The "new economics" of clinical quality improvement: the case of community-acquired pneumonia.EXECUTIVE SUMMARY
Hospitals and health systems have developed substantial infrastructure, at significant expense, to improve care quality and support the collection and distribution of quality metrics. Yet providers often have little understanding of what return, if any, they have earned on the investment because they typically view quality improvement efforts simply as a cost of doing business. After analyzing data from 10,512 patients with community-acquired pneumonia community-acquired pneumonia Pneumonia caused by an infection currently present in the community; CAP is the most common cause of infectious death–US, and number 6 killer overall; of the 57% of CAPs in which a pathogen is identified, S pneumoniae , we found that better performance on two quality measures was associated with shorter length of stay and improved financial performance. For example, a one-day decrease in the time until patients were shifted from intravenous to oral antibiotics was associated with a 0.8-day reduction in length of stay and a nearly 60 percent increase in margins. Providers can adapt the methods we used to derive these findings to identify other quality metrics that simultaneously increase care quality and generate economic value. To derive maximum clinical and financial benefit, however, providers must ensure that clinical quality staff members are adequately supported and skilled to set priorities and to implement effective initiatives.
Ensuring the quality of care delivered to sick and injured patients is central to the mission of all hospitals and health systems. Yet providers waste millions of dollars annually on efforts to improve clinical quality. Too often, the investments yield neither benefits to patients (Dedier et al. 2001; Saint et al. 2003; Stone et al. 2005) nor proven economic return (HFMA HFMA Healthcare Financial Management Association
HFMA Hawaii Food Manufacturer's Association 2005; Leatherman et al. 2003). It need not be this way. When properly focused, efforts to improve care quality can both enhance patient outcomes and generate economic value for providers. When such efforts are bolstered with strong senior executive support and an execution-oriented skill set, they can give providers a sustainable competitive advantage--both clinically and financially.
Obtaining these results is not easy. The process requires providers to think more strategically about their efforts to improve quality--that is, where they should focus and which skills are necessary to enable performance improvement. However, given the centrality of quality to organizational mission and the tight margins most providers face, we believe the journey is well worth undertaking. In this article, we demonstrate how providers' investments in quality, when properly focused and executed, can simultaneously improve patient care and generate attractive financial returns. Although our examples focus on community-acquired pneumonia (CAP), our recommendations could be applied in a variety of hospital settings. Successful implementation, however, requires that providers have appropriate metric selection and solid frontline front·line also front line
1. A front or boundary, especially one between military, political, or ideological positions.
2. Basketball See frontcourt.
3. Football The linemen of a team. skills and resources in place to sustain improvement.
TODAY'S APPROACH TO QUALITY
Hospitals and health systems have developed--at significant and increasing expense--intricate processes and substantial infrastructure to improve the quality of care and support the collection, verification, and distribution of information related to quality of care. Why do providers invest in these efforts if they are not producing direct financial benefit and if the evidence for clinical benefit is not always clear? In addition to wanting to ensure care quality, today's providers must respond to political and regulatory pressures as well as to the growing demands of increasingly active consumers. The Joint Commission (2006), for example, requires providers to report compliance with an evolving set of core measures and publishes the results on its website. Several other groups also publicly rate providers (IPRO IPRO Island Peer Review Organization 2006; HHS HHS Department of Health and Human Services. 2006; U.S. News & World Report 2005). Increasingly, many providers are viewing pay-for-performance programs as an important, albeit indirect, source of value (Safavi 2006).
These forces have combined to make quality improvement (QI) (1) a top priority for providers. Yet several factors currently impede QI efforts, including a lack of executive leadership, a lack of organized focus on concomitant financial outcomes, discrepancies between who must bear the cost of certain treatments and who benefits (financially or otherwise) from those treatments, and inappropriate frontline staff skill sets.
Lack of Leadership
Most senior hospital and health system executives have remained largely uninvolved un·in·volved
Feeling or showing no interest or involvement; unconcerned: an uninvolved bystander.
