Measuring Performance
CMS Process Measures and Mortality
A cross-sectional study was used to determine whether quality, as measured by the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare Web site, is correlated with and predictive of hospitals' risk-adjusted mortality rates. Ten process performance measures, for acute myocardial infarction, heart failure, and pneumonia, were compared with hospital risk-adjusted mortality rates measured using Medicare Part A claims data. The authors found that the process measures only predict small differences in hospital risk-adjusted mortality rates, suggesting the need to develop performance measures that are tightly linked to patient outcomes. R. M. Werner and E. T. Bradlow (2006) Relationship Between Medicare's Hospital Compare Performance Measures and Mortality Rates. Journal of the American Medical Association 296, 2694–2702.
Better Heart Failure Measures Needed
The authors examined the relationship between current American College of Cardiology/American Heart Association (ACC/AHA) performance measures for patients hospitalized with heart failure and relevant clinical outcomes. Sixty- to 90-day post-discharge data were collected from 5,791 patients at 91 U.S. hospitals. None of the five ACC/AHA heart failure performance measures was found to be significantly associated with reduced early mortality risk, and only angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use at discharge was associated with 60- to 90-day post-discharge mortality or rehospitalization. The authors conclude that better methods for validating heart failure performance measures may be needed to improve the care of these patients. G. C. Fonarow et al. (2007) Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure. Journal of the American Medical Association 297, 61–70.
Measuring Performance Using EMRs
A cross-sectional study was used to determine the extent to which selected chart review–based clinical performance measures could be accurately replicated using readily available and directly analyzable electronic medical record (EMR) data. The authors merged full chart review results from the Veterans Health Administration's External Peer Review Program to EMR data. More than 80 percent of the data on these selected measures found in chart review were available in a directly analyzable form in the EMR, and there was no evidence of systematic differences in performance values. J. L. Goulet et al. (2007) Measuring Performance Directly Using the Veterans Health Administration Electronic Medical Record: A Comparison with External Peer Review. Medical Care 45, 73–79.
Quality Tools in Practice
Improving Dementia Care
A clinic-level, randomized, controlled trial was used to test the effectiveness of a dementia guideline–based disease management program on quality of care and outcomes for patients with dementia. The authors found the mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group, 63.9 percent vs. 32.9 percent, respectively. This suggests that such programs can improve quality of care for patients with dementia. B. G. Vickrey et al. (2006) The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care: A Randomized, Controlled Trial. Annals of Internal Medicine 145, 713–726.
At or Near Zero Birth Trauma
Perinatal safety was identified by Ascension Health as one of eight priorities for action in a system-wide effort to achieve zero preventable injuries and deaths by July 2008. Three sites of differing size, patient demographics, and available resources developed and implemented practices aimed at eliminating preventable birth trauma. Using a combined uniform and facility-specific approach, the three sites achieved birth trauma rates that were at or near zero. F. Mazza et al. (2007) Clinical Excellence Series: Eliminating Birth Trauma at Ascension Health. Joint Commission Journal on Quality and Patient Safety 33, 15–24.
JCAHO Discharge Instructions Reduce Readmission
A retrospective study was conducted on randomly sampled, heart failure patients at a tertiary care hospital to determine whether documentation of compliance with any or all of the six required Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) discharge instructions is correlated with hospital readmission or mortality. The authors found that patients who received all instructions were significantly less likely to be readmitted for any cause and for heart failure than those who missed at least one type of instruction; there was no association between the discharge instructions and mortality. M. VanSuch et al. (2006) Effect of Discharge Instructions on Readmission of Hospitalised Patients with Heart Failure: Do All of the Joint Commission on Accreditation of Healthcare Organizations Heart Failure Core Measures Reflect Better Care? Quality and Safety in Health Care 15, 414–417.
Health Care System Performance
Study Finds IMGs Provide Better Care
A cross-sectional study found that patients cared for in integrated medical groups (IMGs) generally received higher-quality primary care than those cared for in individual practice associations IPAs. The authors based their finding on measurements of the percentage of PacifiCare enrollees receiving mammograms, Pap smear screening, Chlamydia screening, diabetic eye examinations, asthma controller medications, or beta blockers after acute myocardial infarction. Also, they note that the differences were not explained by the presence of EMRs or the implementation of quality improvement strategies. A. Mehrotra et al. (2006) Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations? Annals of Internal Medicine 145, 826–833. (See related editorial, Which Type of Medical Group Provides Higher-Quality Care?)
