What Makes a Difference in the Outcomes of QI Participation? (Text Version)

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; Plugin Software Help).

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