Hospital Characteristics

8/2/2019 Hospital Characteristics

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A project supported by the Robert Wood Johnson Foundation

Comparing Hospital Charac teristics Rela ted to Improving

Quality and Red uc ing Hea lth Care Disparities

Introduction

Recognizing the need for action at the local level and

cooperation across many entities in a community to

elevate health care quality and reduce health caredisparities, the Aligning Forces for Quality (AF4Q) initiative

(see insert) is a community-level intervention designed to

improve overall quality of care through multi-stakeholder

hea lth c a re a llianc es. The first phase of AF4Q, launc hed

in 2006, supp orted c om munity lea dership tea ms to w ork

with physicians in ambulatory care settings to improve

quality of care, measure and publicly report

performance, and engage consumers to make informed

c hoices ab out their hea lth a nd hea lth c a re. The p rog ram

expanded in June 2008 to include a focus on reducing

racial and ethnic disparities and improving equity in

care.

Also in 2008, the AF4Q program extended its focus

beyond ambulatory care to include inpatient care.Hospitals in the AF4Q communities enacted a variety of

quality improvement initiatives that ranged from

increasing the role of nurses in improving quality and

reducing hospital readmissions among cardiac care

pa tients, to imp roving language servic es for pa tients with

limited English proficiency and increasing the efficiency

of hosp ital em ergenc y dep a rtments. The participa ting

Contents

1 Introduction

2 Method s and Data Sources

3 Hospital Characteristics

4 Community Orientation and

Collaboration

5 Sa fety Ne t Sta tus

6 Rac e, Ethnic ity, and Prima ry

Langua ge Da ta Co llection

by Hospitals

7 Electronic Health Rec ords

8 Patient Experienc e and

Proc esses of Ca re

9 Discussion

10 References

Research Sum mary No. 8 August 2011

Raymond Kang and Rom ana Hasna in-Wynia, PhD

_____________________

If 513 hospitals in 16

dive rse AF4Q com munities

can improve c are and

reduce d isparities, thenother hospitals throughout

the nation can lea rn from

their efforts and do the

same.

__________________


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hospitals engaged in these various activities under the

broad umbrella of the Hospital Quality Network, which

ultimately aspires to improve inpatient quality in the AF4Q

communities and diffuse promising practices throughout

the na tion. The p remise is, if 513 hosp ita ls in 16 d iverse AF4Q

communities can improve care and reduce disparities,

then other hospitals throughout the nation can learn from

their efforts and do the same (Pa inter and Lavizzo-Mourey,

2008). Resea rc hers, hea lth c are lea ders, and polic y ma kers

need to be careful when measuring the progress of AF4Q

communities, however, because hospitals in these

communities may be quantitatively different along some

dimensions from hospitals in non-AF4Q communities. A

variety of factors are associated with hospital quality of

c are. Seve ra l stud ies have show n tha t c hanges in payment

policy and market conditions have an impact on hospital

infrastructure and the activities that hospitals engage in

both internally and in the community. Bazzoli and

c ollea gue s found tha t a spec ts of a hosp ita ls infrastructure

and supporting processes may be affected by declining

financial performance, which have important implications

for ca re d elive ry (Bazzoli et a l., 2007). These find ings sug gest

that it is important to look broadly at hospital operations

when e xam ining the fac tors that m ay have an impa ct on

quality.

In this research summary, we describe hospital

characteristics and activities that are associated with

improving quality and reducing health care disparities;

based on these factors, we compare hospitals in AF4Q

c om munities with hosp itals in the rest o f the c ountry. This

baseline understanding can help to highlight potential

fac ilitato rs and barriers tha t influenc e or imped e suc c ess in

Aligning Forces for Quality

The Rob ert Wood Johnson

Foundation (RWJF) is

investing in efforts to improvehealth systems in 17

communities across the

nation.