Accountable Care Organizations
This article reviews the local delivery systems—physicians and the hospitals where they work or deliver care—that provide care to Medicare beneficiaries. The authors conclude that efforts to improve quality and reduce costs should focus less on individual providers and more on these accountable care organizations, the extended hospital medical staff. E. S. Fisher et al. (2006) Creating Accountable Care Organizations: The Extended Hospital Medical Staff. Health Affairs Web Exclusive. Posted Dec. 5.
Patient Safety
CPOE and NQF's Practice Standard
The authors evaluate the evidence for achieving computerized physician order entry (CPOE), designated as one of the National Quality Forum's (NQF) 30 Safe Practices for Better Healthcare in 2003. Their review finds that CPOE has the potential to reduce rates of medication errors and serious medication errors, and leads them to suggest updates and revisions to the current NQF CPOE practice standard and implementation examples. P. M. Kilbridge et al. (2006) The National Quality Forum Safe Practice Standard for Computerized Physician Order Entry: Updating a Critical Patient Safety Practice. Journal of Patient Safety 2, 183–190.
Nursing Home Safety
The "patient safety culture" of a nationally representative sample of nursing homes was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) and compared with existing hospital data. Eleven of the 12 HSOPSC subscale scores from the nursing home sample were considerably lower than the benchmark hospital scores, with almost all item scores from nursing homes considerably lower than the benchmark hospital scores. The authors conclude that nursing homes do not have a well-developed safety culture, putting residents at risk of harm. N. G. Castle and K. E. Sonon (2006) A Culture of Patient Safety in Nursing Homes. Quality and Safety in Health Care 15, 405–408.
Reducing Patient Misidentification
Three Plan-Do-Study-Act (PDSA) cycles were used to review the incidence of registration-associated patient misidentification errors at Johns Hopkins Hospital, occurring seven to 15 times per month. An interdisciplinary team identified information systems deficiencies, inadequate training, and the lack of a single master patient index among the root causes. Through this iterative PDSA process, registration-associated misidentification errors for established patients were reduced (80.5%). Based on this success, the authors developed a checklist that other organizations can use to assess their vulnerability to registration-associated patient misidentification errors. M. J. Bittle et al. (2007) Performance Improvement: Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections. Joint Commission Journal on Quality and Patient Safety 33, 25–33.
CMS Process Measures and Mortality
A cross-sectional study was used to determine whether quality, as measured by the Centers for Medicare and Medicaid Services' (CMS) Hospital Compare Web site, is correlated with and predictive of hospitals' risk-adjusted mortality rates. Ten process performance measures, for acute myocardial infarction, heart failure, and pneumonia, were compared with hospital risk-adjusted mortality rates measured using Medicare Part A claims data. The authors found that the process measures only predict small differences in hospital risk-adjusted mortality rates, suggesting the need to develop performance measures that are tightly linked to patient outcomes. R. M. Werner and E. T. Bradlow (2006) Relationship Between Medicare's Hospital Compare Performance Measures and Mortality Rates. Journal of the American Medical Association 296, 2694–2702.
Better Heart Failure Measures Needed
The authors examined the relationship between current American College of Cardiology/American Heart Association (ACC/AHA) performance measures for patients hospitalized with heart failure and relevant clinical outcomes. Sixty- to 90-day post-discharge data were collected from 5,791 patients at 91 U.S. hospitals. None of the five ACC/AHA heart failure performance measures was found to be significantly associated with reduced early mortality risk, and only angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use at discharge was associated with 60- to 90-day post-discharge mortality or rehospitalization. The authors conclude that better methods for validating heart failure performance measures may be needed to improve the care of these patients. G. C. Fonarow et al. (2007) Association Between Performance Measures and Clinical Outcomes for Patients Hospitalized with Heart Failure. Journal of the American Medical Association 297, 61–70.
Measuring Performance Using EMRs
A cross-sectional study was used to determine the extent to which selected chart review–based clinical performance measures could be accurately replicated using readily available and directly analyzable electronic medical record (EMR) data. The authors merged full chart review results from the Veterans Health Administration's External Peer Review Program to EMR data. More than 80 percent of the data on these selected measures found in chart review were available in a directly analyzable form in the EMR, and there was no evidence of systematic differences in performance values. J. L. Goulet et al. (2007) Measuring Performance Directly Using the Veterans Health Administration Electronic Medical Record: A Comparison with External Peer Review. Medical Care 45, 73–79.
Quality Tools in Practice
Improving Dementia Care
A clinic-level, randomized, controlled trial was used to test the effectiveness of a dementia guideline–based disease management program on quality of care and outcomes for patients with dementia. The authors found the mean percentage of per-patient guideline recommendations to which care was adherent was significantly higher in the intervention group than in the usual care group, 63.9 percent vs. 32.9 percent, respectively. This suggests that such programs can improve quality of care for patients with dementia. B. G. Vickrey et al. (2006) The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care: A Randomized, Controlled Trial. Annals of Internal Medicine 145, 713–726.
