The strategic use of outcome information

BACKGROUND: Most health care executives see outcome measurement as a technical or tactical matter rather than as a strategic tool. Accordingly, provider investment in outcome measurement and management is relatively small. Nevertheless, outcome information can be key to achieving an organization's strategic objectives. Advances in risk adjustment and improvements in technology for data collection and analysis have made outcome measurement a practical tool for individual hospital use. CASE STUDIES: Strategically integrated outcome measurement efforts can give providers a competitive advantage over organizations that only use outcomes tactically. One of the best examples of an acute care provider that has used outcome information for strategic advantage is Intermountain Health Care (IHC; Salt Lake City). In 1997 IHC made clinical quality and outcomes the primary focus of its five-year strategic plan. To support the new strategy IHC's board of trustees approved the development of an outcome information system that generated data along clinical processes of care and the creation of a new management structure to use these data to hold professionals accountable and to set and achieve clinical improvement goals. From 1996 to 1999, IHC's share of the commercial health care market in Utah increased from roughly 50% to about 62% of the market, with the result that it has stopped actively marketing its services. DISCUSSION: Health care executives will not willingly invest in outcomes until they believe that they have business value. Therefore, making the business case for outcomes can help improve the quality of health care and the lives of individuals.     

Implementing guidelines for interdisciplinary care of low back pain: a critical role for pre-appointment management of specialty referrals.

BACKGROUND: Improving health care will require more effective guideline implementation and redesign of delivery processes and systems. Patient referral for specialty care is a key component of health system function that needs to be improved. Low back pain care is a widely documented example of the need for improvement. An interdisciplinary systemwide back pain program was developed using process improvement methods. Proactively managing referrals for specialty care-a departure from traditional referral processes-played a critical role in implementing the program. METHODS: Program components included guidelines for care, defined provider roles, uniform service coding, provider and patient education, pre-appointment specialty referral management, and monitoring of management processes. To evaluate program performance, system back pain visits were compared before, during, and after implementation of referral management. A case series study was performed on 581 consecutive patients with low back pain or lumbar radiculopathy referred for consultative spine care between April 1998 and March 1999. RESULTS: A shift of care was accomplished for acute back pain from spine orthopedists to primary physicians and for chronic back pain from spine orthopedists to medical specialists. More than 95% of initial assignments were accurate. Seventy-six percent of surveyed chronic back pain patients improved, and 90% were highly satisfied with the referral management process. This program has saved an estimated $400,000 per year in manpower cost and has reduced specialty service billings by 20%. DISCUSSION: Pre-appointment referral management offers an approach for improving guideline implementation, access to specialty services, and the effectiveness of care for complex health problems. It deserves broader study and adoption.     

The forgotten component of the quality triad: can we still learn something from "structure"?

BACKGROUND: Quality assessment was founded on structural measures, such as accreditation status of facilities, credentialing of providers, and type of provider. Recent efforts in measures development have focused on processes and outcomes because research has suggested that structural measures are not strong markers of the quality of care at the health plan or provider levels. Nevertheless, the literature on the quality of health care contains a number of examples illustrating the potential application of structural measures to the assessment of quality. The continued development of measures of structure-which would at least measure aspects of the physical environment, working conditions, organizational culture, and provider satisfaction--may be helpful because generalizing from studies of process and outcome requires specification of the conditions under which these linkages are found. A ROAD MAP FOR MEASURES DEVELOPMENT: The Leapfrog Group of large purchasers has promoted the application of three patient safety "leaps" that are, in essence, structural measures: the use of computerized physician order entry, the selective referral of patients to high-volume providers for certain procedures, and the availability of board-certified critical care specialists in intensive care units. Structural measures, like process and outcomes measures, face the same challenges of standardization, reliability, validity, and portability. Field testing of potential measures will be required to examine the feasibility and added value of these measures in real-world settings. CONCLUSION: Research to date suggests that a new cadre of structural measures of health care quality, which have largely been overlooked in the recent measures development boom, have the potential to fill in important gaps in our ability to assess quality.     

