The Relationship Between Organizational Factors and Performance Among Pay-for-

Performance Hospitals

Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT.

Background

• Pay for Performance (P4P)

• Hospital Quality Incentive Demonstration (HQID) Project

• Rewarding high performance hospitals with 2% bonus on Medicare payments

Objective

• To identify the key quality improvement (QI) factors associated with higher performance in hospitals in a P4P program

Sampling frame

• Hospitals participating in the HQID project across 5 clinical conditions or procedures:

– Acute myocardial infarction (AMI)

– Heart failure (HF)

– Pneumonia (PN)

– Total hip or total knee replacement (THR/TKR)

– Coronary artery bypass graft (CABG)

Study sample

# participating hospitals, during year 2 of the HQID project = 255 exclude # hospitals that reported data for at least 3 of 5 clinical conditions or procedures = 223 exclude

# hospitals in deciles 3 to 8 = 131

# hospitals in the top 2 and bottom 2 deciles = 92

# hospitals that did NOT report data for at least 3 clinical conditions or procedures, withdrew or failed validation = 32

Overall Composite Quality Score (O-CQS)

• Overall Composite Quality Score (O-CQS)

– Calculated by Premier, Inc.

– Utilized O-CQS from year 2(October 1, 2004 - September 30, 2005)

– Combines composite process score (CPS) and composite outcome score (COS)

Structured telephone interview

• Telephone interviews were conducted by Zynx Health investigators (blinded to each hospital’s performance ranking): July, 2007 - October, 2007

• Average interview: ~35 minutes

• Respondents were asked to focus on theirQI activities during the past year

QI domains

1. Quality improvement (QI) interventions

2. Data feedback systems (quality compliance)

3. Physician leadership

4. Organizational support for QI

5. Organizational culture

Results

• 92 hospitals were eligible for the study

• 84 (91%) completed the interview

– 45 were in the top 2 deciles

– 39 were in the bottom 2 deciles

Hospital characteristics

Characteristics Bottom Decile

(n = 39)

Top Decile

(n = 45) Mean number of beds 285 334 Geographic region Pacific 14 2 Mountain 0 1 Midwest 6 24 East 19 18 Demographics Urban 31 40 Rural 8 5 Teaching status Academic 7 8 Non-academic 32 37

QI interventions

*P < .01

Order Sets

0 20 40 60 80 100

AMI

HF

PN

THR/TKR

CABG

Clin

ica

l Co

nd

itio

n/P

roc

ed

ure

% Utilization

Top

Bottom

*

QI interventions

*P < .01

Clinical Pathways

0 20 40 60 80 100

AMI

HF

PN

THR/TKR

CABG

Cli

nic

al C

on

dit

ion

/Pro

ced

ure

% Utilization

Top

Bottom

*

*

*

*

QI interventions: Electronic capabilities

Electronic Capability Top Decile Bottom Decile

CPOE – hospital, %, (n) 24.4, (45)* 7.9, (38)*

Alerts for physicians, %, (n) 27.9, (43) 13.2, (38)

Alerts for nonphysicians, %, (n) 59.5, (42) 52.6, (38)

Paper-based order sets, %, (n) 92.9, (42) 94.9, (39) *P < .05.

Data feedback

Frequency (month) Time Period (month) Top Deciles

Bottom Deciles

P value

Top Deciles

Bottom Deciles

P value

Collection of hospital-specific reports

1.47 1.44 ns 2.99 2.64 ns

Reporting physician-specific reports to Department Chair

3.40 6.13 ns 6.30 6.09 ns

Physician leadership

• Among hospital CMOs with the general role of improving quality,

– Percentage who recruited “physician champions” (82.1% vs 69.4%, P<.05).