Adj. 1. in QI efforts (Meurer et al. 2004). Typically, they take a hands-off approach to clinical matters, leaving decisions about patient care to physicians and other health professionals. Perhaps as a result, it has been regulatory agencies, medical societies, and payers--not providers--that have led the debate over which quality metrics to measure. (Payers may be the most sophisticated in their ability to assess the economic consequences of QI agendas, but their perspective and goals are often quite different from those of providers [Safavi 2006].) Because most senior executives have remained uninvolved in QI efforts, they tend to regard those efforts as an unavoidable cost of doing business, not as a strategic investment. They rarely demand the types of financial returns that similar investments in efficiency improvements or supply chain management might yield. Even more rarely do they attempt to measure the extent of such returns (HFMA 2005).
Yet the absence of senior executive involvement may send an inadvertent signal that such efforts do not have strong organizational support. Indeed, lack of leadership may partially explain why many physicians neither participate in QI activities nor modify their behavior in response to change initiatives (Audet et al. 2005; Bradley et al. 2003).
Lack of Organized Focus on Financial Outcomes
Currently, the QI agendas for most providers are set by stakeholders Stakeholders
All parties that have an interest, financial or otherwise, in a firm-stockholders, creditors, bondholders, employees, customers, management, the community, and the government.
with few incentives to think through the financial implications of their decisions (Shulkin 2000). At most hospitals and health systems, the agenda is developed by the medical staff and QI directors (typically, nurses who have transitioned into an administrative role). These people select the metrics they are required to report or those they believe are the most clinically important. The financial impact (positive or negative) of their decisions is a secondary consideration.
Regulators, medical societies, and other interest groups use similar methods to set their QI agendas; again, the financial impact on providers is not a central concern. For example, both the Joint Commission (2002) and the Centers for Medicare & Medicaid Services (2005) have defined oxygenation oxygenation /ox·y·gen·a·tion/ (ok?si-je-na´shun)
1. the act or process of adding oxygen.
2. the result of having oxygen added. assessment as a core measure for CAP patients. Because these groups require that the percentage of hospitalized CAP patients who undergo this assessment be monitored, providers must assign nurses not only to measure oxygenation levels but also to double-check and report on whether such measurements have been taken. Yet the Joint Commission (2002) has acknowledged that before the test was defined as a core measure, oxygenation assessment was being performed in 95 percent of hospitalized CAP patients. Thus, the requirement to report compliance with this assessment is unlikely to have a substantive effect on patient outcomes, but it does increase providers' costs.
Providers must often shoulder the cost of interventions designed to improve patient outcomes, even though the benefits are not realized until after discharge and thus accrue to other stakeholders. For example, predischarge pneumococcal pneumococcal /pneu·mo·coc·cal/ (-kok´al) pertaining to or caused by pneumococci. vaccination requires providers to pay for the cost of the vaccine plus the staff to deliver it. However, any subsequent financial rewards from pneumonia prophylaxis prophylaxis (prō'fĭlăk`sĭs), measures designed to prevent the occurrence of disease or its dissemination. Some examples of prophylaxis are immunization against serious diseases such as smallpox or diphtheria; quarantine to confine go to the payer, employer, or patient.
In general, it has been difficult to demonstrate that providers can derive financial benefit from QI efforts (Leatherman et al. 2003). We have found, however, that hospitals can derive financial benefit from QI efforts that reduce costs immediately (Table 1). Examples of such efforts include strategies to decrease the rate of uncompensated uncompensated (n·kômˑ·p complications and, in many cases, to lower length of stay (LOS) (HFMA 2004). The best approach, therefore, is to focus on quality metrics that not only increase compliance with regulatory requirements but also provide immediate improvements in care quality and significant economic value to providers.
Inappropriate Skill Sets
Even if QI staff members are given strong incentives to focus on the financial implications of their decisions, they may not have the skills or resources to do so. Frontline QI personnel often have no training in the analyses needed to identify which problems are most significant, which quality metrics create the greatest financial value, or even which changes have the greatest effect on patient outcomes (Sullivan, Bretschneider, and McCausland 2003). In many cases, team members lack the ability to execute effective quality improvement efforts (Woodard 2005). As Barron and colleagues (2005, 225) have noted, performance improvement in healthcare requires "knowledge and tools that reside largely outside the training and experience of most clinicians and health care managers."