Applying the domain management model in treating patients with chronic diseases

BACKGROUND: In the health care system in the United States, the management of chronic health conditions and their functional consequences challenge and frustrate patients, caregivers/families, health care providers, and physicians. Contributing factors include a lack of physician and health care provider training and a health system that emphasizes diagnosis and management of acute illnesses. A broader patient care model is required for patients with chronic disease(s). USING THE DOMAIN MANAGEMENT MODEL (DMM) TO CLASSIFY PATIENTS' CLINICAL PROBLEMS: The DMM is a synthesis of approaches used in internal medicine, geriatric medicine, and physical medicine and rehabilitation. All clinical problems, their treatments, and their outcomes can be classified and followed over time in a multiaxial model with four domains-medical/surgical issues, mental status/emotions/coping, physical function, and living environment. APPLICATIONS OF THE DMM IN MEDICAL RECORD TEMPLATES: Use of the four domain headings in standard templates can lead to an improved awareness of all the relevant issues in the management of chronic illnesses. This awareness precedes a physician's implementation of better care processes. Also, good patient care decisions require good information. MANAGEMENT OF FUNCTIONAL PROBLEMS: The DMM can be used to educate care providers and organize care in terms of important and common functional problem (for example, trouble walking, which lacks a standard approach in health care). CONCLUSION: This common framework for the organization, documentation, and communication of patients' care over time will help teach systematic mangement of chronic health conditions and help with future research on complex patient management.     

The five-year evolution of a malnutrition treatment program in a community hospital

BACKGROUND: Studies suggest that 30%-55% of hospitalized patients are at risk for malnutrition, an avoidable comorbidity contributing to increases in hospitalization and readmission, length of stay, complications, and mortality. Yet a variety of issues have impeded many hospitals' implementation of effective nutrition intervention programs. BENCHMARKING STUDY: St Francis Hospital (SFH), a 395-bed community acute care facility in Wilmington, Delaware, participated in a nationwide benchmark study in fall 1993. In comparison with the 12-hospital means, data for SFH showed both delays in initiating a nutrition care plan for acutely ill patients and a significantly higher risk for malnutrition. NUTRITION SCREENING PILOT: A pilot study was implemented in 1994 to identify nutrition needs within 48 hours of admission as a first step in the improvement process. Although interventions occurred earlier for a greater number of high-risk patients, nutrition intervention was not being provided in a uniform and timely manner. THE MALNUTRITION CLINICAL PATHWAY: A free-standing hospital committee, the Nutrition Care Committee (NCC), with guidance from the care management department, began developing a malnutrition pathway that would serve as an integrated plan for providing nutrition care to high-risk patients. The original pathway was organized into four stages that outlined the progression and timing of care--identification of the patient at high risk for malnutrition, nutrition care decisions, treatment in progress (the remainder of the patient's hospitalization), and discharge planning. OUTCOME STUDIES: Outcome studies were conducted in 1996 and again in 1998 to assess the malnutrition treatment pathway's impact on patient health outcomes and the cost of care. The 1996 outcome study indicated significant improvements in the identification of high-risk patients (from 25.9% to 86%) and the timeliness of nutrition intervention (from 6.9 days to 2.4 days). A second outcome study was conducted in 1998, following revision of the pathway. Comparison of the 1996 after-pathway patient population with a matched study group in 1998 indicated reductions in average length of stay from 10.8 to 8.1 days; the incidence of major complications from 75.3% to 17.5%; and 30-day readmission rates from 16.5% to 7.1%. DISCUSSION: The performance improvement project described in this article began with SHF's voluntary participation in an interdisciplinary benchmarking study and continued when it was apparent that SFH had an opportunity for performance improvement. Forming an NCC at SFH was the first step in a process that gained the administrative support necessary to fully develop the program. SUMMARY AND CONCLUSIONS: SFH has developed and implemented a malnutrition treatment program that is integrated into the care plan of all acute care patients and is included in the discharge planning process. Outcome studies have demonstrated the effect of the malnutrition treatment program on patient recovery and cost of care.     

Taking the national guideline for care of acute myocardial infarction to the bedside: developing the guideline applied in practice (GAP) initiative in Southeast Michigan.