Organizational support

Top Deciles

Bottom Deciles

Organizational Support Physicians strongly support QI 2.24 2.36 Hospital administrators strongly support QI 1.16 1.26 Nurses strongly support QI 1.78‡ 2.28‡ Physicians participate in QI projects 2.44 2.64 Physicians build order sets quickly 2.43 2.97 Adequate human resources for QI projects 2.18‡ 2.82‡ *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational support

Top Deciles

Bottom Deciles

Organizational Support Physicians strongly support QI 2.24 2.36 Hospital administrators strongly support QI 1.16 1.26 Nurses strongly support QI 1.78‡ 2.28‡ Physicians participate in QI projects 2.44 2.64 Physicians build order sets quickly 2.43 2.97 Adequate human resources for QI projects 2.18‡ 2.82‡ *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational support

Top Deciles

Bottom Deciles

Organizational Support Physicians strongly support QI 2.24 2.36 Hospital administrators strongly support QI 1.16 1.26 Nurses strongly support QI 1.78‡ 2.28‡ Physicians participate in QI projects 2.44 2.64 Physicians build order sets quickly 2.43 2.97 Adequate human resources for QI projects 2.18‡ 2.82‡ *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational culture

Top Deciles

Bottom Deciles

Organizational Culture

Decision-making is participatory 1.87 1.95 Senior administrators see eye-to-eye with staff 2.43 2.54 Hospital is likely to be the first to try new QI activities 1.84‡ 3.10‡ Hospital has tried new QI activities with track record 4.13‡ 3.18‡ It is difficult to coordinate quality care 3.53‡ 2.87‡ Change takes place slowly 3.49‡ 2.23‡

Hospital assigns blame to individuals 4.51* 4.05* *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational culture

Top Deciles

Bottom Deciles

Organizational Culture

Decision-making is participatory 1.87 1.95 Senior administrators see eye-to-eye with staff 2.43 2.54 Hospital is likely to be the first to try new QI activities 1.84‡ 3.10‡ Hospital has tried new QI activities with track record 4.13‡ 3.18‡ It is difficult to coordinate quality care 3.53‡ 2.87‡ Change takes place slowly 3.49‡ 2.23‡

Hospital assigns blame to individuals 4.51* 4.05* *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational culture

Top Deciles

Bottom Deciles

Organizational Culture

Decision-making is participatory 1.87 1.95 Senior administrators see eye-to-eye with staff 2.43 2.54 Hospital is likely to be the first to try new QI activities 1.84‡ 3.10‡ Hospital has tried new QI activities with track record 4.13‡ 3.18‡ It is difficult to coordinate quality care 3.53‡ 2.87‡ Change takes place slowly 3.49‡ 2.23‡

Hospital assigns blame to individuals 4.51* 4.05* *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational culture

Top Deciles

Bottom Deciles

Organizational Culture

Decision-making is participatory 1.87 1.95 Senior administrators see eye-to-eye with staff 2.43 2.54 Hospital is likely to be the first to try new QI activities 1.84‡ 3.10‡ Hospital has tried new QI activities with track record 4.13‡ 3.18‡ It is difficult to coordinate quality care 3.53‡ 2.87‡ Change takes place slowly 3.49‡ 2.23‡

Hospital assigns blame to individuals 4.51* 4.05* *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Organizational culture

Top Deciles

Bottom Deciles

Organizational Culture

Decision-making is participatory 1.87 1.95 Senior administrators see eye-to-eye with staff 2.43 2.54 Hospital is likely to be the first to try new QI activities 1.84‡ 3.10‡ Hospital has tried new QI activities with track record 4.13‡ 3.18‡ It is difficult to coordinate quality care 3.53‡ 2.87‡ Change takes place slowly 3.49‡ 2.23‡

Hospital assigns blame to individuals 4.51* 4.05* *P < .05; ‡P < .01 Likert scale: 1 = strongly agree, 5 = strongly disagree

Limitations

• Voluntary participants in a P4P program

• Participants not blinded own performance rankings

• Unable to evaluate association of QI efforts to future performance

Conclusions

• Main factors associated with high performance:

– Organizational structure

– Organizational support for QI

– Organizational culture

Policy implications

• Strategies should encourage development of improved organizational structure, support and culture for quality

• Develop and strengthen resources to support QI activities

Acknowledgements

• Zynx Health, Inc.

• Premier, Inc.

• Centers for Medicare & Medicaid Services

• Questions?

References

• (1) Centers for Medicare and Medicaid Services (CMS) / Premier Hospital Quality Incentive Demonstration Project. Internet 2008 January 3;Available at: URL: http://www.premierinc.com/quality-safety/tools-services/p4p/hqi/hqi-whitepaper041306.pdf

• (2) Centers for Medicare and Medicaid Services (CMS) / Premier Hospital Quality Incentive Demonstration Project. Internet 2008 January 3;Available at: URL: http://www.premierinc.com/quality-safety/tools-services/p4p/hqi/resources/hqi-whitepaper-year2.pdf

• (3) Lindenauer PK, Remus D, Roman S et al. Public reporting and pay for performance in hospital quality improvement. N Engl J Med 2007 February 1;356(5):486-96.

