Genomic Diversity and Phenotypic Variation in Fungal Decomposers Involved in Bioremediation of Persistent Organic Pollutants.

Fungi work as decomposers to break down organic carbon, deposit recalcitrant carbon, and transform other elements such as nitrogen. The decomposition of biomass is a key function of wood-decaying basidiomycetes and ascomycetes, which have the potential for the bioremediation of hazardous chemicals present in the environment. Due to their adaptation to different environments, fungal strains have a diverse set of phenotypic traits. This study evaluated 320 basidiomycetes isolates across 74 species for their rate and efficiency of degrading organic dye. We found that dye-decolorization capacity varies among and within species. Among the top rapid dye-decolorizing fungi isolates, we further performed genome-wide gene family analysis and investigated the genomic mechanism for their most capable dye-degradation capacity. Class II peroxidase and DyP-type peroxidase were enriched in the fast-decomposer genomes. Gene families including lignin decomposition genes, reduction-oxidation genes, hydrophobin, and secreted peptidases were expanded in the fast-decomposer species. This work provides new insights into persistent organic pollutant removal by fungal isolates at both phenotypic and genotypic levels.

Identifying and overcoming implementation challenges: Experience of 59 noninstitutional long-term services and support pilot programs in the Veterans Health Administration.

BACKGROUND: From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs. PURPOSE: The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced. METHODOLOGY: Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded. RESULTS: The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources. DISCUSSION: This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support). IMPLICATIONS: Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.

Team Process Variation Across Diabetes Quality of Care Trajectories.

Conceptual frameworks in health care do not address mechanisms whereby teamwork processes affect quality of care. We seek to fill this gap by applying a framework of teamwork processes to compare different patterns of primary care performance over time. We thematically analyzed 114 primary care staff interviews across 17 primary care clinics. We purposefully selected clinics using diabetes quality of care over 3 years using four categories: consistently high, improving, worsening, and consistently low. Analyses compared participant responses within and between performance categories. Differences were observed among performance categories for action processes (monitoring progress and coordination), transition processes (goal specification and strategy formulation), and interpersonal processes (conflict management and affect management). Analyses also revealed emergent concepts related to psychological and organizational context that were reported to affect team processes. This study is a first step toward a comprehensive model of how teamwork processes might affect quality of care.

Making housing first happen: organizational leadership in VA's expansion of permanent supportive housing.

BACKGROUND: While most organizational literature has focused on initiatives that transpire inside the hospital walls, the redesign of American health care increasingly asks that health care institutions address matters outside their walls, targeting the health of populations. The US Department of Veterans Affairs (VA)'s national effort to end Veteran homelessness represents an externally focused organizational endeavor. OBJECTIVE: Our aim was to evaluate the role of organizational practices in the implementation of Housing First (HF), an evidence-based homeless intervention for chronically homeless individuals. DESIGN: This was an interview-based comparative case study conducted across eight VA Medical Centers (VAMCs). PARTICIPANTS: Front line staff, mid-level managers, and senior leaders at VA Medical Centers were interviewed between February and December 2012. APPROACH: Using a structured narrative and numeric scoring, we assessed the correlation between successful HF implementation and organizational practices devised according to the organizational transformation model (OTM). KEY RESULTS: Scoring results suggested a strong association between HF implementation and OTM practice. Strong impetus to house Veterans came from national leadership, reinforced by Medical Center directors closely tracking results. More effective Medical Center leaders differentiated themselves by joining front-line staff in the work (at public events and in process improvement exercises), by elevating homeless-knowledgeable persons into senior leadership, and by exerting themselves to resolve logistic challenges. Vertical alignment and horizontal integration advanced at sites that fostered work groups cutting across service lines and hierarchical levels. By contrast, weak alignment from top to bottom typically also hindered cooperation across departments. Staff commitment to ending homelessness was high, though sustainability planning was limited in this baseline year of observation. CONCLUSION: Key organizational practices correlated with more successful implementation of HF for homeless Veterans. Medical Center directors substantively influenced the success of this endeavor through their actions to foster impetus, demonstrate commitment and support alignment and integration.

