Christian Health Administrator Discussion Paper

• Prompt: How does the biblical teaching of the plumb line found in Amos 7:7-8 provide guidance to the Christian health administrator in the measurement of quality?
• Requirements: 250 words minimum initial post, 100 words minimum reply

ORIGINAL CONTRIBUTION Is Emergency Department Quality Related to Other Hospital Quality Domains? Megan McHugh, PhD, Jennifer Neimeyer, PhD, Emilie Powell, MD, MS, Rahul K. Khare, MD, MS, and James G. Adams, MD Abstract Objectives: Systems theory suggests that there should be relatively high correlations among quality measures within an organization. This was an examination of hospital performance across three types of quality measures included in Medicare’s Hospital Inpatient Value-Based Purchasing (HVBP) program: emergency department (ED)-related clinical process measures, inpatient clinical process measures, and patient experience measures. The purpose of this analysis was to determine whether hospital achievement and improvement on the ED quality measures represent a distinct domain of quality. Methods: This was an exploratory, descriptive analysis using publicly available data. Composite scores for the ED, inpatient, and patient experience measures included in the HVBP program were calculated. Correlations and frequencies were run to examine the extent to which achievement and improvement were related across the three quality domains and the number of hospitals that were in the top quartile for performance across multiple quality domains Christian Health Administrator Discussion Paper

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Results: Achievement scores were calculated for 2,927 hospitals, and improvement scores were calculated for 2,842 hospitals. There was a positive, moderate correlation between ED and inpatient achievement scores (correlation coefficient of 0.50, 95% confidence interval [CI] = 0.47 to 0.53), but all other correlations were weak (0.16 or less). Only 96 hospitals (3.3%) scored in the top quartile for achievement across the three quality domains; 73 (2.6%) scored in the top quartile for improvement across all three quality domains. Conclusions: Little consistency was found in achievement or improvement across the three quality domains, suggesting that the ED performance represents a distinct domain of quality. Implications include the following: 1) there are broad opportunities for hospitals to improve, 2) patients may not experience consistent quality levels throughout their hospital visit, 3) quality improvement interventions may need to be tailored specifically to the department, and 4) consumers and policy-makers may not be able to draw conclusions on overall facility quality based on information about one domain. Christian Health Administrator Discussion Paper

ACADEMIC EMERGENCY MEDICINE 2014;21:551–557 © 2014 by the Society for Academic Emergency Medicine T he Centers for Medicare and Medicaid Services (CMS) is changing the way that it pays for health services.1 In an effort to improve the value of its expenditures, CMS now reimburses providers based on care quality, not just the quantity of services provided. One important component of CMS’ value-based purchasing strategy is the Hospital Inpatient Value-Based Purchasing (HVBP) program.2 Beginning October 2012, CMS began withholding 1% of Medicare payments and redistributing those funds back to hospitals based on achievement or improvement on 12 process measures and eight patient satisfaction measures (Table 1). Of the 12 process measures included in the first year of the program, four are related to care delivered in the emergency department (ED): fibrinolytic therapy received within 30 minutes of hospital arrival (acute myocardial infarction [AMI]-7a), primary percutaneous coronary intervention (PCI) received within 90 minutes of hospital From the Center for Healthcare Studies (MM, JN, EP RKK), the Department of Emergency Medicine (MM, EP, RKK, JA), Northwestern University, Feinberg School of Medicine, Chicago, IL. Received October 21, 2013; revisions received November 15 and November 17, 2013; accepted November 18, 2013. The authors did not receive outside support or funding for this research. This work has not been published or presented elsewhere. Christian Health Administrator Discussion Paper

The authors have no potential conflicts of interest to disclose. Supervising Editor: Lowell Gerson, PhD. Address for correspondence and reprints: Megan McHugh, PhD; e-mail: [email protected]. © 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12376 ISSN 1069-6563 PII ISSN 1069-6563583 551 551 552 McHugh et al. • ED QUALITY AND HOSPITAL QUALITY arrival (AMI-8a), blood cultures performed in the ED prior to initial antibiotic received in hospital (pneumonia [PN]-3b), and initial antibiotic selection for community acquired pneumonia (CAP) in immunocompetent patients (PN-6).2,3 There is a growing interest in emergency medicine to understand factors influencing performance on these measures.4,5 Systems theory holds that high performance results from a culture of excellence that permeates throughout a hospital and that one should see correlation among quality measures within an organization.6,7 However, previous studies have found that hospitals that perform highly on one dimension of quality (e.g., patient experience) do not necessarily perform highly on others (e.g., mortality).8–10 One could speculate that ED performance represents a distinct dimension of hospital quality. EDs are physically separate and have different reimbursement structures, management, and staffing than inpatient units. If ED performance is not related to hospital performance, it signals a lack of consistency in quality within an organization and that broad hospital quality improvement initiatives may need to be tailored to individual departments. We have previously described hospital performance on the ED measures included in the HVBP program.11 However, to date, there has been no examination of the extent to which ED performance mirrors performance on other domains of hospital quality. We examined hospital achievement and improvement across the three domains of hospital quality included in Medicare’s HVBP program: ED-related clinical process measures, inpatient clinical process measures, and patient experience measures. Our purpose was to determine whether a hospital’s achievement and improvement on the ED quality domain is related to achievement and improvement on the inpatient and patient experience quality domains. Although several studies have investigated hospital performance on publicly reported quality measures,12,13 this effort is unique in its focus on emergency care, its examination of both achievement and improvement, and its use of measures included the new HVBP program. Results have important implications for department and quality improvement leaders, consumers, and policy-makers. METHODS Study Design This was an exploratory, descriptive analysis of secondary data. Our institutional review board determined that approval was not required because the study did not involve human subjects. Study Setting and Population We obtained 2008 through 2010 performance data for the four ED-related clinical process measures, eight inpatient clinical process measures, and eight patient experience measures from the CMS Web site Hospital Compare (http://www.hospitalcompare.hhs.gov/). The clinical process measures are chart-abstracted measures that assess hospitals’ compliance on evidence-based care related to AMI, heart failure, pneumonia, and surgical care improvement Christian Health Administrator Discussion Paper.

