National Healthcare Quality and Disparities Report
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Topics
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AHRQ Research Studies
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Research Studies is a compilation of published research articles funded by AHRQ or authored by AHRQ researchers.
Results
1 to 25 of 89 Research Studies DisplayedNapolitano N, Laverriere EK, Craig N
Apneic oxygenation as a quality improvement intervention in an academic PICU.
The objective of this prospective pre/post observational study was to evaluate if the use of apneic oxygenation during tracheal intubation in children is feasible and would decrease the occurrence of oxygen desaturation. The investigators concluded that implementation of apneic oxygenation in PICU was feasible, and was associated with significant reduction in moderate and severe oxygen desaturation. They suggest that use of apneic oxygenation should be considered when intubating critically ill children.
AHRQ-funded; HS021583; HS022464; HS024511.
Citation: Napolitano N, Laverriere EK, Craig N .
Apneic oxygenation as a quality improvement intervention in an academic PICU.
Pediatr Crit Care Med 2019 Dec;20(12):e531-e37. doi: 10.1097/pcc.0000000000002123..
Keywords: Children/Adolescents, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Patient Safety, Adverse Events
Stoops C, Stone S, Evans E
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
The purpose of this study was to test if acute kidney injury (AKI) is preventable in patients in the neonatal intensive care unit and if infants at high-risk of nephrotoxic medication-induced AKI can be identified using a systematic surveillance program previously used in the pediatric non-intensive care unit setting. The authors concluded that a systematic surveillance program to identify high-risk infants can prevent nephrotoxic-induced AKI and has the potential to prevent short and long-term consequences of AKI in critically ill infants.
AHRQ-funded; HS023763.
Citation: Stoops C, Stone S, Evans E .
Baby NINJA (Nephrotoxic Injury Negated by Just-in-Time Action): reduction of nephrotoxic medication-associated acute kidney injury in the neonatal intensive care unit.
J Pediatr 2019 Dec;215:223-28.e6. doi: 10.1016/j.jpeds.2019.08.046..
Keywords: Newborns/Infants, Medication, Medication: Safety, Patient Safety, Kidney Disease and Health, Intensive Care Unit (ICU), Critical Care, Quality Improvement, Quality of Care, Prevention, Adverse Drug Events (ADE), Adverse Events
Sheetz KH, Dimick JB, Nathan H
Centralization of high-risk cancer surgery within existing hospital systems.
Centralization is often proposed as a strategy to improve the quality of certain high-risk health care services. In this study, the investigators evaluated the extent to which existing hospital systems centralize high-risk cancer surgery and whether centralization is associated with short-term clinical outcomes. The investigators concluded that greater centralization of complex cancer surgery within existing hospital systems was associated with better outcomes.
AHRQ-funded; HS023597.
Citation: Sheetz KH, Dimick JB, Nathan H .
Centralization of high-risk cancer surgery within existing hospital systems.
J Clin Oncol 2019 Dec 1;37(34):3234-42. doi: 10.1200/jco.18.02035..
Keywords: Surgery, Cancer, Risk, Hospitals, Health Systems, Quality Improvement, Quality Indicators (QIs), Quality of Care, Outcomes
Mafi JN, May FP, Kahn KL
Low-value proton pump inhibitor prescriptions among older adults at a large academic health system.
Researchers sought to characterize the prevalence of potentially low-value proton pump inhibitor (PPI) prescriptions among older adults to inform a quality improvement intervention. Subjects were patients, aged 65 years or older, receiving primary care at a large academic health system in 2018. The researchers found that one in eight older adults were prescribed a PPI, and over one-third of prescriptions were potentially low-value. They conclude that, with most potentially low-value prescribing concentrated among a small subset of primary care physicians, interventions targeting them and/or applying EHR-based automatic stopping rules may protect older adults from harm.
AHRQ-funded; HS024067.
Citation: Mafi JN, May FP, Kahn KL .
Low-value proton pump inhibitor prescriptions among older adults at a large academic health system.
J Am Geriatr Soc 2019 Dec;67(12):2600-05. doi: 10.1111/jgs.16117..
Keywords: Elderly, Medication, Quality Improvement, Quality of Care, Primary Care
Singh H, Graber ML, Hofer TP
Measures to improve diagnostic safety in clinical practice.
In this paper, the investigators discuss how the need to develop measures to improve diagnostic performance could move forward at a time when the scientific foundation needed to inform measurement is still evolving. They highlight challenges and opportunities for developing potential measures of "diagnostic safety" related to clinical diagnostic errors and associated preventable diagnostic harm. In doing so, they propose a starter set of measurement concepts for initial consideration that seem reasonably related to diagnostic safety and call for these to be studied and further refined.