VA's expansion of supportive housing: successes and challenges on the path toward Housing First.

OBJECTIVES: The U.S. Department of Veterans Affairs (VA) is transitioning to a Housing First approach to placement of veterans in permanent supportive housing through the use of rental vouchers, an ambitious organizational transformation. This qualitative study examined the experiences of eight VA facilities undertaking this endeavor in 2012. METHODS: A multidisciplinary team interviewed facility leadership, midlevel managers, and frontline staff (N=95 individuals) at eight VA facilities representing four U.S. regions. The team used a semistructured interview protocol and the constant comparative method to explore how individuals throughout the organizations experienced and responded to the challenges of transitioning to a Housing First approach. RESULTS: Frontline staff faced challenges in rapidly housing homeless veterans because of difficult rental markets, the need to coordinate with local public housing authorities, and a lack of available funds for move-in costs. Staff sought to balance their time spent on housing activities with intensive case management of highly vulnerable veterans. Finding low-demand sheltering options (that is, no expectations regarding sobriety or treatment participation, as in the Housing First model) for veterans waiting for housing presented a significant challenge to implementation of Housing First. Facility leadership supported Housing First implementation through resource allocation, performance monitoring, and reliance on midlevel managers to understand and meet the challenges of implementation. CONCLUSIONS: The findings highlight the considerable practical challenges and innovative solutions arising from a large-scale effort to implement Housing First, with particular attention to the experiences of individuals at all levels within an organization.

The relationship between organizational climate and quality of chronic disease management.

OBJECTIVE: To test the utility of a two-dimensional model of organizational climate for explaining variation in diabetes care between primary care clinics. DATA SOURCES/STUDY SETTING: Secondary data were obtained from 223 primary care clinics in the Department of Veterans Affairs health care system. STUDY DESIGN: Organizational climate was defined using the dimensions of task and relational climate. The association between primary care organizational climate and diabetes processes and intermediate outcomes were estimated for 4,539 patients in a cross-sectional study. DATA COLLECTION/EXTRACTION METHODS: All data were collected from administrative datasets. The climate data were drawn from the 2007 VA All Employee Survey, and the outcomes data were collected as part of the VA External Peer Review Program. Climate data were aggregated to the facility level of analysis and merged with patient-level data. PRINCIPAL FINDINGS: Relational climate was related to an increased likelihood of diabetes care process adherence, with significant but small effects for adherence to intermediate outcomes. Task climate was generally not shown to be related to adherence. CONCLUSIONS: The role of relational climate in predicting the quality of chronic care was supported. Future research should examine the mediators and moderators of relational climate and further investigate task climate.

Job satisfaction of primary care team members and quality of care.

In recent years, hospitals and payers have increased their efforts to improve the quality of patient care by encouraging provider adherence to evidence-based practices. Although the individual provider is certainly essential in the delivery of appropriate care, a team perspective is important when examining variation in quality. In the present study, the authors modeled the relationship between a measure of aggregate job satisfaction for members of primary care teams and objective measures of quality based on process indicators and intermediate outcomes. Multilevel analyses indicated that aggregate job satisfaction ratings were associated with higher values on both types of quality measures. Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care.

Accounting for variation in technical quality and patient satisfaction: the contribution of patient, provider, team, and medical center.

BACKGROUND: The delivery of healthcare depends on individual providers, coordination within teams, and the structure of the work setting. We analyzed the amount of variation in technical quality and patient satisfaction accounted for at the patient, provider, team, and medical center level. METHODS: Data abstracted from Veterans Health Administration patient medical records for 2007 were used to calculate measures of technical quality based on adherence to best practice guidelines in 5 domains. Outpatient satisfaction was obtained from a 2007 standardized national mail survey. Hierarchical linear models that accounted for the clustering of patients within providers, providers within teams, and teams within medical centers were used to partition the variation in technical quality and satisfaction across patients and components of the system (ie, providers, teams, and medical centers). RESULTS: Providers accounted for the largest percent of system-level variance for all technical quality domains, ranging from 46.5% to 71.9%. For the single-item measure of patient satisfaction, medical centers, teams, and providers accounted for about the same percent of system-level variance (31%-34%). For the doctor/patient interaction scale providers explained 59.9% of system-level variance, more than double that of teams and medical centers. For all the measures, the residual variance (composed of patient-level and random error) explained the largest proportion of the total variance. CONCLUSIONS: Providers explained the greatest amount of system-level variation in technical quality and patient satisfaction. However, in both of these domains, differences between patients were the predominant source of nonrandom variance.