Called Aligning Forces for

Quality (AF4Q), the initiative

brings a commitment of

resources, expertise and

training to turn promising

practices into real results at

the c om munity level. AF4Q

asks the people who getcare, give care and pay

for care to work

together toward common

fundamental objectives to

lead to better care.

The initia tive a ims to lift the

overall qua lity of hea lth c are,

reduce racial and ethnic

disparities and provide

mo dels for nationa l refo rm.

It advances threeinterrelated reforms that

experts believe are essential

to improving health care

quality:

Performance

mea sureme nt and pub lic

reporting

Consumer engagement

Quality imp rovement

For more information about

AF4Q, p lea se v isit

http://www.rwjf.org/qualitye

quality/af4q/index.jsp

For more information about

RWJF, p lea se visit

http://www.rwjf.org/


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improving quality. In order to provide an

initial snapshot of key factors that may be

associated with hospital quality of care,

the majority of data presented here are

aggregated across all hospitals in AF4Q

communities; the information for each

AF4Q community is available upon

request.

We present information about hospitals

demographic characteristics (e.g., bedsize, ownership); level of community

orientation; safety net status; collection of

patient race, ethnicity, and language

data; and adoption of electronic health

record systems. We also provide

information about hospital performance

on patient experience measures and

composite process of care measures for

acute myocardial infarction (AMI), heart

failure (HF), and pneumonia (PN).

Methods and Data Sourc es

We obtained information on hospital

characteristics from the 2005-2007

American Hospital Associations (AHA)

Annua l Survey. We a lso ob ta ined

hospitals performance on care processes

for AMI, HF, and PN and the p erce ntage of

minority patients from the Centers for

Med ic are & Me d ic a id Servic e s (CMS)

2008 Hospital Quality Alliance Data.

Information on patient experience was

collected from the 2008 Hospital Consumer

Assessment o f Hea lthc are Providers and

Syste ms Hospita l Survey (HCAHPS).

Hospita l Cha rac teristics

Stud ies have show n tha t spec ific hosp ital

characteristics are associated with higher

qua lity. For exam p le, large , not-for-p rofit a nd

teaching hospitals have higher performancesc ores on an a rray of p roc esses relate d to the

treatment of AMI, HF, and PN, even after

controlling for individual patient

demographics (Vogeli et al., 2009).

Furthermore, while high nurse staffing levels

are assoc iated with significa ntly low er ra tes of

mortality and adverse events (Kane et al.,

2007), we know that in general, minority

patients receive care in lower-performing

hospitals with relatively low nurse staffing

ratios (Hasnain-Wynia et al., 2007 and 2010,

Jha et al., 2007).

Tab le 1 c ompares these c ha rac teristics in a ll

U.S. hospitals with hospitals in the AF4Q

communities; along many of these

dimensions, hospitals in AF4Q communities

are similar to hospitals in the rest of the

c ountry. For example, hosp itals in

AF4Q c om munities a re just as likely to be

teaching hospitals and health system

members (versus sta nd -alone hosp ita ls). They


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Table 1: Charac teristics of Hospita ls in the U.S., AF4Q Communities,

and Non-AF4Q Comm unities

U.S. AF4Q Non-AF4Q

Number of Hospitals 4,492 513 3,979

Ownership

Not-For-Profit 60% 81% 58%

Priva te -For-Prof it 15% 5% 16%

Pub lic 24% 13% 26%

Size

Large (300 or more bed s) 17% 18% 17%

Me dium (100-299 beds) 35% 35% 35%

Small (Less than 100 beds) 48% 47% 48%Location

Urban 56% 63% 55%

Sub urban 19% 13% 19%

Rura l 26% 24% 26%

Teac hing and System Status

Membe r of the Counc il of

Teac hing Hospita ls (COTH) 6% 8% 6%

System Member 54% 55% 54%

Nurse Staffing Ratio

Nurses per 1000 Patient Days 7.57 8.11 7.50Sourc e: 2007 Ame ric an Hospita l Assoc iation s Annual Survey

also are similar in size to hospitals in the rest of the country. However, in terms of location,

ownership status, and nursing ratios, hospitals in AF4Q communities are more likely to be

urban, not-for-profit, and have a higher ra tio of nurses to inpa tient days.