BACKGROUND: The Guideline Applied in Practice (GAP) program was developed in 2000 to improve the quality of care by improving adherence to clinical practice guidelines. For the first GAP project, the American College of Cardiology (ACC) partnered with the Southeast Michigan Quality Forum Cardiovascular Subgroup and the Michigan Peer Review Organization (MPRO) to develop interventions that might facilitate the use of the ACC/AHA Acute Myocardial Infarction (AMI) guideline in the practice setting. Ten Michigan hospitals participated in implementing the project, which began in March 2000. DESIGNING THE PROJECT: The project developed a multifaceted intervention aimed at key players in the care delivery triangle: the physician, nurse, and patient. Intervention components included a project kick-off presentation and dinner, creation and implementation of a customized tool kit, identification and assignment of local nurse and physician opinion leaders, grand rounds site visits, and measurement before and after the intervention. IMPLEMENTING THE PROJECT: The GAP project experience suggests that hospitals are enthusiastic about partnering with ACC to improve quality of care; partners can work together to develop a program for guideline implementation; rapid-cycle implementation is possible with the GAP model; guidelines and quality indicators for AMI are well accepted; and hospitals can adapt the national guideline for care into usable tools focused on physicians, nurses, and patients. DISCUSSION: Important structure and process changes--both of which are required for successful QI efforts--have been demonstrated in this project. Ultimately, the failure or success of this initiative will depend on an indication that the demonstrated improvement in the quality indicators is sustained over time.     

John M. Eisenberg Patient Safety Awards. System innovation: Concord Hospital

BACKGROUND: The Cardiac Surgery Program at Concord Hospital (Concord, NH) restructured clinical teamwork for improved safety and effectiveness on the basis of theory and practice from human factors science, aviation safety, and high-reliability organization theory. A team-based, collaborative rounds process--the Concord Collaborative Care Model--that involved use of a structured communications protocol was conducted daily at each patient's bedside. METHODS: The entire care team agreed to meet at the same time each day (8:45 AM to 9:30 AM) to share information and develop a plan of care for each patient, with patient and family members as active participants. The cardiac surgery team developed a structured communications protocol adapted from human factors science. To provide a forum for discussion of team goals and progress and to address system-level concerns, a biweekly system rounds process was established. RESULTS: Following implementation of collaborative rounds, mortality of Concord Hospital's cardiac surgery patients declined significantly from expected rates. Satisfaction rates of open heart patients scores were consistently in the 97th-99th percentile nationally. A quality of work life survey indicated that in every category, providers expressed greater satisfaction with the collaborative care process than with the traditional rounds process. Practice patterns in the Cardiac Surgery Program at Concord Hospital have changed to a much more collaborative and participatory process, with improved outcomes, happier patients, and more satisfied practitioners. A culture of continuous program improvement has been implemented that continues to evolve and produce benefits.     

Increasing understanding of patient needs during and after hospitalization

BACKGROUND: The value of patient satisfaction surveys in health care improvement remains controversial. This study examined the value of alternative ways of identifying patient needs and estimating importance of those needs in improving the impact of satisfaction surveys. METHODS: Ninety-one acute myocardial infarction (AMI) patients from three southeast U.S. community hospitals were surveyed in 1992. Critical incident and person-focused interviews were used to identify patient needs. Besides overall/global satisfaction with care, patients rated satisfaction with and importance of 12 care delivery and 18 information and support needs. Unmet need scores (importance minus satisfaction) were estimated. Derived importance scores were assessed by correlating global satisfaction with individual need satisfaction scores. A two-step process for identifying priority areas for improvement was proposed. RESULTS: Patients identified and assigned greater scores to unmet needs for information and support needs (not included in typical satisfaction surveys) compared to typically assessed care delivery needs (p < 0.0001). Direct importance ratings differed substantially from those derived through correlation analyses (r = 0.28, p > 0.3 for care delivery needs and r = -0.17, p > 0.4 for information and support needs). Needs that received high importance and low satisfaction scores were all information and support needs. DISCUSSION: Needs that patients consider very important are usually ignored in typical patient surveys. Derived approaches typically used to assess importance of need from satisfaction data may provide misleading results. If satisfaction surveys are to result in real performance improvement, a fresh examination of the content and importance assessment strategies, as proposed, is needed.     

Improving the care of patients with community-acquired pneumonia: a multihospital collaborative QI project