Frontline QI personnel also often lack the skills necessary to influence physicians' behavior (Shulkin 2000). Yet if improvement efforts are to succeed, a compelling case for change must be made to the hospital's physicians (Bradley et al. 2003). To assess the effectiveness of hospital quality staff in leading QI initiatives, we conducted a survey of 69 frontline QI directors at one healthcare system (the response rate was 80 percent). The directors reported that they spent, on average, only about 5 percent of their time conducting analyses to inform their choice of metrics (Table 2 and Figure 1). (In fairness, more than half of the metrics they track are Joint Commission requirements.) Fewer than one-third said they consistently use analytic techniques to understand processes, diagnose bottlenecks, and track improvement. More typically, the directors focus on basic compliance and administrative tasks (e.g., data gathering, validation, and distribution of quality metrics) or on "putting out fires." Only 10 percent of their time is spent on activities directly related to improving quality of care.
BUSINESS CASE FOR QI
Providers that want to improve their focus on financial outcomes should begin by using a more comprehensive evaluation of how QI investments can affect hospital economics. Four factors must be considered, as shown in the following equation:
Profit from quality improvement =
([DELTA] Volume * [DELTA] Price) - ([DELTA] Cost of QI infrastructure + [DELTA] Cost of inpatient care inpatient care Managed care Services delivered to a Pt who needs physician care for > 24 hrs in a hospital )
Historically, the primary lever that providers used to increase the impact of QI efforts was to minimize the cost of their QI infrastructure. Volume and price came into play only when payers, employers, or patients demanded greater (or lesser) access to care or looked less favorably on hospitals with poor perceived quality. More recently, providers have put greater emphasis on volume and price because of their concern about quality scorecards: the information in these scorecards may enable healthcare purchasers/consumers to divert volume to providers of choice, and it has given both purchasers and providers a new negotiating lever. For example, certain governmental organizations and large payers have established criteria that allow some providers to be defined as centers of excellence (OWH OWH Office of Women's Health (US CDC)
OWH Overtime Work Hours 2006; UHC UHC UnitedHealthcare
UHC United Health Care
UHC University Hospitals of Cleveland
UHC United Hitech Corporation
UHC Udvar-Hazy Center (National Air and Space Museum)
UHC University Health/System Consortium
UHC Unburned Hydrocarbons 2006); providers with that designation often experience a boost in volume.
Furthermore, providers may qualify for additional reimbursement Reimbursement
Payment made to someone for out-of-pocket expenses has incurred. under pay-for-performance programs if they can demonstrate compliance with the programs' guidelines (Alexander 2005; O'Hare 2005; Safavi 2006). Many providers may have overlooked the fourth lever--the cost of inpatient care--as a way to profit from QI efforts. Yet we believe this lever is very important.
To investigate this hypothesis, we examined a database containing clinical and administrative records for 10,512 primary admissions for adult CAP; all patients had been admitted to a 97-hospital healthcare system between June 2002 and December 2003. The healthcare system we studied includes a variety of small (25-50 bed) to large (400-600 bed) community hospitals as well as five academic medical centers. The hospitals have significant autonomy with regard to the focus of, and approach used in, their clinical quality programs. However, the system imposes a few structural requirements (e.g., each hospital must employ a director of clinical QI and participate in Leapfrog initiatives). Furthermore, a corporate (systemwide) clinical quality department provides training and information to the QI staff at each institution.
To identify appropriate patients, we used the Joint Commission's definition of pneumonia and specific demographic and clinical criteria--for example, all patients had to be at least 18 years old, they had to be discharged alive within 19 days of admission (the 95th percentile of LOS in our dataset), and those who were readmitted to the same hospital within 14 days were excluded. Because LOS has such a strong impact on inpatient costs, many of our analyses focused on CAP metrics that might reduce this variable. Both simple t-test and multivariate analyses were used to investigate relationships among the various parameters. The linear multivariate regressions included the standard Joint Commission CAP metrics captured during hospitalization--for example, whether blood cultures were drawn before antibiotic administration, whether the first dose of antibiotics was given within four hours of admission, whether the antibiotics were appropriate, and whether an oxygenation assessment was completed.