Community Orientation and Collaboration

Because of the AF4Q programs focus on developing a community-level infrastructure to

improve quality, we examined the level of community orientation (CO) of hospitals in AF4Q

c om munities c om pared w ith hosp ita ls in the rest of c ount ry. Orig inally prop osed by Proe nc a

(1998), CO is defined as the organization-wide generation, dissemination, and use of

community intelligence to address present and future community health needs.

Co mm unity orienta tion d istinguishes itself from d irec t pa tient c a re b y foc using on p revention

(e.g., sc reening and ed uca tion ac tivities), co llec tion of c om munity health informa tion, and

collaboration with other key organizations, such as schools, religious institutions, and

gove rnme nt agenc ies. The d eg ree of a hosp ita l s CO is influenc ed by ma ny fac tors, suc h as

environmental pressures and hospital characteristics. For example, Proenca et al. (2000)


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Hospitals are a wa rde d a po int fo

every positive response to the

following questions.

Does the hospital

1. Provide a spe c ific b udg et for

Comm unity Bene fit Ac tivities?

2. Dedica te staff to ma nag e

Comm unity Bene fit Ac tivities?

3. Provide suppo rt for Com munity

Building Ac tivities?

4. Provide financ ial c ontributions

c omm unity programs?

5. Work with othe rs to c ond uc t a

Community Health Assessment?

6. Work with othe rs to d eve lop acapa c ity assessme nt?

7. Work with othe rs to c ollect a nd

track health info across

organizations?

8. Dissem inate Qua lity Reports?

found that large, not-for-profit health system or network hospitals demonstrate a

greater commitment to CO and that hospitals with a strong commitment to CO tend

to o ffer mo re he a lth p rom otion servic es, even a fter co ntrolling for the c harac teristics of

the c om munity (Ginn and Moseley, 2004).

To mea sure c om munity orienta tion, we c om bined e ight questions from the AHA

Annua l Survey to c rea te a CO sc ore (see insert). On a sc a le o f 0-8 (0 = no c om mitme nt

to CO, 8 = high commitment to CO), we defined High commitment as having a

sc ore of 7 or 8 and Med ium c om mitment as having a sc ore of

between 4 and 6; hospitals with a CO score less than 4 were

c onsidered Low c om mitme nt. Tab le 2 d isp lays the d istribution of

hospitals in AF4Q and non-AF4Q communities based on their

commitment to CO activities. Overall, hospitals in AF4Q

communities were more likely to have a High commitment to

CO activities and less likely to have a Low commitment

compared with hospitals in non-AF4Q communities (49% vs. 39%

and 13% vs. 22%). Betwee n and w ithin AF4Q a llianc e c om munities,

there was c onsiderab le va riation in the level of hosp ita l CO.

Tab le 2: Hospital Co mm unity Orientation Co mm itment b y AF4Q

Community and Non-AF4Q Community

Sourc e: 2007 AHA A nnua l Survey Dat a.*Inc ludes hospitals in Albuq uerque , Boston ,

Humb oldt C ounty, Mem phis, and South C entral PA.