BACKGROUND: Performance of several processes of care was measured in eight acute care hospitals in Connecticut which provided inpatient treatment to 713 elderly patients with community-acquired pneumonia (CAP). BASELINE DATA ABSTRACTION AND FEEDBACK: Chart review feedback was provided, and the hospitals were requested to design their own quality improvement (QI) interventions, after which reexamination of process of care performance was conducted. HOSPITAL QI INTERVENTIONS: Six of the eight hospitals had submitted QI plans. The quality indicators dealing with timeliness of antibiotic delivery were specifically addressed by five hospitals. However, each hospital also picked one or two other processes of care for intervention. RESULTS: The mean time to antibiotic administration decreased from 5.5 hours (+/- 0.2) to 4.7 hours (+/- 0.3; p < 0.0001), and the percentage of patients who received antibiotics within four hours increased from 41.5% to 61.8% (p < 0.0001). DISCUSSION: This project called for obtaining buy-in from both the clinician and administrative representatives of each hospital early in the process. In this way, the targeted processes of care were likely to have relevance for each of the participating hospitals. Education of practicing physicians and other health professionals, as the method chosen by each hospital to address delays in antibiotic administration, appears to have been successful in this project as part of a multifaceted intervention. The project also helped establish a collegial environment that has served as the basis for more ambitious pneumonia QI projects. SUMMARY AND CONCLUSIONS: Widespread improvements in process of care performance can result from hospitals' participation in Quality Improvement Organization collaboration.     

Developing indicators for emergency medical services (EMS) system evaluation and quality improvement: a statewide demonstration and planning project

BACKGROUND: The state of California, like every other state, has no system for assessing the quality of prehospital emergency medical services (EMS) care. As part of a statewide project, a process was designed for the evaluation and quality improvement (QI) of EMS in California. Local EMS agency (LEMSA) representatives made a commitment to submit data from both the providers and the hospitals they work with. INDICATOR SELECTION AND DEVELOPMENT: For conditions such as cardiac chest complaints, standardized indicators had already been developed, but for many other areas of interest there was either little literature or little consensus in the literature. Definitional differences were often linked to local-practice protocol differences. A related comparison challenge lay in the fact that care protocols may differ across systems. Some aspects of care may not be offered at all, which may reflect resource shortages or variable medical direction. DATA COLLECTION PROCEDURES: Each indicator was precisely defined, and definition sheets and data troubleshooting report forms were provided to participants in three data-collection rounds. Participants were given 1 month to collect the data, which consisted of summary-level elements (for example, average time to defibrillation for all patients 15 years or older who received defibrillation in 1998). Data were then aggregated, analyzed, and prepared for display in graphs and tables. ACCESS AND MEASUREMENT ISSUES: Numerous data collection problems were encountered. For example, not all participants could actually access data that they thought would be available. Linking data on patients as they travel through the continuum of EMS care (dispatch, field, hospital) and linking EMS data to hospital outcomes was also difficult. Yet even when data were easily available, challenges arose. The need for specificity, the potential misfit between definitions and the available data, and the challenges of data retrieval remained salient for the duration of the project and made cross-LEMSA and cross-provider comparison problematic. RECOMMENDATIONS AND LESSONS LEARNED: The project led to formal policy recommendations regarding development of a state-defined minimum data set of structure, process, and outcome indicators and their associated data elements; provision in the minimum data set for both local-level and statewide indicators; and provision of technical assistance at the local-provider level. EPILOGUE: Since the project's conclusion in June 2000, many regional and local EMS groups have begun to collect data on indicators. Many of the project's recommendations have been incorporated into the work plan of the state's System Review and Data Committee.     

Use of consumer ratings for quality improvement in behavioral health insurance plans

BACKGROUND: The Consumer Assessment of Behavioral Healthcare Services (CABHS) survey collects consumers' reports about their health care plans and treatment. The use of the CABHS to identify opportunities for improvement, with specific attention to how organizations have used the survey information for quality improvement, is described. METHODS: In 1998 and 1999, data were collected from five groups of adult patients in commercial health plans and five groups of adult patients in public assistance health plans with services received through four organizations (one of three managed behavioral health care organizations or a health system). Patients who received behavioral health care services during the previous year were mailed the CABHS survey. Non-respondents were contacted by telephone to complete the survey. RESULTS: Response rates ranged from 49% to 65% for commercial patient groups and from 36% to 51% for public assistance patients. Promptly getting treatment from clinicians and aspects of care most influenced by health plan policies and operations, such as access to treatment and plan administrative services, received the least positive responses, whereas questions about communication received the most positive responses. In addition, questions about access- and plan-related aspects of quality showed the most interplan variability. Three of the organizations in this study focused quality improvement efforts on access to treatment. DISCUSSION: Surveys such as the CABHS can identify aspects of the plan and treatment that are improvement priorities. Use of these data is likely to extend beyond the behavioral health plan to consumers, purchasers, regulators, and policymakers, particularly because the National Committee for Quality Assurance is encouraging behavioral health plans to use a similar survey for accreditation purposes.     

