Quality Matters Archive

Quality Matters reported on emerging models and trends in health care delivery reform and interviews with leaders in the field. Please read its successor, Transforming Care.

  • August/September 2011 Issue
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Publications of Note

Hospital Board-Level Quality Scorecards Inconsistent, Incomplete
A study designed to identify and evaluate the measures hospital boards use to assess performance on quality and safety efforts found wide variation in how the hospitals conveyed that performance to their boards. The scorecards the hospitals used contained a mix of process measures that were nationally defined and outcomes measures that were not. In addition, the metrics on board scorecards frequently included efficiency measures, patient satisfaction measures, and human resource/staffing measures under the mantle of quality and safety. The researchers say the results of the study raise substantial concerns about how well hospital leaders and boards identify measures to assess operations and track quality improvement and hazards. C. A. Goeschel, S. M. Berenholtz, R. A. Culbertson et al., "Board Quality Scorecards: Measuring Improvement," American Journal of Medical Quality, July/August 2011 26(4):254–60. 

Low Health Literacy Associated with Poor Health Outcomes
Researchers conducted a systematic review of evidence to understand the relationship between levels of health literacy and use of health care services, health outcomes, and costs, as well as disparities in health outcomes. They found low health literacy—as measured by a patient's reading level—was associated with more hospitalizations; greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to interpret labels and health messages; and, among elderly persons, poorer overall health status and higher mortality rates. The relationship between health literacy level and other outcomes was less clear, primarily because of a lack of studies and relatively unsophisticated methods in available studies. N. D. Berkman, S. L. Sheridan, K. E. Donahue et al., "Low Health Literacy and Health Outcomes: An Updated Systematic Review," Annals of Internal Medicine, July 2011 155(2):97–107.

Dutch Model Has the Potential to Significantly Increase Access to After-Hours Care in the U.S.
Commenting on a journal article that described the Netherlands' system for providing after-hours care to patients, the authors of this commentary suggested the U.S. would benefit from implementing a similar system. In the Netherlands model, cooperatives of 40 to 250 primary care physicians make triage nurses with physician backup available by phone for patients during evenings and weekends. Nurses responding to urgent patient requests follow triage protocols and offer advice ranging from self-care to emergency department referral. Using a similar system, the U.S. could increase the percentage of physicians providing after-hours care, a percentage that declined from 40 percent in 2006 to 29 percent in 2009. Implementing such a program would require support from government and private payers. It would also require primary care practices to assume some risk for the cost of emergency department visits to ensure their continued focus on cost-containment methods, the authors said. D. Margolius and T. Bodenheimer, "Redesigning After-Hours Primary Care," Annals of Internal Medicine, July 2011, 155(2):131.

Health Information Technology Program Increases Patient Monitoring
A survey of registry capability among physicians participating in the Massachusetts eHealth Collaborative—a four-year, $50 million health information technology program—found physicians who participated in the program increased their ability to generate registries for laboratory results and medication use. The analysis also suggested that physicians who used their electronic health records more intensively were more likely to use registries, particularly in caring for patients with diabetes, compared with physicians reporting less avid use of electronic health records. M. Fleurant, R. Kell, J. Love et al., "Massachusetts e-Health Project Increased Physicians' Ability to Use Registries, and Signals Progress Toward Better Care," Health Affairs, July 2011 30(7):1256–64. 

Waiting Times in Emergency Department Affect Outcomes for Low-Acuity Patients
A study assessing the impact of waiting times on adverse outcomes among patients in Ontario, Canada, found patients who presented to the emergency department during busy periods were at greater risk of later admission to the hospital and death. For patients of low acuity (i.e. lower triage status) whose mean length of stay in the emergency department was greater than one hour but less than or equal to six hours, the adjusted odds ratio for death was 1.71 while the odds ratio for admission to the hospital was 1.66. The study also found that reducing the mean length of stay in the emergency department by an average of one hour could have potentially decreased the number of deaths in lower-acuity patients by 261, or 12.7 percent. In contrast, patients who were well enough to leave without being seen were not at higher risk of short-term adverse events. A. Guttman, M. J. Schull, M. J. Vermeulen et al., "Association Between Waiting Times and Short Term Mortality and Hospital Admission After Departure from Emergency Department: Population Based Cohort Study from Ontario, Canada," British Medical Journal, published online June 1, 2011. 