Commitment to Community Orientation

AF4Q Allianc e Low (0-3) Medium (4-6) High (7-8)

Cinc inna ti 0% 43% 57%

Cleve land 0% 0% 100%

Detroit 10% 28% 63%

Kansas City 5% 32% 64%

Maine 6% 53% 42%

Minne sota 19% 50% 31%Pug et Sound 16% 32% 53%

West Mic higa n 6% 38% 56%

Western New York 33% 13% 53%

Willamet te Valley 8% 28% 64%

Wisconsin 18% 41% 40%

All AF4Q Allianc es* 13% 38% 49%

Non-AF4Q

Hospita ls 22% 39% 39%


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Safety Net Status

Vulnerable patient populations such as racial/ethnic minorities are more likely to be seen in

safety net hospitals where they may be less likely to receive recommended care (Hasnain-

Wynia e t a l., 2007 and 2010). Stud ies have shown tha t ho sp itals tha t serve vulnerab le

pop ula tions tend to ha ve lowe r pe rforma nc e sc ores c om pa red with other hosp itals and they

a lso show sma ller ga ins in performa nc e over time (Werner et a l., 2008). How ever, a

c ha lleng e to investiga ting qua lity of c a re a t sa fety net ho sp ita ls is the a bsenc e o f a standa rd

method for identifying safety net hospitals, especially given that they are a heterogeneous

group (Mc Hugh et al., 2009). Dep end ing on the sa fety net definition used , qua lity of ca re

ma y vary.

We used three different approaches for identifying safety net hospitals: (1) the hospitals

provision of uncompensated care (UC); (2) percentage of Medicaid patients; and (3)

perce ntage of m inority pa tients admitted for AMI, HF, and PN. Hosp itals in AF4Q c om munities

were less likely to be sa fety net p rovide rs ac ross multip le d efinitions of sa fety ne t sta tus (Tab le

3). Only 10% of hosp ita ls in AF4Q comm unities p rovide a g rea t dea l of unc om pensa ted c a re

compared with 16% of hospitals in non-AF4Q communities. Although hospitals in both AF4Q

and non-AF4Q communities provide a similar amount of care to the Medicaid population

(12% vs. 13%), on ly 1% of ho sp ita ls in AF4Q c ommunities (vs. 4% in the rest o f the c ount ry) serve

a very high percentage of minority patients, and only 9% of hospitals in AF4Q communities

(vs. 22% in the rest o f the U.S.) are in the Me d ium c a tegory for serving m inority pa tients.

Although hospitals in AF4Q communities are more likely to be located in urban areas, they

a re less likely to serve a high percenta ge o f minority p a tients. Overa ll, only 11% of hosp itals in

AF4Q c om munities mee t a ny o f the sa fety ne t d efinitions (vs. 18% in the rest o f the U.S.).

Because safety net hospitals often present the best opportunity to improve health care for

underserved pop ula tions, suc h a s rac ial and ethnic minorities, it is important to rec og nize thesmaller number of sa fety net hosp itals in AF4Q c om munities.


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Table 3: Safe ty Ne t Status of Hospitals in the U.S., AF4Q Co mmunities, and Non- AF4Q

Communities

U.S. Hospitals AF4Q Hospita ls Non-AF4Q Hospita ls

Number % Number % Number %

Unco mp ensated CareBurden

High Uncompensated

Care* 694 15% 55 10% 639 16%

Low Uncompe nsate d

Care 3,798 85% 458 90% 3,340 84%

Medic aid Burden

High Me dica id Burde n 597 13% 62 12% 535 13%

Low Me dica id Burde n 3,895 87% 451 88% 3,444 87%

Minority Hospita l**

High Minority 142 3% 7 1% 135 4%

Medium Minority 875 21% 43 9% 832 22%

Low Minority 3,216 76% 456 90% 2,760 74%Any Safety Net***

Yes 788 18% 58 11% 730 18%

No 3704 82% 466 89% 3238 82%Sourc e: 2007 AHA Annua l Survey Data and 2008 CMS Hospita l Quality Allianc e Da ta . *High Uncomp ensa ted Ca re

safe ty net hospitals either provide a large am ount o f UC relative to the ir tota l expe nses, or provide a large am ount o f