Depressive symptom severity,contributing factors,and self‐management among chronic dialysis patients

Despite the high prevalence of depressive symptoms in patients receiving chronic dialysis, there has been inadequate attention to patient‐related barriers to management of depressive symptoms, such as factors identified by these patients as contributing to their symptoms, and how they responded to the symptoms. Participants (N = 210) in an ongoing longitudinal observational study of multidimensional quality of life in patients receiving chronic dialysis completed a battery of measures monthly for 12 months. For each patient at each measurement point, an event report was generated if he or she scored outside of the normal range on the depressive symptom scale (Center for Epidemiologic Studies Depression Scale‐Short Form [CESD‐SF] ≥10) or expressed suicidal ideation. Of the 210 participants, 100 (47.6%) had a CESD‐SF score ≥10 at least once resulting in 290 event reports. Of these 100 participants, 15 (15%) had also reported suicidal ideation in addition to having depressive symptoms. The most frequently stated contributing factors included “managing comorbid conditions and complications” (56 event reports, 19.3%), “being on dialysis” (50, 17.2%), “family or other personal issues” (37, 12.8%), and “financial difficulties” (31, 10.7%). On 11 event reports (3.8%) participants had been unaware of their depressive symptoms. On 119 event reports (41%) participants reported that they discussed these symptoms with their dialysis care providers or primary care providers, while on 171 event reports (59%) symptoms were not discussed with their health‐care providers. The prevalence of depressive symptoms is high and many patients lack knowledge about effective self‐management strategies.     

Lessons from Europe on quality improvement: report on the Velen Castle WHO meeting.

BACKGROUND: In conjunction with the German Ministry of Health, the European Regional Office of the World Health Organization (WHO/EURO) held a workshop, "Experiences with Quality Management in an International Context," at Velen Castle, Velen (Nordrhein-Westfalen), Germany, January 15-17, 1998. The approximately 50 participants were selected in part on the basis of recommendations of their respective countries' health ministries. IMPLEMENTATION AND EVALUATION OF QUALITY MANAGEMENT: Possible ways to introduce quality management ranged from introduction of specific process control projects to total quality management (TQM) and reengineering. STRATEGIES FOR IMPLEMENTING QUALITY MANAGEMENT: Working group sessions identified specific strategies for high-level managers, health care providers, and various kinds of consumers to facilitate quality management. For example, managers need to transmit a vision, create a quality management infrastructure, develop reporting structures, establish a system of incentives, and manage the hospital according to the principles of continuous improvement. QUALITY MANAGEMENT MODELS AND TOOLS: Hospitals and other health care providers in Sweden are testing various methods and systems to assess and improve their organizations' ability to meet patients' demands. Benchmarking is being used as a tool for quality management of diabetes care (DiabCare-France). The benchmarking data are processed centrally and made available to the health care providers in a user-friendly format for application to their own quality improvement processes. Clinical databases-registries containing process and outcome data for a well-defined patient population-can be used for quality and technology assessment, to answer questions of treatment effectiveness, and as an information tool. PRINCIPLES AND STRATEGIES FOR QUALITY MANAGEMENT AND DEVELOPMENT: Successful implementation of quality improvement benefits from local, professional, and national policies and objectives. A balance of incentives can reward efficiency or specific activities. Laws, rules, and regulations can be useful, especially if used sparingly. More education is needed at all levels of the health care system about how to understand and use information and information systems. Research is needed on what processes result in favorable outcomes. Despite optimism about the cost-saving potential of quality improvement efforts, many interventions are likely to be cost-effective without actually saving costs. Public release of performance data requires careful consideration, with participation of the professions.     