The patient experience measures are derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, which was developed by the Agency for Table 1 Measures Included in the Hospital Inpatient Value-Based Purchasing Program, Fiscal Year 2013 ED-related Clinical Process Measures AMI-7a Fibrinolytic therapy received within 30 minutes of hospital arrival AMI-8a Primary PCI received within 90 minutes of hospital arrival PN_3b Blood cultures performed in the ED prior to initial antibiotic received in hospital PN_6 Initial antibiotic selection for CAP in immunocompetent patient Inpatient Clinical Process Measures HF_1 Discharge instructions SCIP_INF_1 Prophylactic antibiotic received within 1 hour prior to surgical incision SCIP_INF_2 Prophylactic antibiotic selection for surgical patients SCIP_INF_3 Prophylactic antibiotics discontinued within 24 hours after surgery ends SCIP_INF_4 Cardiac surgery patients with controlled 6 AM postoperative serum glucose SCIP_CARD_2 Surgery patients on a beta blocker prior to arrival that received a beta blocker during the postoperative period SCIP_VTE-1 Surgery patients with recommended venous thromboembolism prophylaxis ordered SCIP-VTE-2 Surgery patients who received appropriate venous thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours after surgery Patient Experience Measures Nurses “‘always” communicated well Doctors “always” communicated well Patients “always” received help as soon as they wanted Pain was “always” well controlled Staff “always” explained Room was “always” clean and room was “always” quiet at night Yes, staff “did” give patients discharge information Patients who gave a rating of “9” or “10” (high) Source: Federal Register 2011;76;26490–547. Additional information on measure specifications can be found in the measure specifications manual on CMS’ QualityNet website: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic% 2FPage%2FQnetTier4&cid=1228771525863. AMI = acute myocardial infarction; CAP = community-acquired pneumonia; CARD = cardiac; HF = heart failure; INF = infection; PCI = percutaneous coronary intervention; PN = pneumonia; SCIP = surgical care improvement project; VTE = venous thromboembolism. *ED-related measures. ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org Christian Health Administrator Discussion Paper

Healthcare Research and Quality, and asks patients about their experience in the hospital. Although public reporting of data on Hospital Compare is voluntary, only hospitals that report their performance measures are eligible for a full Medicare payment update. Ninetyseven percent of hospitals satisfactorily met the reporting requirements in 2010.14 We linked these data to the 2009 American Hospital Association Annual Survey, which contains information on hospital characteristics (e.g., size, ownership, region, teaching status) to compare the characteristics of the study hospitals with all other general medical and surgical hospitals. Study Protocol We limited our analysis to hospitals that met the criteria for the HVBP program. Hospitals must be acute care hospitals paid under the Inpatient Prospective Payment System (IPPS). An exception was made for acute care hospitals in Maryland, which are not paid under the IPPS, but are included in the program. Additionally, between 2009 and 2010, hospitals must have reported data from at least 100 HCAHPS surveys and data for at least four clinical process measures with at least 10 eligible cases Christian Health Administrator Discussion Paper.

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We calculated scores for each performance measure according to the method used by CMS for the HVBP program, the details of which are described in the program’s Final Rule published in the Federal Register on May 6, 2011.2 In brief, for each performance measure, hospitals receive an achievement score between 1 and 10 based on how much their current performance score exceeds the median for all hospitals. If the score is below the median, the hospital receives an achievement score of 0. Additionally, hospitals also receive an improvement score between 1 and 10 based on how much the score on the performance measure improved from the previous (i.e., baseline) year. If performance did not improve, the hospital receives an improvement score of 0. Under the HVBP program, the final performance score is the higher of the achievement or improvement score. However, because we were interested in looking at both achievement and improvement, we investigated both scores separately. In administering the HVBP program, CMS calculates a composite score for all clinical process measures included in the program.  Christian Health Administrator Discussion Paper