All of these metrics were entered as dichotomized variables, Joint Commission CAP metrics associated with discharge (e.g., pneumococcal vaccination) were not included because they are unlikely to affect LOS. Two metrics were included that were not from the Joint Commission: time to ambulation am·bu·late
intr.v. am·bu·lat·ed, am·bu·lat·ing, am·bu·lates
To walk from place to place; move about.
[Latin ambul and time to conversion from intravenous to oral antibiotic administration; both of these metrics were measured in days. All of the analyses were adjusted for sex, age, pneumonia severity index The pneumonia severity index is a clinical prediction rule that medical practitioners can use to calculate the probability of morbidity and mortality among patients with community acquired pneumonia. , and admission source. They were conducted using STATA (version 8, College Station, Texas College Station is a city in Brazos County, Texas, situated in Central Texas. It is located in the heart of the Brazos Valley. The city is located within the most populated region of Texas, near to three of the 10 largest cities in the United States - Houston, Dallas, and San ).
Evidence of Clinical Benefit
Four of the six CAP measures investigated were not associated with any change in mean LOS: rapidity of initial antibiotic administration, antibiotic selection consistent with guidelines, assessment of oxygenation, and performance of blood cultures. However, two metrics--time to oral antibiotic conversion and time to ambulation--had a statistically significant association with hospitalization hospitalization /hos·pi·tal·iza·tion/ (hos?pi-t'l-i-za´shun)
1. the placing of a patient in a hospital for treatment.
2. the term of confinement in a hospital. duration. Each one-day reduction in time until patients were converted from intravenous to oral antibiotics was associated with a 0.8-day (95 percent confidence interval confidence interval,
n a statistical device used to determine the range within which an acceptable datum would fall. Confidence intervals are usually expressed in percentages, typically 95% or 99%. [CI], 0.78-0.81) decrease in LOS; each one-day improvement in getting patients to ambulate am·bu·late
intr.v. am·bu·lat·ed, am·bu·lat·ing, am·bu·lates
To walk from place to place; move about.
[Latin ambul was associated with a 0.2-day (95 percent CI, 0.18-0.21) LOS decrease.
Other investigators have also demonstrated that these two clinical practices are associated with decreased LOS, and neither appears to increase the risk of adverse outcomes (Mundy et al. 2003; Rhew et al. 1998). Indeed, our findings suggest that both practices are associated with a lower complication rate. Furthermore, patients report high levels of satisfaction with earlier antibiotic conversion (Ramirez et al. 1999).
As the American College of Chest Physicians has noted, "Hospitalization is not without hazard" (Ramsdell et al. 2005, 1759). Among the risks the ACCP ACCP American College of Chest Physicians
ACCP American College of Clinical Pharmacy
ACCP Army Correspondence Course Program
ACCP Atlantic Climate Change Program
ACCP Association of Caribbean Commissioners of Police
ACCP Assembly of Caribbean Community Parliamentarians cites for hospitalized CAP patients are deconditioning, pressure ulcers, and bacterial colonization colonization, extension of political and economic control over an area by a state whose nationals have occupied the area and usually possess organizational or technological superiority over the native population. with virulent vir·u·lent
1. Extremely infectious, malignant, or poisonous. Used of a disease or toxin.
2. Capable of causing disease by breaking down protective mechanisms of the host. Used of a pathogen.
3. or drug-resistant organisms. These risks are lowered with reduced LOS. Reduced LOS has no impact on the subsequent rates of complications, readmissions, or death as long as CAP patients are clinically stable at discharge and have no severe coexisting illnesses (Mundy et al. 2003; Ramirez et al. 1999; Rhew et al. 1998).