Using a SANE interdisciplinary approach to care of sexual assault victims

BACKGROUND: Many hospitals have recognized the need to develop policies and procedures for female sexual assault victims' prompt access to emergency medical care and for collecting law enforcement evidence. At Lehigh Valley Hospital (Allentown, Penn), care in the emergency department (ED) for sexual assault victims was covered by oncall obstetricians and gynecologists. Although many aspects of rape management were in place, a busy ED with varying levels of physician response and exposure to the process of rape management contributed to a lack of standardized, objective, timely, and compassionate medical management of sexual assault victims. DEVELOPING THE PROGRAM: The Sexual Assault Nurse Examiner (SANE) interdisciplinary approach to care of sexual assault victims was implemented in May 1998. Community education and awareness projects emphasized prevention of sexual assault and domestic violence, as well as minimization of trauma for victims by promoting services that provide a supportive, caring, and healing environment. RESULTS: Comparing a baseline group of 130 sexual assault victims with 39 patients who were evaluated after the SANE approach was implemented indicated increased clinical interaction and significant improvements in quality indicators, such as completeness of evaluation and information gathered relevant to medical-legal issues. DISCUSSION: Law enforcement staff developed a more collaborative relationship with SANE examiners through the interdisciplinary team approach. Collaborative relationships were initiated with several other hospitals in the hospital's integrated delivery system to help offset some of the program's training, continuing education, and on-call costs and to allow for joint outcomes collection. The SANE program became a core ED service in July 1999.     

Assessing consumer perceptions of inpatient psychiatric treatment: the perceptions of care survey

BACKGROUND: Consumer perceptions of behavioral health care are widely recognized as important quality indicators. This article reports the development and use of the Perceptions of Care (PoC) survey, a standardized public domain measure of consumer perceptions of the quality of inpatient mental health or substance abuse care. The goals were to develop a low-cost, low-burden survey that would address important quality domains, allow for interprogram comparisons and national benchmarks, be useful for quality improvement purposes, and meet accreditation and payer requirements. METHODS: The sample was composed of 6,972 patients treated in 14 inpatient behavioral health or substance abuse treatment programs. The PoC survey was given to patients by program staff in the 24-hour period before discharge. RESULTS: Aggregate reports and ratings of care identified areas that are highly evaluated by consumers, as well as areas that provide opportunities for quality improvement. Factor analysis identified four domains of care, and a 100-point score was developed for each domain. Regression analyses identified significant predictors of perceptions of care for use in computing risk-adjusted scores. Unadjusted and adjusted scores were presented to demonstrate the impact of risk adjustment on quality of care scores and relative ranking of programs. Examples were given of how programs used survey results to improve the quality of care. DISCUSSION: Results demonstrated that the PoC survey is sensitive to detecting differences among inpatient behavioral health programs and can be useful in guiding quality improvement efforts. However, risk adjustment is important for appropriate interpretation of results.     

The integrated management for renal replacement therapy in Portugal

Portugal was the first European country to introduce an integrated management of end‐stage renal disease (IM ESRD). This new program integrates various dialysis services and products, which are reimbursed at a fixed rate/patient/week called “comprehensive price payment.” This initiative restructured the delivery of dialysis services, the monitoring of outcomes, and the funding of renal replacement therapy. This article described the implementation of a new model of comprehensive provision of hemodialysis (HD) services and aimed to assess its impact on dialysis care. Quality assessments and reports of patient satisfaction, produced by the Ministry of Health since 2008, as well as national registries and reports, provided the data for this review. Indicators of HD services in all continental facilities show positive results that have successively improved along the period of 2009–2011, in spite of an average annual growth of 3% of the population under HD treatment. Mortality rates for HD patients were 12.7%, 12%, and 11%, respectively in 2009, 2010, and 2011; annual hospitalization rates were 4.9%, 3.8%, and 4.4% for the same years; key performance indicators showed averages above the reference values such as hemoglobin, serum phosphorus, eKt/V, water quality, number of days of hospitalization per patient per year, and number of weekly dialysis sessions. The financing analysis of IM ESRD demonstrates a sustained control of global costs, without compromising quality. The IM ERSD program is an innovative and quality‐driven approach that benefits both dialysis patients and providers, contributing toward the rationalization of service provision and the efficient use of resources.     

Balancing accountability and improvement: a case study from Massachusetts

BACKGROUND: The Massachusetts Health Quality Partnership (MHQP), a coalition of health care providers and insurers, and business and government organizations, conducted a voluntary statewide survey about patients' experiences with inpatient care at Massachusetts hospitals in 1998, and made the results public. METHODS: MHQP contracted with The Picker Institute (Boston) to conduct the statewide survey about seven dimensions of care for adult medical, surgical, and maternity patients at 58 hospitals across Massachusetts. The communications strategy for public report release was designed to promote fair reporting by the news media and emphasize the improvement goals of performance measurement above evaluation. Along with critical agreements on report design, trial surveys, advertising, and commitments from coalition members about the use of survey results, these measures sought to drive out fear of participation and unfair evaluation. RESULTS: Statewide news media coverage reflected the project's communications goals. Editorial praise for the report was widespread. The project stimulated numerous hospital quality improvement efforts and focused hospital leaders on the need to improve patients' experiences with hospital care. All participating hospitals voluntarily renewed their enrollment for a third survey and public report cycle, and new hospitals joined the project. DISCUSSION: Voluntary public release of performance information by health care providers is possible when the risks, motivations, rewards, and penalties of measurement and public reporting are understood and carefully managed. The goals of public accountability reporting will be realized sooner when it is wedded to the spirit of continuous quality improvement and when providers are engaged as partners at every step of the measurement and reporting process.     