UC in the ir ma rket, o r bot h. **2008 CMS Hospita l Qua lity Allianc e Da ta . Minority hospita l sta tus is ba sed on the

pe rcenta ge of m inority pat ients ad mitted for AMI, HF, and PN. High minority hospitals are in the to p 5%, Med ium

hospitals are the rest of the top qua rtile, and Low hospitals are a ll other hospitals. ***Hospita ls that me et any o f the

three safe ty net de finitions

Race, Ethnic ity, and Prima ry Language Data Collec tion by

Hospitals

As communities become more diverse, hospitals are challenged to design and

imp lement p rog ram s to red uc e dispa rities and imp rove qua lity of c a re (Ver Ploeg and

Perrin, 2004). It is well recognized that valid and reliable race, ethnicity, and primary

lang uag e d ata a re fundam enta l building b loc ks for ide ntifying differences in c are a nd

develop ing targete d interventions to imp rove qua lity for spec ific po pulations to red uce

d ispa rities. There ha ve b een c lea r c a lls to a c tion to system a tica lly collec t d a ta on

patients race, ethnicity, and language; identify disparities where they exist; and tailor

interventions to red uc e them. The system atic and standard ized c ollec tion and use of

race, ethnicity, and primary language data are critical activities that hospitals in AF4Q

communities are expected to engage in as a foundation for targeting disparities in

care.


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Source:2007

AHA

Annual

Survey

Data Source:

2007

AHA

Annual

Survey

Data

Comparing hospitals in AF4Q communities with their non-AF4Q counterparts, Charts 1 and 2

display the p ercenta ge of hospitals that c ollec ted rac e, ethnicity, and p rima ry lang uag e d a ta

from 2005 to 2007. Overall, the collection of race/ethnicity data is increasing over time and,

while hospitals in AF4Q c om munities were slightly less likely to c ollec t rac e/ ethnic ity da ta in

2005 (83% vs. 85%), they c losed the gap with the rest o f the c ountry by 2006. The percen ta ge o f

hospitals collecting primary language information also has increased, but hospitals in

AF4Q c om munities a re m ore likely to c ollec t p rimary language da ta than hosp itals in non-AF4Q

c ommunities (88% vs. 78%).

65%

70%

75%

80%

85%

90%

2005 2006 2007

Chart1:PercentageofHospitalsCollectingRace/EthnicityDataoverTime

US(n=4,492)

NonAF4Q

(n=3,979)

AF4Q(n=513)

65%

70%

75%

80%

85%

90%

2005 2006 2007

Chart2:PercentageofHospitalsCollectingPrimaryLanguageDataoverTime

US(n=4,492)

NonAF4Q

(n=3,979)

AF4Q(n=513)

Elec tronic Hea lth Rec ords

Ac c ording to Jha, et a l. (2010), the numb er

of U.S. hosp ita ls tha t ha ve adop ted

electronic health records (EHRs) has

increased modestly from 2008 to 2009 (9%

to 12%) with large, private, and urban

hosp ita ls more likely to a dop t EHRs. Small,

public, and rural hospitals are further

behind in adoption, and gaps are

widening. Centers for Medicare &

Med ica id Servic e c rea ted EHR incentive

prog rams to increase the a dop tion of EHRs

(http://www.cms.gov/EHRIncentiveProgra

ms/ 30_Meaning ful_Use.asp ); for certain

hospitals, the incentives may not be

enoug h or the m ea ningful use c riteria ma y

be too d iffic ult to mee t. These c ond itions

could expand the digital divide (i.e., the

ga p be tween individua ls and c omm unities

that have, and do not have, access to

information technologies that are

improving the delivery of care), particularly

for under-resourced or safety net hospitals,

and therefore increase health care

disparities.