Evidence of Financial Benefit
We then calculated the potential cost savings associated with reduced LOS from earlier ambulation or antibiotic conversion (Table 3). To perform this calculation, we had to determine the direct variable costs that would be saved by eliminating each of these excess days. The provider system we examined uses a cost-accounting system that assigns direct and indirect (variable and fixed) cost dollar values for each charge line item appearing on a patient's bill, using a relative-value-unit methodology that is standard in the provider industry. For CAP patients, the average variable cost across all inpatient days was $876 per day.
We reasoned, however, that the final day of hospitalization might have lower costs, given its generally lower intensity of care. Therefore, we ran a specific analysis that included a group of patients with diagnosis-related group diagnosis-related group Managed care A prospective payment system used by Medicare and other insurers to classify illnesses according to diagnosis and treatment; DRGs are used to group all charges for hospital inpatient services into a single 'bundle' for payment (DRG DRG,
n the abbreviation for diagnosis-related group.
see dorsal respiratory group.
DRG Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and ) 089 (simple pneumonia) to examine just the final 24 hours before discharge. We found that the variable costs for these final 24 hours were 35 percent lower than the average across all days (data not shown), so we used this lower, more conservative estimate to better match true cost savings in reducing LOS for patients with CAP.
On average, a 0.8-day reduction in LOS therefore produced $456 in direct per-patient savings. Assuming that a hospital is reimbursed $8,000 for a given pneumonia patient (based on DRG 089) and earns 10 percent margins at baseline, this $456 savings increases per-patient profit margin by nearly 60 percent.
Factors that Influence Results
Three provider-specific factors affect the actual amount of value that can be captured through this type of QI effort. First, a given hospital's case mix and types of patients admitted will affect the level of savings from any change initiative. Second, the hospital's baseline performance clearly influences how much improvement is possible. Third, the payment system and contract structure a provider has with a payer determines whether savings from reduced LOS accrue directly or indirectly to the hospital. In prospective payment systems (e.g., Medicare), the hospital is at risk for incremental costs; thus, any savings accrue directly to it. But when a hospital is reimbursed on a per diem per diem adj. or n. Latin for "per day," it is short for payment of daily expenses and/or fees of an employee or an agent. basis, LOS reductions can only lower costs indirectly, through negotiating tactics to achieve price concessions (e.g., share-the-value savings). Without such concessions, the savings accrue to the payer; indeed, LOS reductions could be value-destroying for the provider (HFMA 2005). In our study, however, the vast majority of CAP patients with long LOSs were Medicare patients, which suggests that reducing hospitalization duration presents an important economic opportunity.
An additional limitation of our calculations must be noted: we did not quantify several other potentially important drivers of economic value, such as the impact of improved quality metrics on pay-for-performance revenue or negotiating leverage with payers. Furthermore, we did not include the revenues gained from refilling liberated beds in capacity-constrained hospitals or the impact marketing campaigns could have on nonconstrained hospitals. Had we included these other drivers in our calculations, the impact on margins would likely have been higher.
CAPTURING VALUE FROM QI
We identified two quality metrics that are associated with both reduced LOS for patients with CAP and favorable hospital economics. Although our results are promising, we recommend that providers replicate our analyses to confirm the clinical and economic value of these metrics at their institutions. Providers can also use our analyses to assess other quality metrics that are likely to correlate with economic value. These analyses require time and expertise, however: two things that may be lacking at the front line.
If QI efforts are to succeed, providers must invest in training programs for their frontline QI staff; of particular importance is training in analytic and organizational tools (Sullivan, Bretschneider, and McCausland 2003; Woodard 2005). Furthermore, senior executives must lead the way if they want QI efforts to have sustained clinical and financial impact (Barron et al. 2005). Finally, broad awareness of, and commitment to, the quality agenda among all constituents (physicians, nurses, and ancillary staff) is crucial for successful QI efforts (HFMA 2004).
Unfortunately, getting buy-in from physicians for change initiatives is notoriously difficult (Audet et al. 2005). One method that has proved effective is to report accurate quality metric profiles on a physician-by-physician basis (Ballard 2005; HFMA 2004). (The physicians' identities are disguised in the public report, but each of them knows his or her own results.) Presenting these reports to physicians requires not only a firm grounding in clinical data but also the confidence to challenge existing perspectives.