At or Near Zero Birth Trauma
Perinatal safety was identified by Ascension Health as one of eight priorities for action in a system-wide effort to achieve zero preventable injuries and deaths by July 2008. Three sites of differing size, patient demographics, and available resources developed and implemented practices aimed at eliminating preventable birth trauma. Using a combined uniform and facility-specific approach, the three sites achieved birth trauma rates that were at or near zero. F. Mazza et al. (2007) Clinical Excellence Series: Eliminating Birth Trauma at Ascension Health. Joint Commission Journal on Quality and Patient Safety 33, 15–24.
JCAHO Discharge Instructions Reduce Readmission
A retrospective study was conducted on randomly sampled, heart failure patients at a tertiary care hospital to determine whether documentation of compliance with any or all of the six required Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) discharge instructions is correlated with hospital readmission or mortality. The authors found that patients who received all instructions were significantly less likely to be readmitted for any cause and for heart failure than those who missed at least one type of instruction; there was no association between the discharge instructions and mortality. M. VanSuch et al. (2006) Effect of Discharge Instructions on Readmission of Hospitalised Patients with Heart Failure: Do All of the Joint Commission on Accreditation of Healthcare Organizations Heart Failure Core Measures Reflect Better Care? Quality and Safety in Health Care 15, 414–417.
Health Care System Performance
Study Finds IMGs Provide Better Care
A cross-sectional study found that patients cared for in integrated medical groups (IMGs) generally received higher-quality primary care than those cared for in individual practice associations IPAs. The authors based their finding on measurements of the percentage of PacifiCare enrollees receiving mammograms, Pap smear screening, Chlamydia screening, diabetic eye examinations, asthma controller medications, or beta blockers after acute myocardial infarction. Also, they note that the differences were not explained by the presence of EMRs or the implementation of quality improvement strategies. A. Mehrotra et al. (2006) Do Integrated Medical Groups Provide Higher-Quality Medical Care than Individual Practice Associations? Annals of Internal Medicine 145, 826–833. (See related editorial, Which Type of Medical Group Provides Higher-Quality Care?)
Accountable Care Organizations
This article reviews the local delivery systems—physicians and the hospitals where they work or deliver care—that provide care to Medicare beneficiaries. The authors conclude that efforts to improve quality and reduce costs should focus less on individual providers and more on these accountable care organizations, the extended hospital medical staff. E. S. Fisher et al. (2006) Creating Accountable Care Organizations: The Extended Hospital Medical Staff. Health Affairs Web Exclusive. Posted Dec. 5.
Patient Safety
CPOE and NQF's Practice Standard
The authors evaluate the evidence for achieving computerized physician order entry (CPOE), designated as one of the National Quality Forum's (NQF) 30 Safe Practices for Better Healthcare in 2003. Their review finds that CPOE has the potential to reduce rates of medication errors and serious medication errors, and leads them to suggest updates and revisions to the current NQF CPOE practice standard and implementation examples. P. M. Kilbridge et al. (2006) The National Quality Forum Safe Practice Standard for Computerized Physician Order Entry: Updating a Critical Patient Safety Practice. Journal of Patient Safety 2, 183–190.
Nursing Home Safety
The "patient safety culture" of a nationally representative sample of nursing homes was evaluated using the Hospital Survey on Patient Safety Culture (HSOPSC) and compared with existing hospital data. Eleven of the 12 HSOPSC subscale scores from the nursing home sample were considerably lower than the benchmark hospital scores, with almost all item scores from nursing homes considerably lower than the benchmark hospital scores. The authors conclude that nursing homes do not have a well-developed safety culture, putting residents at risk of harm. N. G. Castle and K. E. Sonon (2006) A Culture of Patient Safety in Nursing Homes. Quality and Safety in Health Care 15, 405–408.
Reducing Patient Misidentification
Three Plan-Do-Study-Act (PDSA) cycles were used to review the incidence of registration-associated patient misidentification errors at Johns Hopkins Hospital, occurring seven to 15 times per month. An interdisciplinary team identified information systems deficiencies, inadequate training, and the lack of a single master patient index among the root causes. Through this iterative PDSA process, registration-associated misidentification errors for established patients were reduced (80.5%). Based on this success, the authors developed a checklist that other organizations can use to assess their vulnerability to registration-associated patient misidentification errors. M. J. Bittle et al. (2007) Performance Improvement: Registration-Associated Patient Misidentification in an Academic Medical Center: Causes and Corrections. Joint Commission Journal on Quality and Patient Safety 33, 25–33.