Team Work Improves with Focus on Patient-Centered Care
This study was designed to identify the determinants of collaborative capacity, which is the likelihood that providers will collaborate as if they were members of an egalitarian team even in the absence of a formal team structure. The researchers found that clear task direction, specifically an emphasis on patient-centered care, is significantly associated with higher levels of task interdependence, higher quality of staff interactions, and collaboration. The study collected data from staff in 45 units from nine hospitals and seven health care systems in upstate New York. The study also found that measures for team structure and collaboration do not vary significantly between hospitals, only by unit and occupational group. The researchers concluded that collaborative capacity is somewhat constrained by a rigid hierarchy of health care occupations and division of labor. However, collaborative capacity may be improved at the unit level through an emphasis on patient-centered care and a context that supports providers' work. D. B. Weinberg, D. Cooney-Miner, J. N. Perloff et al., "Building Collaborative Capacity: Promoting Interdisciplinary Teamwork in the Absence of Formal Teams," Medical Care, Aug. 2011 49(8):716–23. 

Present-on-Admission Diagnoses Improve Mortality Rate Calculations
This study found that the comprehensive use of diagnoses identified as "present on admission" improves methods for comparing hospital mortality rates. The study examined 91,511 discharge records for patients with heart failure from 365 California hospitals for patients discharged in 2007. G. J. Stukenborg, "Hospital Mortality Risk Adjustment for Heart Failure Patients Using Present on Admission Diagnoses: Improved Classification and Calibration," Medical Care, Aug. 2011 49(8):744–51.

Barriers to Innovation Identified
In this commentary, Victor R. Fuchs and Arnold Milstein outlined several barriers to the diffusion of more cost-efficient care models. Among them: the unwillingness of insurers to standardize coverage benefits and administrative transactions; the reluctance of employers to make inefficient models of care financially unattractive to employees; the opposition to reform from legislators who seek campaign contributions for stakeholders who benefit from inefficient arrangements; hospital administrators who resist efforts to reduce hospital occupancy; and physicians who resist practice changes for financial and nonfinancial reasons. V. R. Fuchs and A. Milstein, "The $640 Billion Question—Why Does Cost-Effective Care Diffuse So Slowly?" New England Journal of Medicine, June 2011 364(21):1985–7. 

Proposal to Reduce Medicare Spending Outlined
In this commentary, Alain C. Enthoven outlines a plan for aligning growth in Medicare spending with growth in the gross domestic product (GDP). His strategy calls for reducing beneficiaries' demand for a fee-for-service model of care by offering standardized health plans that are distinguished by their provider networks. To encourage cost-conscious choice of plan, beneficiaries would pay the difference between the price of the least costly plan and the plan of their choice. Enthoven believes this would compel insurers to compete on value for money. Enthoven's plan also calls for the government to pay the price of the least costly plan. He also recommends linking beneficiaries' premium support payments to the growth in GDP and using global prospective payments to give providers the incentive they need to reduce the cost of care. A. C. Enthoven, "Reforming Medicare by Reforming Incentives," New England Journal of Medicine, published online May 26, 2011. 

New Framework for Increased Collaboration Among Children's Hospitals
Hospital executives and pediatric department chairs from 14 children's hospitals worked together to develop a framework for integrating quality and safety improvement programs across their institutions. The framework encourages: 1) alignment of quality priorities and resources across the organizations; 2) education and training for physicians in the science of improvement; and 3) professional development and career progression for physicians in recognition of quality-improvement activities. The framework can be used to assess the institutions' level of integration, plot a path toward further integration, track progress, and identify potential collaborators and models of advanced integration. F. Howard Levy, R. J. Brilli, L. R. First et al., "A New Framework for Quality Partnerships in Children's Hospitals," Pediatrics, June 2011 127(6): 1147–56. 

Factors That Led to Success of a Collaborative CLABSI-Prevention Program
Researchers analyzed the methods and results of the Michigan Intensive Care Unit (ICU) project, which dramatically reduced rates of central line–associated bloodstream infections (CLABSIs), to determine how and why such programs are successful. They found the project achieved its effects by among other things: 1) generating pressures for ICUs to join the program and conform to its requirements; 2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; 3) reframing the infections as a social problem and addressing it through a professional movement that combines "grassroots" features with a vertically integrated program structure; 4) using several interventions that functioned in different ways to shape a culture of commitment to doing better in practice; and 5) harnessing data on infection rates as a disciplinary force. M. Dixon-Woods, C. L. Bosk, E. L. Aveling et al., "Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program," Milbank Quarterly, June 2011 89(2). 

Developing EHRs That Improve Quality and Efficiency
In this commentary, the authors argue that meeting federal meaningful use regulations for electronic health records (EHRs) will not produce the comprehensive functionality needed to improve quality and efficiency. To go beyond the regulations, they recommend that providers develop systems that speed the communication of critical test results, enhance transitions in care, improve test result tracking, and provider robust and complex real-time decision support to providers. Broad integration between systems is also necessary to ensure that information, including laboratory, pharmacy, billing, and ordering information, can be transferred between systems without manual entry. S. K. Abbett, D. W. Bates, and A. Kachalia, "The Meaningful Use Regulations in Information Technology: What Do They Mean for Quality Improvement in Hospitals?" Joint Commission Journal on Quality and Patient Safety, July 2011 37(7):333–66. 

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