Improving frontline capabilities is the best way to ensure the success of change initiatives. However, some hospitals have another option available to them: system-level clinical quality organizations. These organizations generally have more resources and better access to the databases that can help define the optimal set of quality metrics for each hospital. Based on the value at stake, we believe a stronger role for and significant upfront investment in these organizations are justified.
Many providers can perform better on their dual mission--to deliver high-quality patient care while ensuring economic stability and strength--if they focus their QI efforts on a rigorously derived set
We did not analyze the incremental cost required to successfully transform QI efforts, because they vary substantially from provider to provider. (They are heavily dependent on each provider's baseline skill mix and infrastructure.) It seems reasonable, however, to assume that for many providers, expenses may rise initially, but in many cases these costs will soon be outweighed by the financial and clinical benefits of the quality improvement. Further research to fully understand the impact of QI efforts on provider economics would be valuable. In particular, analyses are needed to quantify the size and financial impact of volume shifts driven by patients, physicians, payers, and employers in response to quality initiatives and to assess the impact of QI efforts on providers' pricing leverage in negotiations with payers.
For more information on the concepts in this article, please contact Dr. Grote at Kurt_Grote@McKinsey.com.
RELATED ARTICLE: Practitioner application.
Louis M. Cocorullo, FACHE FACHE Fellow American College of Healthcare Executives , vice president/chief financial officer, Martin Memorial Health Systems, Stuart, Florida
This article is a valuable addition to the literature for hospital administrators and clinical quality staff who are concerned with earning a return on investment for their clinical quality initiatives.
As a practicing hospital system CFO See Chief Financial Officer. , I am part of the decision to invest hundreds of thousands, if not millions, of the organization's dollars to improve our clinical quality and patient safety outcomes. Much of this investment delivers a clear return in terms of improved clinical outcomes, reduced error rates, and increased patient satisfaction. However, many of us have long appreciated the fact that the clinical improvements that result from this investment also have important financial implications. The financial impact of these clinical benefits is typically not considered when we establish our quality priorities and when we follow those set by the Centers for Medicare and Medicaid Services The Centers for Medicare and Medicaid Services (CMS), previously known as the Health Care Financing Administration (HCFA), is a federal agency within the United States Department of Health and Human Services (DHHS) that administers the Medicare program and (CMS (1) See content management system and color management system.
(2) (Conversational Monitor System) Software that provides interactive communications for IBM's VM operating system. ).
This study, to my knowledge, is the first to provide a useable framework for evaluating the return on these quality investments. It should motivate hospital administrators not only to critically look at the quality measures they are tracking but also to ensure that they are directly involved in setting the agenda for quality improvement initiatives. In my healthcare system, a reduction of a day or more in length of stay for pneumonia patients (who are predominantly covered by Medicare) could generate financial savings--something that would clearly be on my radar screen, and I suspect that many other hospital administrators would think the same way.
The authors focus on just a few examples of quality measures that correlate with financial value, but their work outlines an approach that could be expanded to deal with other financially oriented questions about quality improvement. For example, what other quality measures we use correlate with a reduction in complications, readmissions, or in-hospital costs? While the authors' analytic approach is rigorous, even a simplified approach could have great merit. I can imagine working with the quality staff to identify interventions expected to correlate with reduced cost, testing those hypotheses against retrospective hospital data, and using those findings to shape our focus on quality improvement.
The article indicates the need for an evolving relationship among quality, finance, and operations. Quality leaders understand the impact of their initiatives on patient outcomes; financial leaders can make a similar assessment of quality initiatives to evaluate the initiatives' financial implications. Operational leaders must communicate to frontline staff the importance of quality initiatives and must ensure that staff members (especially the quality staff) are trained appropriately and rewarded for their performance on achieving quality goals as well as financial outcomes.