AHRQ-funded; HS022087.
Citation: Singh H, Graber ML, Hofer TP .
Measures to improve diagnostic safety in clinical practice.
J Patient Saf 2019 Dec;15(4):311-16. doi: 10.1097/pts.0000000000000338.
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Keywords: Patient Safety, Diagnostic Safety and Quality, Healthcare Delivery, Quality Improvement, Quality of Care, Medical Errors, Adverse Events
Rosenthal M, Shortell S, Shah ND
Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data.
The purpose of this study was to characterize the strategies that physician practices use to improve clinician performance and determine their association with accountable care organizations (ACOs) and other payment reforms. The investigators concluded that ACO-affiliated practices are using more performance improvement strategies than other practices, but base only a small fraction of compensation on quality or cost.
AHRQ-funded; HS024075.
Citation: Rosenthal M, Shortell S, Shah ND .
Physician practices in Accountable Care Organizations are more likely to collect and use physician performance information, yet base only a small proportion of compensation on performance data.
Health Serv Res 2019 Dec;54(6):1214-22. doi: 10.1111/1475-6773.13238..
Keywords: Provider Performance, Payment, Quality Improvement, Quality of Care
Barbash IJ, Kahn JM
Sepsis quality in safety-net hospitals: an analysis of Medicare's SEP-1 performance measure.
Researchers studied the relationship between hospital safety-net status and performance on Medicare's SEP-1 quality measure. Data from 2827 hospitals were analyzed. They found that existing sepsis policies may harm safety-net hospitals and widen health disparities. They suggest that strategies to promote collaboration among hospitals may be an avenue for sepsis performance improvement in these hospitals.
AHRQ-funded; HS025455.
Citation: Barbash IJ, Kahn JM .
Sepsis quality in safety-net hospitals: an analysis of Medicare's SEP-1 performance measure.
J Crit Care 2019 Dec;54:88-93. doi: 10.1016/j.jcrc.2019.08.009.
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Keywords: Sepsis, Quality Measures, Quality of Care, Hospitals, Provider Performance, Quality Improvement
King CR, Abraham J, Kannampallil TG
Protocol for the effectiveness of an anesthesiology control tower system in improving perioperative quality metrics and clinical outcomes: the TECTONICS randomized, pragmatic trial.
The primary objective of this trial was to determine whether an anesthesiology control tower (ACT) prevents clinically relevant adverse postoperative outcomes including 30-day mortality, delirium, respiratory failure, and acute kidney injury. Clinicians in operating rooms randomized to ACT support receive decision support from clinicians in the ACT. In operating rooms randomized to no intervention, the current standard of anesthesia care is delivered. The intention-to-treat principle will be followed for all analyses.
AHRQ-funded; HS024581.
Citation: King CR, Abraham J, Kannampallil TG .
Protocol for the effectiveness of an anesthesiology control tower system in improving perioperative quality metrics and clinical outcomes: the TECTONICS randomized, pragmatic trial.
F1000Res 2019 Nov 29;8:2032. doi: 10.12688/f1000research.21016.1.
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Keywords: Quality Measures, Quality Improvement, Quality of Care, Surgery, Telehealth, Health Information Technology (HIT)
Schuttner L, Wong ES, Rosland AM
Association of the patient-centered medical home implementation with chronic disease quality in patients with multimorbidity.
The purpose of this retrospective cohort study was to examine the association of Patient-Aligned Care Team (PACT) implementation, the Veterans Health Administration (VA) PCMH model, and care quality for multimorbid patients enrolled in VA primary care from 2012 to 2014. The investigators found that for one-third of metrics (5/15), greater implementation of PACT in 2012 was associated with higher predicted probability of meeting the quality metric in 2013-2014. This association persisted for only two metrics among patients with > 5 chronic diseases.
AHRQ-funded; HS026369.
Citation: Schuttner L, Wong ES, Rosland AM .
Association of the patient-centered medical home implementation with chronic disease quality in patients with multimorbidity.
J Gen Intern Med 2020 Oct;35(10):2932-38. doi: 10.1007/s11606-020-06076-7..
Keywords: Patient-Centered Healthcare, Implementation, Chronic Conditions, Primary Care: Models of Care, Primary Care, Quality Improvement, Quality of Care
Grant MC, Gibbons MM, Ko CY
Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery.