• (4) Bradley EH, Herrin J, Mattera JA et al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care 2005 March;43(3):282-92.

• (5) Bradley EH, Herrin J, Mattera JA et al. Quality improvement efforts and hospital performance: rates of beta-blocker prescription after acute myocardial infarction. Med Care 2005 March;43(3):282-92.

• (6) Marciniak TA, Ellerbeck EF, Radford MJ et al. Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. JAMA 1998 May 6;279(17):1351-7.

• (7) Metersky ML, Galusha DH, Meehan TP. Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project. Jt Comm J Qual Improv 1999 April;25(4):182-90.

References

• (8) Ferguson TB, Jr., Peterson ED, Coombs LP et al. Use of continuous quality improvement to increase use of process measures in patients undergoing coronary artery bypass graft surgery: a randomized controlled trial. JAMA 2003 July 2;290(1):49-56

• (9) Fonarow GC, Abraham WT, Albert NM et al. Influence of a performance-improvement initiative on quality of care for patients hospitalized with heart failure: results of the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure (OPTIMIZE-HF). Arch Intern Med 2007 July 23;167(14):1493-502.

• (10) Fung CH, Lim YW, Mattke S, Damberg C, Shekelle PG. Systematic review: the evidence that publishing patient care performance data improves quality of care. Ann Intern Med 2008 January 15;148(2):111-23.

• (11) Berwick DM, James B, Coye MJ. Connections between quality measurement and improvement. Medical Care 2003;41(1):I30-8.

BACK-UP SLIDES

QI InterventionsTop Decilesa Bottom Decilesb Quality

Improvement Intervention

AMI HF PN THR/TKR

CABGc AMI HF PN THR/TKR

CABGc

OS with physician signature

93.3 88.9 93.3 91.1‡ 93.5 89.7 76.9 84.6 64.1‡ 87.5

Standing OS, no physician signature

20.0 8.9 48.9 4.4 6.5 12.8 5.1 51.3 2.6 6.3

Clinical pathways

48.9‡ 44.4‡ 37.8‡ 55.6‡ 45.2 15.4‡ 17.9‡ 12.8‡ 23.1‡ 31.3

Educational sessions, physicians

77.8 75.6 71.1 62.2 67.7 71.8 71.8 69.2 53.8 68.8

Educational sessions, nurses

86.7 86.7 82.2 71.1 74.2 76.9 74.4 76.9 79.3 68.8

Multidiscip-linary team

93.3* 93.3‡ 86.7 84.4 96.8 76.9* 69.2‡ 74.4 66.7 81.3

Abbreviation: OS, order sets. a(n=45) for AMI, HF, PN, THR/TKR & (n=31) for CABG. b(n=39) for AMI, HF, PN, THR/TKR & (n=16) for CABG. c Asked only of respondents of hospitals that performed CABG. *P < .05; ‡P < .01.

QI Interventions

*P < .05; ‡P < .01.

Multidisciplinary Team

0 20 40 60 80 100

AMI

HF

PN

THR/TKR

CABG

Cli

nic

al C

on

dit

ion

/Pro

ced

ure

% Utilization

Top

Bottom

‡‡

**

Results, Summary

Domain QI Factor (Clinical Condition, if Applicable) OS with physician signature (THR/TKR)‡ OS updated at least once in last year (THR/TKR)‡ Clinical pathways (AMI, HF, PN, THR/TKR)‡ Multidisciplinary team with the goal of improving quality (AMI†, HF‡)

QI interventions

CPOE hospital* Physician leadership

CMO, with the role of improving quality, recruiting “physician champions”* Nurses strongly support QI‡ Organizational

support Adequate human resources for QI projects‡ Is not difficult to coordinate quality care ‡ Change not taking place slowly ‡ Hospital not trying only new activities with track records‡ Hospital being likely to be the first to try new QI activities ‡

Organizational culture

Hospital not tending to assign blame to individuals * *P < .05; ‡P < .01