I do not expect this study to shut down many aspects of my organization's current quality measurement and reporting methods, because measuring and reporting CMS metrics, regardless of their direct financial value, will continue to be important. Nonetheless, this article is very useful in that it points out that clinical quality has a broader role in achieving financial objectives. With the emergence of more pay-for-performance programs, center-of-excellence designations by payers, and volume shifting by payers on the basis of quality and cost, the insight that hospitals should reorganize re·or·gan·ize
v. re·or·gan·ized, re·or·gan·iz·ing, re·or·gan·iz·es
To organize again or anew.
To undergo or effect changes in organization. to connect quality to operations and finance is a timely one.
The approach in this article is intriguing and useable for practitioners in the field. It has the potential to substantially improve a hospital's financial performance.
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n. pl. col·lo·qui·ums or col·lo·qui·a
1. An informal meeting for the exchange of views.
2. An academic seminar on a broad field of study, usually led by a different lecturer at each meeting. , Cambridge, Massachusetts This article is about the city of Cambridge in Massachusetts. For the English university town, see Cambridge, England. For other places, see Cambridge (disambiguation).
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Ramirez, J. A., S. Vargas, G. W. Ritter rit·ter
n. pl. ritter
[German, from Middle High German riter, from Middle Dutch ridder, from r , M. E. Brier brier or briar, name sometimes given any thorny plant, more specifically the sweetbrier, and the greenbrier. French brier, or brierroot, is a name for the root of the European white heath so widely used in the manufacture of smoking pipes. , A. Wright, S. Smith, D. Newman, 1. Burke, M. Mushtaq, and A. Huang. 1999. "Early Switch from Intravenous to Oral Antibiotics and Early Hospital Discharge." Archives of Internal Medicine 159 (20): 2449-54.
Ramsdell, J., G. L. Narsavage, J. B. Fink fink Slang
1. A contemptible person.
2. An informer.
3. A hired strikebreaker.
intr.v. finked, fink·ing, finks
1. To inform against another person. , American College of Chest Physicians' Home Care Network Group. 2005. "Management of Community-Acquired Pneumonia in the Home: An American College of Chest Physicians Clinical Position Statement." Chest 127 (5): 1752-63.
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1. killing microorganisms or suppressing their multiplication or growth.
2. an agent with such effects. Therapy." Chest 113 (1): 142-46.
Safavi, K. 2006. "Patient-Centered Pay for Performance: Are We Missing the Target?" Journal of Healthcare Management 51 (4): 215-18.
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Stone, R. A., M. K. Mot, J. R. Lave, L. J. Hough n. 1. Same as Hock, a joint.
v. t. 1. Same as Hock, to hamstring.
imp. & p. p. os>
p. pr. & vb. n. os>
n. 1. An adz; a hoe.
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U.S. Department of Health and Human Services Noun 1. Department of Health and Human Services - the United States federal department that administers all federal programs dealing with health and welfare; created in 1979
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Six Sigma is a set of practices originally developed by Motorola to systematically improve processes by eliminating defects. A defect is defined as nonconformity of a product or service to its specifications. the Answer?" Journal of Healthcare Management 50 (4): 226-36.
(1.) In this article, we use the term "quality improvement" to describe any type of program designed to enhance the care delivered to patients; it is not meant to characterize any particular type of program.
Kurt Grote, M.D., consultant, McKinsey & Company, Los Angeles Los Angeles (lôs ăn`jələs, lŏs, ăn`jəlēz'), city (1990 pop. 3,485,398), seat of Los Angeles co., S Calif.; inc. 1850. ; Edd Fleming, M.D., consultant, McKinsey & Company, Palo Alto, California “Palo Alto” redirects here. For other uses, see Palo Alto (disambiguation).
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Palo Alto (păl`ō ăl`tō), city (1990 pop. 55,900), Santa Clara co., W Calif.; inc. 1894. Although primarily residential, Palo Alto has aerospace, electronics, and advanced research industries. ; Russell Richmond, M.D., chief medical officer, D2Hawkeye, Boston; Saumya Sutaria, M.D., consultant, McKinsey & Company, Palo Alto; Francine C. Wiest, M.D., Seattle, Washington This page is protected from moves until disputes have been resolved on the .
