Practices and Organizational Characteristics of Consistently High Performing Hospitals

Research Objective: Identify care practices and organizational characteristics of hospitals with consistent high performance across multiple clinical areas/measure sets of the National Hospital Quality Measures (NHQM).

Study Design: Mixed methods were used, first statistical analysis to identify high, medium, and low performing hospitals followed by open-ended telephone interviews with hospital leadership and front-line staff involved in performance improvement. Interviews were transcribed and then coded using NVivo. Within- and between-case analysis was conducted to understand trends and patterns. Cases were grouped by performance category: high, middle and low, to highlight differences between groups. Site visits were conducted with three selected high performing hospitals to document specific practices associated with high performance.

Population Studied: 360 hospitals participating with the Quality Indicator Project and with complete data for pneumonia, heart failure, myocardial infarction, and surgery NHQM measure sets from 3rd quarter 2007 to 2nd quarter 2008. High, low, and medium performers were defined as those with all composite scores above, below, or between two standard deviation above and below the mean. Purposeful sampling was applied to select 5 hospitals from each group (15 hospitals). A total of 42 individuals were interviewed including data abstraction and analysis staff, quality directors, nursing and physician liaisons and chairs, and senior executives. Principal Findings: 91 of 360 hospitals were distinguished as consistent high (37), middle (40) or low (14) performers. The three key differentiators of high performers were (a) concurrent data collection, analysis and management of patients in the NQHM measure populations, (b) physician buy-in, engagement and direct accountability, and (c) support and encouragement at the executive level. High performing hospitals were also more likely to set specific improvement goals, rely on interdisciplinary performance improvement teams meeting frequently, and communicate performance results in timely fashion through dashboards and posting. Regarding major barriers to successful performance, all hospitals cited manual processes due to the lack of electronic medical records. Follow-up site visits revealed a wide range of strategies to assure concurrent monitoring and management, a challenge since most measures define patient population by discharge diagnosis. Manual and electronic systems identify patients eligible for measures on admission, monitor and manage care during the stay, and assure complete discharge follow-through.

Conclusions: The strategies identified can be used by low and medium performing hospitals to increase performance on clinical measures organization-wide. These strategies focus on process and do not necessarily require additional resources.