Pay-for-performance in safety net settings: issues, opportunities, and challenges for the future.

A major trend among Medicaid programs is the adoption of pay-for-performance (P4P) programs, but little evidence exists about the impact of these programs on quality improvement. Our in-depth case investigation of P4P in two safety net settings suggests that such programs may have minimal short-term effect on quality improvement. Two potentially important barriers for P4P in safety net settings are limited motivational effects from financial incentives and complex patient care requirements. We did not uncover any opposition against P4P among providers, nor did we find any evidence that P4P programs may compromise quality of care through unintended consequences. Overall, study results point to opportunities to improve the design and implementation of P4P programs in safety net settings.

Physician attitudes toward pay-for-quality programs: perspectives from the front line.

Pay-for-quality (P4Q) initiatives are becoming an increasingly popular mechanism for improving quality performance and reducing health care costs in the United States. Because these programs often target primary care physicians, it is important to understand how these physicians perceive and respond to P4Q to design successful programs going forward. This study reports results of a survey regarding attitudes toward P4Q among physicians participating in such programs in Massachusetts and California. Findings indicate physicians have generally positive attitudes toward the concept of P4Q, but are ambivalent about certain features of these programs as currently designed and implemented.

Effects of paying physicians based on their relative performance for quality.

BACKGROUND: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. OBJECTIVE: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. PARTICIPANTS: There were 334 participating primary care physicians in Rochester, New York. DESIGN: The design of the study is a retrospective cohort study using pre/post analysis. MEASUREMENTS: The measurements adhere to 4 diabetes performance measures between 1999 and 2004. RESULTS: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. CONCLUSIONS: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

The early experience of a hospital-based pay-for-performance program.

This study evaluated the effect of a health-plan-sponsored, hospital-based financial incentive program, focused on heart-failure quality indicators, to improve quality. We conducted separate, hour-long, semistructured group interviews with senior managers and cardiologists at ten hospitals involved in the Participating Hospital Agreement (PHA) program implemented by Blue Cross Blue Shield of Michigan (BCBSM). Under PHA, hospitals are eligible for an annual incentive payment of up to 4 percent of BCBSM's diagnosis-related-group-based inpatient claims, depending on their performance in patient safety, community outreach, and selected quality indicators. Interviews focused on knowledge, perceptions, and impact of pay-for-performance (P4P) strategies. We compared BCBSM-provided data on heart-failure quality indicators between 2002 and 2004 with our qualitative findings. Our analyses suggest that pursuit of incentive-based quality targets may be largely dependent on the context of a particular hospital. In settings where performance did not change, incentives did not appear to drive organizational or individual practice changes. Underperforming hospitals with some of the infrastructure necessary for quality improvement had the greatest success when presented with incentives. We concluded that one formula for a successful P4P program is to direct incentive payment to an organized entity capable of supporting process improvement by applying resources and organizational expertise. In this model, the incentive program supports the organization, and the organization in turn may apply resources to facilitate improvement in clinician performance. Consideration of the requirements of organizations to facilitate improvement in relation to existing quality improvement infrastructure may lead to the future success of hospital-based P4P programs.

Pay-for-performance as a method to establish the business case for quality.

One of the major reasons providers give for not implementing promising quality-enhancing interventions (QEI) is that no "business case" for quality has been made. This article clarifies the concepts of the business case for quality and the related economic case for quality and identifies the perspectives of the various actors in health care financing, production, and consumption decisions. A methodology to evaluate the business case for quality from the perspective of payers and providers is presented. The article then uses implemented QEIs to show how a pay-for-performance (P4P) program can alter the business cases for payers and providers. Specifically, the P4P programs described in this article allow a provider to implement a QEI with the financial alignment of the payer in order to achieve financial and non-financial benefits. In some cases, providers and payers may be able to establish P4P programs providing net benefits for both parties.

