found no significant association. L. P. Kernisan, S. J. Lee, W. J. Boscardin et al., Association Between Hospital-Reported Leapfrog Safe Practices Scores and Inpatient Mortality, Journal of the American Medical Association, April 1, 2009 301(13):1341–48.
Hospital Quality Alliance Data Used to Assess Individual Care Quality
A retrospective analysis of Hospital Quality Alliance patient-level data was used to assess the quality of care provided to patients hospitalized for acute myocardial infarction (AMI), heart failure, or pneumonia. Variations in quality by patient and hospital characteristics, and the sensitivity of all-or-none performance to the number and type of processes, were assessed. The authors found that 82.8 percent of AMI patients, 57.3 percent of heart failure patients, and 41.7 percent of pneumonia patients received all recommended care during their hospitalizations. C. Vogeli, R. Kang, M. B. Landrum, Quality of Care Provided to Individual Patients in U.S. Hospitals: Results from an Analysis of National Hospital Quality Alliance Data, Medical Care, May 2009 47(5):591–99.
Health Care System Performance
Hospital Safety Events Increase Readmission Rate
This study examined the effects of adverse safety events on readmissions among a population of almost 1.5 million adult surgery patients, initially treated in 1,088 short-stay hospitals, who are at risk for at least one of nine types of patient safety events. It found the one-month readmission rate was 11 percent for those with no safety events and 16 percent when a safety event was recorded. The three-month readmission rates were about 17 percent and 25 percent, respectively. B. Friedman, W. Encinosa, H. J. Jiang et al., Do Patient Safety Events Increase Readmissions? Medical Care, May 2009 47(5):583–90.
Teaching Residents About QI
This perspective reviews the challenges to teaching quality improvement—defined as methods of improving the processes of clinical care—to medical residents and then makes recommendations on how to overcome them. Among the authors' suggestions are setting learner objectives; providing training over an extended period of time; obtaining support from faculty who teach clinical medicine; and showing the connection between evidence-based medicine and systems improvement. G. Mosser, K. K. Frisch, P. K. Skarda et al., Addressing the Challenges in Teaching Quality Improvement, American Journal of Medicine, May 2009 122 (5):487–91.