Is emergency department quality related to other hospital quality domains?

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. 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.

An advanced look at surgical performance under Medicare's hospital-inpatient value-based purchasing program: who is winning and who is losing?

BACKGROUND: The Centers for Medicare and Medicaid Services (CMS) is beginning to shift from paying providers based on volume to more explicitly rewarding quality of care. The hospital value-based purchasing (VBP) program is the first in a series of mandatory programs to financially reward and penalize US hospitals based on quality measure performance. Our objective was to identify the characteristics of hospitals that perform well (and those that perform poorly) on the surgical measures in CMS' hospital VBP program. STUDY DESIGN: Using 2008 to 2010 performance data from CMS' Hospital Compare website and the 2009 American Hospital Association annual survey, we examined surgical measure performance for all acute care general hospitals in the US. Outcomes were determined by a composite surgical performance score indicating the percentage of eligible surgical performance points that a hospital received. RESULTS: There were 3,030 hospitals included in our study. Composite surgical performance scores were 15.6% lower at public hospitals than at for-profit hospitals (p < 0.01). Additionally, there were significant differences in the routes by which hospitals achieved points, with smaller hospitals, for-profit hospitals, Magnet hospitals, and NSQIP hospitals all more likely to obtain points via the achievement route. CONCLUSIONS: The results of our study indicate that public hospitals perform worse on the surgical measures in the hospital VBP program. This study raises important questions about the impact that this new, mandatory program will have on public hospitals, which serve an important safety-net role and appear to be disadvantaged in the hospital VBP program. This issue should continue to be investigated as these mandatory quality programs are updated in future years.

An early look at performance on the emergency care measures included in Medicare's hospital inpatient Value-Based Purchasing Program.

STUDY OBJECTIVE: Medicare's new, mandatory Hospital Inpatient Value-Based Purchasing Program introduces financial rewards or penalties to hospitals according to achievement or improvement on several publicly reported quality measures. Our objective was to describe hospital reporting on the 4 emergency department (ED)-related program measures, variation in performance on the ED measures across hospital characteristics, and the characteristics of hospitals that were more likely to receive performance scores based on improvement versus achievement. METHODS: This was an exploratory, descriptive analysis. We merged 2008 to 2010 performance data from Hospital Compare with the 2009 American Hospital Association Annual Survey. We calculated a composite score for the 4 ED measures and used Kruskal-Wallis tests to examine differences in performance across hospital characteristics. We also examined differences in the percentage of scores that were awarded according to improvement versus achievement. RESULTS: There were 2,927 hospitals that qualified for the value-based purchasing program and were included in the analysis. For-profit hospitals received the highest scores; public hospitals and hospitals lacking The Joint Commission (TJC) accreditation received the lowest scores. Public hospitals had the largest share of scores awarded according to improvement (39.8%); for-profit hospitals had the lowest (27.8%). CONCLUSION: We found variation in performance by hospital characteristics on the ED-related program measures. Although public and non-TJC-accredited hospitals trailed in performance, they showed strong signs of improvement, signaling that performance gaps by ownership and accreditation may decrease. Considering the increasing scope of the value-based purchasing program, ED leaders should monitor both achievement and improvement on the 4 ED-related program measures.