Slide Presentation from the AHRQ 2008 Annual Conference
On September 10, 2008, Shoshanna Sofaer, Dr.P.H., made this presentation at the 2008 Annual Conference. Select to access the PowerPoint® presentation (110 KB).
Slide 1
What Makes a Difference in the Outcomes of Quality Indicator (QI) Participation?
- Shoshanna Sofaer, Dr.P.H.
School of Public Affairs
Baruch College
Slide 2
Overview
- Purpose of the research
- Methods
- Preliminary findings
Slide 3
Purpose of the research
- Identify factors that may make a difference in the results of participation of home health agencies (HHAs) in quality improvement
- Specifically, look at variations across HHAs that participated in Wave 2 of the Reducing Acute Care Hospitalization (ReACH) project
Slide 4
Purpose of the research
- Identify the elements of the ReACH approach which appear to have made a difference in achieving changes in re-hospitalization rates at the local level
Slide 5
Methods
- The ReACH project had extensive data on key outcome and process measures for all HHAs, including changes over time in the:
- Acute Care Hospitalization (ACH) rate for their entire population
- ACH rate for their "target population:
- Rates of performing risk assessments on patients
- Rates of "front-loading" visits for high risk patients
Slide 6
Methods
- We ordered the agencies by performance on the two major outcomes for purposes of sampling.
- Operating in the context of Office of Management and Budget (OMB) constraints, our strategy was to purposively select nine agencies to interview:
- Five high performers
- Four low performers
Slide 7
Methods
- We varied agencies in each performance group by size, ownership and region
- We interviewed key staff at Quality Improvement Organizations (QIOs) in the States where HHAs were located who participated at all in Wave 2 of ReACH prior to interviews with HHA staff
Slide 8
Methods
- We conducted semi-structured, open ended interviews with the person in either the QIO or the HHA who was most directly involved in the project.
- We have completed all QIO interviews and 7 of 9 HHA interviews.
- We present here a preliminary analysis of these interviews, focusing on some but not all issues of interest.
Slide 9
Preliminary Findings
- Who chose to participate and why?
- From the QIO perspective, a major driver was that the re-hospitalization rate was a metric they were required to move by the Centers for Medicare and Medicaid Services (CMS).
- This led them to focus recruitment on agencies with high rates and to some extent larger agencies.
- But many also wanted to influence as many HHAs as possible if they thought they could and would improve; a few just asked everyone.
Slide 10
Preliminary Findings
- Who chose to participate and why?
- From the HHA perspective, decision-makers wanted to lower their rate, get access to high level expertise, tools individual support, education and opportunities to network with peers in their own state and beyond.
- High performers often already had a strong orientation to improvement, at least within the leadership and/or those more directly involved with ReACH.
- Some in both groups were already trying to lower rates.
Slide 11
Preliminary Findings
- Does size matter?
- By design, we chose a range of sizes in both groups.
- But the issue of small size was more likely to be cited by both QIOs and HHAs as a reason for difficulties:
- Being recruited
- Staying in the program
- Being able to change the outcome rates
Slide 12
Preliminary Findings
- Does size matter?
- Larger HHAs much more likely to have staff assigned to and with experience in quality measurement and improvement.
- Small agencies much more vulnerable to losing staff or dealing with staff turnover/shortages.
- Small agencies also seem to have more difficulty raising issues of re-hospitalization with MDs.
Slide 13
Preliminary Findings
- Does ownership matter?
- The hospital-affiliated or hospital-owned agencies were clearly sensitive to the hospital's desire to admit patients and also discharge them as soon as they could.
- But it does not appear that hospital ownership was an insuperable barrier to making progress in agencies with strong leadership commitment to the project.
Slide 14
Preliminary Findings
- Does patient mix matter?
- Apparently yes—small agencies with a high proportion of long-term patients believe that "readmissions are random" and "inevitable"
- They don't believe a "discharge based" ACH rate is appropriate as a measure
Slide 15
Preliminary Findings
- Does process matter?
- Many agencies who didn't move their ACH rate did make enormous progress in instituting key processes.
- This raises two issues:
- Is one year enough time?
- Are we looking at the "right" processes (e.g. is the problem somewhere other than the HHA?)
Slide 16
Preliminary Findings
- Does leadership support matter?
- Almost all those we interviewed "felt" supported by leadership; several QIOs noted that those without leadership support were more likely to drop out; agencies with high level leadership involvement appeared to make this whole process a higher priority.
- But "followership" may be just as important!
Slide 17
Next steps
- Finish interviews
- Conduct a site visit
- Complete analysis
- Disseminate "final" findings
Current as of January 2009
Internet Citation:
What Makes a Difference in the Outcomes of QI Participation?. Slide Presentation from the AHRQ 2008 Annual Conference (Text Version). January 2009. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/about/annualmtg08/091008slides/sofaer.htm