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The Dynamics of Improvement

Dale W. Bratzler

Commentary on the Fund reports Hospital Performance Improvement: Trends in Quality and Efficiency and Hospital Quality Improvement: Case Studies and Strategies

By Dale W. Bratzler, D.O., M.P.H., Quality Improvement Organization Support Center Medical Director, Oklahoma Foundation for Medical Quality. Watch a Commonwealth Fund E-forum, with synched slides and audio from presentations by Dr. Bratzler and others.

Since 2000, major national and local efforts have been implemented to improve the quality of health care. Not only have resources been invested in developing infrastructure to measure and report quality of care, a national process for gaining consensus on performance measures has been created through the National Quality Forum. Congress has helped to drive the public reporting of hospital quality data through pay-for-reporting incentives.

Payers have also begun to introduce programs designed to report and reward quality. The Centers for Medicare and Medicaid Services (CMS) now requires that Medicare Quality Improvement Organizations (QIOs) offer technical assistance to hospitals and other providers to help them improve the quality of care they provide to Medicare beneficiaries. And numerous private-sector quality improvement efforts are under way. These activities have lead to greater accountability of health care providers—and made the assessment of quality a more public process.

In the Commonwealth Fund report, Hospital Performance Improvement: Trends in Quality and Efficiency, Eugene Kroch of CareScience, Inc. and colleagues demonstrate that the quality of hospital care in the United States is improving. The results of this quantitative evaluation are comforting and consistent with recently published findings from CMS and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In the companion report, Hospital Quality Improvement: Case Studies and Strategies, Sharon Silow-Carroll and colleagues from Health Management Associates provide case studies of four hospitals representative of the spectrum of hospitals that demonstrated the greatest improvement in quality during the study period. Consistent with previous work supported by The Commonwealth Fund, CMS, and others, the authors find that leadership commitment to improvement; organizational and structural changes such as team building; nurturing of clinical and process champions; internal and external accountability; and implementation of new processes of care are all characteristics of high-performing hospitals and hospitals that demonstrate the greatest improvement over time.

More Work Ahead
These reports demonstrate that the quality of hospital care has improved, but they also reveal there is still much work to be done. As noted by others, there remains considerable variation in quality and efficiency across hospitals.

While the work revealed in these two reports and the results of prior studies have taught us about the characteristics of high-performing hospitals, we know little about how to transfer this knowledge to hospitals at the low end of the quality spectrum. It would have been interesting if the authors had evaluated in detail a sample of hospitals that were "deteriorating" over the study time frame or unable to achieve steady improvement. What lessons can we learn from hospitals that showed worsening quality and efficiency? And how do we motivate the leadership of poorly performing hospitals to embark on the sequence of events that resulted in rapid improvement in case study hospitals?

The reports also highlight the pivotal role of hospital leadership in achieving improvements in quality of care. Hospital executives and board members must take as much responsibility for the quality of care in their institution as they take for the fiscal health of the organization. While the role of leadership and governance has been consistently demonstrated in studies of high-performing hospitals, and now in the most rapidly improving hospitals, this commitment to quality has not been widely embraced by all hospital executives and boards.

Finally, the reports point to the need to continue to refine the metrics we use to measure hospital quality. The metric used in the Kroch study, length of stay, is an important determinant of hospital costs, but is likely not a good metric of true efficiency of care across the continuum. As noted by the authors, little information was available about subsequent care of the patients beyond hospitalization, and readmission analyses were limited to data from the CareScience clients, which may not be representative of the general hospital population.

Most of the national efforts to measure and report quality of hospital care have focused on diagnosis-specific process-of-care measures that reflect a fraction of the care given to patients. Although the process-of-care measures currently used for national reporting correlate with important patient outcomes such as mortality, they only predict small differences in hospital risk-adjusted mortality rates. Additional measures on patient outcomes and experiences of care that take into account the possibilities of unintended consequences of performance measurement, such as avoiding surgery on high-risk patients or administration of antibiotics to patients who are not ultimately diagnosed with infection, need to be developed. These measures must reflect the quality of care across the continuum of providers interacting with patients.

A Role for Medicare QIOs
The Medicare QIO program may provide some of the necessary infrastructure to continue to learn about the characteristics of highly performing or improving hospitals. In addition, the QIOs may be in a position to disseminate the findings and lessons highlighted in these two companion reports and to provide technical assistance to hospitals to improve processes of care and overcome barriers.

With a local presence in every state, the QIOs have a long history of working directly with hospitals to measure, report, and improve quality of care. Moreover, QIOs are staffed with professionals who have specific skills in performance measurement and assessment, quality improvement, statistics and epidemiology, and health informatics.

The Institute of Medicine agrees that the QIO program has the potential to improve the quality of health care. In the recently published report, Medicare's Quality Improvement Organization Program: Maximizing Potential, the committee recommended that the QIO program become an integral part of strategies for future performance measurement and improvement in the health care system and emphasized QIOs' provision of technical assistance for performance measurement and quality improvement. The committee wrote that "priority should be given to those providers who demonstrate the most need for improvement or who face significant challenges in their efforts to improve quality."

Medicare QIOs are, in fact, already engaged in this work. CMS and the Oklahoma QIO recently sponsored a summit on hospital leadership that was attended by a broad range of constituencies, including health system/hospital executives, clinical leaders, representatives of public agencies, representatives of national and state hospital associations, QIOs, and academicians and researchers. During the summit, we focused on the impact of hospital leadership on quality and quality improvement. In addition, we reviewed studies highlighting gaps in perception regarding commitment to quality and patient safety across leadership levels within hospitals. Hospital executive leadership often perceive an existing high level of engagement in quality and patient safety, while middle management and frontline health care workers often identify much greater opportunities for improved commitment to safety and quality.

A collaborative workgroup was formed to develop a standardized organizational assessment that hospitals can use to self-identify strengths and gaps related to quality improvement leadership, with a particular goal of targeting assessment to institutions that have the greatest need or challenges to improvement. The work presented by Kroch, Silow-Carroll, and colleagues will provide an invaluable foundation upon which to base the development of organizational assessment tools and to begin to learn how to transfer this knowledge to poorly performing hospitals.

The content of this commentary does not necessarily reflect the views or policies of the Department of Health and Human Services or imply endorsement by the U.S. Government. The author assumes full responsibility for the accuracy and completeness of the ideas presented. Nor should the views be attributed to The Commonwealth Fund or its directors, officers, or staff.

Publication Details



D. W. Bratzler, The Dynamics of Improvement, The Commonwealth Fund, April 2007