1. The Relationship Between Organizational Factors and Performance Among Pay-for- Performance Hospitals Vina ER, Rhew DC, Weingarten SR, Weingarten JB, Chang JT.

2. Background Pay for Performance (P4P) Hospital Quality Incentive Demonstration (HQID) Project Rewarding high performance hospitals with 2% bonus on Medicare payments

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

4. 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)

5. Study sample

6. 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)

7. 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 their QI activities during the past year

8. QI domains 1.Quality improvement (QI) interventions 2.Data feedback systems (quality compliance) 3.Physician leadership 4.Organizational support for QI 5.Organizational culture

9. 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

10. Hospital characteristics

11. QI interventions *P <.01

12. QI interventions *P <.01

13. QI interventions: Electronic capabilities

14. Data feedback

15. Physician leadership Among hospital CMOs with the general role of improving quality, –Percentage who recruited “physician champions” (82.1% vs 69.4%, P<.05).

16. Organizational support

19. Organizational culture

24. Limitations Voluntary participants in a P4P program Participants not blinded own performance rankings Unable to evaluate association of QI efforts to future performance

25. Conclusions Main factors associated with high performance: –Organizational structure –Organizational support for QI –Organizational culture

26. Policy implications Strategies should encourage development of improved organizational structure, support and culture for quality Develop and strengthen resources to support QI activities

27. Acknowledgements Zynx Health, Inc. Premier, Inc. Centers for Medicare & Medicaid Services

28. Questions?

29. 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 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 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.

30. 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.

31. BACK-UP SLIDES

34. QI Interventions

35. *P <.05; ‡P <.01.

36. Results, Summary