Pioneering pay-for-quality: lessons from the rewarding results demonstrations.

This article reports six overarching lessons learned from seven pioneering initiatives in the pay-for-quality (P4Q) movement. These lessons relate to the specific design and implementation challenges sponsors of P4Q programs can expect. The lessons are: (1) P4Q can prioritize providers' quality goals, (2) provider engagement is difficult, (3) P4Q escalates concerns for data accuracy and validity, (4) P4Q increases the need for population-based information technology and infrastructure, (5) tradeoffs exist between stimulating investment in quality infrastructure and diluting the power of incentives for individuals, and (6) significant challenges exist in documenting a positive return on investment.

Provider attitudes toward pay-for-performance programs: development and validation of a measurement instrument.

OBJECTIVE: To develop an instrument for assessing physician attitudes toward quality incentive programs, and to assess its reliability and validity. DATA SOURCES: Study involved primary data collection. A 40-item paper and pencil survey of primary care physicians in Rochester, New York, and Massachusetts was conducted between May 2004 and December 2004. Seven-hundred and ninety-eight completed questionnaires were received, representing a response rate of 32 percent (798/2,497). STUDY DESIGN: Based on an extensive review of the literature and discussions with experts in the field, we developed a conceptual framework representing the features of pay-for-performance (P4P) programs hypothesized to affect physician behavior in that context. A draft questionnaire was developed based on that conceptual model and pilot tested in three groups of physicians. The questionnaire was modified based on the physician feedback, and the revised version was distributed to 2,497 primary care physicians affiliated with two of the seven sites participating in Rewarding Results, a national evaluation of quality target and financial incentive programs. DATA COLLECTION: Respondents were randomly divided into a derivation and a validation sample. Exploratory factor analysis was applied to the responses of the derivation sample. Those results were used to create scales in the validation sample, and these were then subjected to multitrait analysis (MTA). One scale representing physicians' perception of the impact of P4P on their clinical practice was regressed on the other scales as a test of construct validity. PRINCIPAL FINDINGS: Seven constructs were identified and demonstrated substantial convergent and discriminant validity in the MTA: awareness and understanding, clinical relevance, cooperation, unintended consequences, control, financial salience, and impact. Internal consistency reliabilities (Cronbach's alpha coefficients) ranged from 0.50 to 0.80. A statistically significant 25 percent of the variation in perceived impact was accounted for by physician perceptions of the other six characteristics of P4P programs. CONCLUSIONS: It is possible to identify and measure the key salient features of P4P programs using a valid and reliable 26-item survey. This instrument may now be used in further studies to better understand the impact of P4P programs on physician behavior.

Incentive implementation in physician practices: A qualitative study of practice executive perspectives on pay for performance.

Pay-for-performance (P4P) programs offer health care providers financial incentives to achieve predefined quality targets. Practice executives sit at a key nexus point for determining how P4P programs are implemented in physician practices. Using a qualitative interview design, this article examines the role practice executives play in the implementation of P4P programs and how their perspectives and decisions can influence the success of these programs. The authors identified five key findings related to practice executives' views on P4P: quality incentives are better than utilization incentives, quality incentives are bonus rewards, quality incentives are agents for change, providers do not feel they have control over attaining quality targets, and the ways in which quality is measured are problematic. The authors discuss five different ways in which practice executives distribute rewards to physicians. These findings may help payers more effectively design and implement financial rewards for quality.

Conceptual issues in the design and implementation of pay-for-quality programs.

This article identifies and discusses key conceptual issues in designing and implementing pay-for-quality programs. Such programs offer financial incentives to providers for achieving predefined quality targets. The purpose of the article is to provide health care professionals with a framework for designing, implementing, and evaluating pay-for-quality programs. Examples are drawn from the Rewarding Results demonstration project for which the authors serve as the national evaluation team.