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Source: 2007 AHA Annual Survey Data

Patient Experienc e a nd Processes of Ca re

The Align ing Force s for Qua lity program p lac es a strong em phasis on pub licly rep orting da ta

to consumers and patients to help them make informed choices about their health care.Almost all hospitals in the AF4Q communities are publicly reporting patient experience of

c are a nd p roc ess of c a re m ea sures for spec ific c ond itions. We p resent som e o f the p ub licly

reported measures to give a sense of how differences in hospital characteristics may

pote ntially transla te into d ifferenc es in qua lity and hea lth ca re d isparities.

Pa tients expe rienc e o f the c a re the y rec eive is a ma rker of q ua lity; the Hosp ita l Co nsume r

Assessment o f Hea lthc are Providers and Systems Survey (HCAHPS) p rovides information on

patients expe rience w ith hosp ital ca re in the United Sta tes. The purpose of the HCAHPS

Survey is to fac ilitate c om parisons of pa tient experienc e of c a re ac ross hosp ita ls, c rea te

incentives for hosp ita ls to imp rove qua lity, and increase the transpa renc y of informa tion.

0% 50% 100%

AF4Q(n=513)

NonAF4Q

(n=3,979)

U.S.(n=4,492)

Chart3:ElectronicHealthRecordImplementation

Fully

Implemented

EHRPartially

Implemented

EHRNoEHR

Unknown

Chart 3 presents information on the

implementation of EHRs for hospitals inAF4Q and non-AF4Q communities.

Co mp ared w ith the rest o f the U.S.,

hospitals in AF4Q communities are more

likely to have a fully implemented EHR

(19.3% vs. 11.0%) and slightly more likely

to have a partially implemented EHR

(37.4% vs. 35.4%).


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Table 4: 2008 Hospital Consumer Assessment o f Hea lthc are Provid ers and System s (HCAHPS)Scores by Percentage of Minority Patients and Location within AF4Q and non-AF4Q communities

Source: 2008 HCAHPS data. Minority hospital status is based on the percentage of minority patients admitted

for AMI, HF, and PN. High minority hospitals are in the top 5%, Medium hospitals are the rest of the top

quartile, and Low hospitals are all other hospitals.

Number

% Patients definitely

rec omm end Hospital

% Patients rate Hospital

9 or 10 out of 10

All Hospita ls 4,492 66.9% 63.3%

% Minority Patients

High 139 57.0% 54.1%

Medium 863 64.2% 60.3%

Low 3,188 68.0% 64.4%

Location

AF4Q 513 69.3% 65.8%

Non-AF4Q 3,979 66.6% 62.9%

A recent study found that non-Hispanic White inpatients receive care at hospitals that

provide better experiences for all patients than hospitals that more often care for minority

pa tients (Go ldstein et a l., 2010). In Tab le 4 below , we p rovide hosp ita ls pa tient expe rienc e

data based on their percentage of minority patients and their location (AF4Q or non-AF4Qcommunity). Compared to hospitals with a low number of minorities, patients in hospitals

with a high perce ntage o f minority pa tients a re less likely to rec om me nd the hosp ita l (57.0%

vs. 68.0%) and are less likely to rate it favorably (54.1% vs. 64.4%). Comparing hospitals in

AF4Q c om munities with hosp itals in a non-AF4Q loc a tion, pa tients a re more likely to

rec om mend the hosp ital (69.3% vs. 66.6%) a nd a re more likely to ra te it favorab ly (65.8% vs.

62.9%).

Throug h CMS, the Hosp ita l Qua lity Allianc e rout inely collec ts and rep orts da ta on

hosp itals performa nc e o n p roc ess of c a re me asures for AMI, HF, and PN, and we rep ort

the results in Tab le 5. Hosp itals with a high perc enta ge of minority pa tients ha ve the

lowest performance scores, and hospitals in AF4Q communities have better

performa nc e a c ross a ll c ond itions.