Using clinical practice analysis to improve care

BACKGROUND: Improving clinical outcomes requires that physicians examine and change their clinical practice. Sustaining outcome improvements requires a dedicated and dynamic program of analyzing and improving patient care. In 1992 North Mississippi Health Services (NMHS) implemented a program to improve physicians' clinical efficiency. CLINICAL PRACTICE ANALYSIS ( CPA): CPA uses evidenced-based guidelines and examines each physician's resource utilization, processes, and outcomes for a diagnosis or procedure. Clinical practice profiles are developed, and individual performance is compared to local and national benchmarks and presented to physicians. The CPA process is used on its own or as a component of more comprehensive performance improvements projects. Physicians have been engaged in outcome improvement by more than 55 CPA projects. RESULTS: NHMS has progressively reduced its Medicare loss and its length of stay (LOS) to 4.9 days. Mortality and readmission rates have been reduced in specific diagnoses. The community-acquired pneumonia project reduced the LOS from 7.7 to 5.1 days, decreaesed the mortality rate from 8.9% to 5.0%, and decreased the cost of care from $4,269 to $3,834. The ischemic stroke project reduced the aspiration pneumonia rate from 6.4% to 0% and mortality from 11.0% to 4.6%. Patients' average LOS decreased from 10.7 days to 6.5 days, and their cost of care was reduced by $1,100 per patient. DISCUSSION: Providing individualized data has engaged physicians in improving outcomes. The program has evolved from improving efficiency to managing outcomes and from simple CPA projects to integrated performance improvement projects; however, the CPA process remains the cornerstone of the current process.     

面向用户个性化需求的云服务商推荐

针对当前不具备专业知识的用户难以从海量云服务中选择满足其偏好的云服务商的问题，构建了满足用户需求偏好的云服务商推荐模型。该模型包括以下3部分：首先，从用户角度，通过模糊评价的方法确定并衡量用户对云服务的需求偏好；其次，从云服务商角度，通过模糊评价法和熵权法确定并衡量其满足用户需求的能力；最后，利用相似距离公式，将用户与候选服务商的相似性程度进行排序，向用户推荐最匹配的云服务商。算例结果表明，与传统的推荐方法相比，该模型能够更好地针对用户对云服务各项指标的偏好进行推荐，提高了用户选择云服务商的准确性。     

The evolution of quality management in state Medicaid agencies: a national survey of states with comprehensive managed care programs

BACKGROUND: Concern has been expressed about whether managed care health plans can successfully meet the special needs of Medicaid beneficiaries. A 1996 survey indicated that state Medicaid agencies had just begun conducting quality oversight and management. Since then the federal government has released guidelines under the Quality improvement System for Managed Care (QISMC) program to assist states with quality management of managed care programs. In 1999 a follow-up telephone survey was conducted with representatives from 45 states to describe the current state of and changes in quality management activities by state Medicaid agencies for Medicaid beneficiaries enrolled in managed care. RESULTS: The 45 states represented a 50% increase between 1995 and 1999. The number of states enrolling the disabled had doubled (from 15 to 30). Most states collecting data on satisfaction and childhood immunizations fed it back to health plans, although feedback of other measures of access and quality occurred less frequently and fewer states provided information to beneficiaries choosing health plans. Fewer than 25% of states reported having even one health plan demonstrate improvement in individual measures of access and quality except for prenatal care (28%) and childhood immunizations (33%). Fewer than half of the states included contractual penalties in their contracts with health plans, and very few (three or fewer per penalty) had over invoked such penalties. CONCLUSIONS: State Medicaid agencies continue to adapt to their new roles as value-based purchasers of health care. Although increasing numbers of states collect data on satisfaction, access, and quality of care, few states have been able to document improved performance in the health plans they oversee.