The reason for its protection is listed on the protection policy page. ; and Jennifer Daley, M.D., associate clinical professor of community health and family medicine, Dartmouth Medical School Dartmouth Medical School is the medical school of Dartmouth College, in Hanover, New Hampshire. The school is closely affiliated with Dartmouth-Hitchcock Medical Center (DHMC) in neighboring Lebanon, New Hampshire. , Hanover, New Hampshire Hanover is a town located on the Connecticut River in Grafton County, New Hampshire, United States. The population was 10,850 at the 2000 census. It is best known as the home of Dartmouth College. , and senior vice president of clinical quality, Tenet Healthcare Tenet Healthcare Corporation (THC) is an operating company that owns and operates 57 hospitals in the United States . It is based in Dallas, Texas. Its stock ticker symbol on the New York Stock Exchange is NYSE: THC. , Dallas, Texas “Dallas” redirects here. For other uses, see Dallas (disambiguation).
The City of Dallas (pronounced [ˈdæl.əs] or [ˈdæl.
TABLE 1 How Timing Affects Who Benefits from Quality Improvement Efforts Stage of Care Acute Illness and After Preventive Hospitalization Hospitalization Quality Pneumococcal * Conversion * Pneumococcal improvement from intravenous vaccination metric vaccination to oral anti- * Provision (examples) biotics in of discharge patients with instructions CAP* * Early ambulation in patients with CAP Sources of Reduced * Reduced LOS ** Reduced financial value rehospitaliza- through quality hospitalization * Reduced comp- tion rate improvement rate lication rate (examples) * Pay-for- performance rewards Primary * Payer/employer * Provider * Payer/employer beneficiaries of * Patient * Payer/employer * Patient financial * Patient savings * Community-acquired pneumonia; ** Length of stay TABLE 2 Responses to Director of Clinical Quality Survey (n = 55) Demographics Experience as director of clinical quality 3.71 (0-15.0) improvement (years, range) Hospital type (percentage) Community hospital 91% Academic medical center 9% Number of beds (percentage) [less than or equal to] 100 15% 101-200 35% 201-300 11% 301-400 28% 400 11% Quality-focused staff in hospital (number, range) 3.77 (0.2-10.0) Director of clinical quality improvement 0.77 (0.2-1.0) Patient safety officer 0.44 (0-1.0) Risk manager 0.69 (0-3.0) Data coordinator 0.74 (0-3.0) Infection control manager 1.13 (0-3.0) Leadership Support Respondents who agree that "hospital leadership provides significant, frequent agenda-shaping guidance on quality improvement" (percentage) About which outcome measures are most important About which metrics should be pursued 25.5% About how improvement in those metrics should 18.2% be driven 25.5% Process Mapping Reported use of process mapping, when applicable, to understand processes, diagnose bottlenecks, and track improvement (percentage) Consistently used 0.9% Inconsistently used 60.0% Never used 9.1 Note: The directors surveyed were all employed by the 97-hospital healthcare system described in the Data Analysis section. TABLE 3 Estimated Average Cost Savings per Hospitalized Patient with CAP *, Based on Two Quality Metrics Savings Earlier Conversion from Intrave- Earlier nous to Oral Ambulation Antibiotics ([dagger]) ([dagger]) A. Average daily variable hospital $876 $876 cost for DRG 089 (simple pneumonia) B. Average decrease in cost for 65% 65% last day of stay C. LOS ** reductions ([dagger]) 0.2 0.8 Total (A x B x C) $114 $456 * Community-acquired pneumonia; ** Length of stay ([dagger]) Each one-day reduction in the time until patients could ambulate was associated with a 0.2-day decrease in LOS; each one-day reduction in the time until patients could be switched from intravenous to oral antibiotics was associated with a 0.8-day decrease in LOS. FIGURE 1 Average Time Allocation by Hospital Quality Directors (Percentages *) Quality Improvement Process Other quality improvement tasks 10 Patient safety tasks 11 Administrative tasks 15 Joint Commission reporting compliance 17 Quality improvement 46 Quality Improvement Process Time Allocation Selecting metrics 11 Gathering data 29 Validating data 25 Distributing data 14 Improving metric 22 Note: Table made from pie graph.