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Tab le 5: 2008 Hospita l Quality A lliance (HQA) Scores by Percentage of Minority

Patients and Location within AF4Q and non-AF4Q communities

Number AMI HF PN

All Hospita ls 4,492 91.4% 83.1% 89.6%

% Minority Patients

High 139 89.0% 82.0% 84.6%

Me dium 863 92.2% 85.1% 88.6%

Low 3,188 91.3% 82.8% 90.2%

Location

AF4Q 513 94.3% 85.5% 91.1%

Non-AF4Q 3,979 91.0% 82.8% 89.4%Source: 2008 CMS Hospital Quality Alliance Data. Minority hospital status is based

on the percentage of minority patients admitted for AMI, HF, and PN. High minority

hospitals are in the top 5%, Medium hospitals are the rest of the top quartile, andLow hospitals are all other hospitals.

Disc ussion

Based on a variety of factors associated with quality of care, such as size, teaching

status, pe rc enta ge o f Med ic aid p a tients, and c ollec tion of rac e/ ethnic ity da ta ,

hosp itals in Aligning Forc es for Qua lity c om munities a re simila r to hosp itals in the rest o f

the country. Along other dimensions, hospitals in AF4Q communities are quite different;

for example, even though they are less likely to provide a large amount of

unco mp ensa ted c are, they are m ore likely to: (1) c ontribute resources and c ollab orate

on c om munity level hea lth c are imp rovem ent initiatives, (2) c ollec t p rima ry lang uag e

data, (3) have electronic health records, and (4) have better performance on patient

expe rience sc ores and p roc ess of c a re m ea sures for ac ute m yoc ard ia l infa rc tion (AMI),

heart failure (HF), and pneumonia (PN). Despite the fact that hospitals in

AF4Q com munities a re m ore likely to b e loc a ted in an urba n a rea , they a re less likely to

serve m inority pa tients c om pared with other hosp itals in the U.S, which is importa nt to

note given the AF4Q initiatives focus on reducing racial and ethnic disparities in care.

While hospitals in AF4Q communities are similar in many ways, the aggregate picture

can mask substantial variation within and between hospitals, as demonstrated by the

d istribution o f CO ac tivities.


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This report wa s prepa red by the Aligning Forc es

for Qua lity Eva luation Tea m w hich is stud ying the

AF4Q initiative to ga in insights ab out community-

based reform that can guide health care

prac tice and po lic y. The AF4Q Eva luat ion Tea m

presents periodic research summaries on key

findings and policy lessons gleaned from its

ongoing mixed-method evaluation of the AF4Q

program.

For mo re information ab out the AF4Q Eva luation

Tea m -

(http://www.hhdev.psu.edu/CHCPR/alignforce/)

This research sum mary p rovides a basic c omparison of hosp ita ls in AF4Q vs. non-AF4Q

c om munities, ac ross spec ific d imensions. Since AF4Q c om munities were no t rand om ly

selecte d nor were they intend ed to be exac tly rep resenta tive o f the entire c ountry (e.g.,

to participate in the initiative, AF4Q grantee communities were required to provide

evidence of prior multi-stakeholder collaboration to improve quality of care in their

communities), it is not surprising that hospitals in AF4Q communities have a head start

over those in non-AF4Q locations. In the program evaluation, it is important to account

for these factors when measuring the progress of AF4Q communities and comparing

them with the rest of the c ountry.

Our results ind ica te tha t c om munities tha t a re intent on imp roving overall qua lity of c a re

and reducing disparities, specifically those working across multi-stakeholder

collaborations, must recognize the context in which these efforts are taking place and

ho w c ontext ca n influenc e p rog ress and pote ntial c om parisons. The c onte xt provided

here c om es from da ta aggreg a ted ac ross a ll hosp ita ls in AF4Q c om munities. These

data show tha t it is imp ortant to c onsider how c harac teristics and c ontexts of ho sp itals in

AF4Q communities vary from other hospitals in the country and, as the promising

practices learned from AF4Q are disseminated, to maintain a realistic attitude toward

the im leme ntation of these rac tice s in other loc ations.


13/13

PAGE 13

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