This paper is an evidence review of enhanced recovery after surgery (ERAS) protocols for gynecologic surgery that will be used as part of AHRQ’s Safety Program for Improving Surgical Care and Recovery. This initiative was developed in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality. The authors conducted a literature review of the various anesthesia components which may influence outcomes and facilitate recovery after gynecological surgery. They included interventions for preoperative, intraoperative, and postoperative phases of care and then summarized the best available evidence for ERAS for gynecological surgery. The best evidence was summarized for recommendations to be used in the initiative.
Citation: Grant MC, Gibbons MM, Ko CY .
Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery.
AHRQ-funded; 233201500020I..
Keywords: Patient Safety, Surgery, Quality Improvement, Quality of Care, Evidence-Based Practice, Patient-Centered Outcomes Research, Women
Davis MM, Gunn R, Kenzie E
Integration of improvement and implementation science in practice-based research networks: a longitudinal, comparative case study.
This study’s goal was to systematically examine implementation science (IS), quality improvement (QI), and IS/QI projects conducted within a practice-based research network (PBRN) over time to identify similarities, differences, and synergies. Documents were reviewed and staff interviews were conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019. Almost 30% of ORPRN’s projects (26/99) included IS or QI elements, and 54% were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and settings. Randomized designs and theoretical frameworks were used by over half of the IS and IS/QI projects, while no QI projects did. Projects used a similar number of practice change strategies.
AHRQ-funded; HS027080.
Citation: Davis MM, Gunn R, Kenzie E .
Integration of improvement and implementation science in practice-based research networks: a longitudinal, comparative case study.
J Gen Intern Med 2021 Jun;36(6):1503-13. doi: 10.1007/s11606-021-06610-1..
Keywords: Implementation, Quality Improvement, Quality of Care
Sharma H, Konetzka RT, Smieliauskas F
The relationship between reported staffing and expenditures in nursing homes.
AHRQ-funded; HS024967.
Citation: Sharma H, Konetzka RT, Smieliauskas F .
The relationship between reported staffing and expenditures in nursing homes.
Med Care Res Rev 2019 Dec 1;76(6):758-83. doi: 10.1177/1077558717739214..
Keywords: Nursing Homes, Long-Term Care, Quality Improvement, Quality of Care, Provider Performance, Medicare
Sheetz KH, Dimick JB, Englesbe MJ
Hospital-acquired condition reduction program is not associated with additional patient safety improvement.
In 2013 the Centers for Medicare and Medicaid Services announced that it would begin levying penalties against hospitals with the highest rates of hospital-acquired conditions through the Hospital-Acquired Condition Reduction Program. This study evaluates whether the program has been successful in improving patient safety or not. The investigators concluded that the program did not improve patient safety in Michigan beyond existing trends.
AHRQ-funded; HS000053; HS026244.
Citation: Sheetz KH, Dimick JB, Englesbe MJ .
Hospital-acquired condition reduction program is not associated with additional patient safety improvement.
Health Aff 2019 Nov;38(11):1858-65. doi: 10.1377/hlthaff.2018.05504..
Keywords: Healthcare-Associated Infections (HAIs), Hospitals, Patient Safety, Provider Performance, Quality Improvement, Quality of Care, Infectious Diseases, Payment
Keshvani N, Berger K, Gupta A
Improving respiratory rate accuracy in the hospital: a quality improvement initiative.
Researchers initiated a quality improvement (QI) initiative in hospitals to improve respiratory rate measurement accuracy. Time-keeping devices were added to vital sign carts and patient care assistants were retrained on a newly modified workflow that included concomitant respiratory rate (RR) measurement during automated blood pressure measurement. The median RR measurement rate increased postintervention. This intervention was associated with a 7.8% reduced incidence of tachypnea-specific systemic inflammatory response syndrome. This QI initiative was interdisciplinary, low-cost, and low-tech.
AHRQ-funded; HS022418.
Citation: Keshvani N, Berger K, Gupta A .
Improving respiratory rate accuracy in the hospital: a quality improvement initiative.
J Hosp Med 2019 Nov 1;14(10):673-77. doi: 10.12788/jhm.3232..
Keywords: Patient-Centered Outcomes Research, Quality Improvement, Inpatient Care, Diagnostic Safety and Quality, Hospitals, Quality of Care, Outcomes
Blecker S, Austrian JS, Horwitz LI
Interrupting providers with clinical decision support to improve care for heart failure.
The goal of this study was to develop a clinical decision support (CDS) system to recommend an angiotenson converting enzyme (ACE) inhibitor during hospitalization so it could be promoted for continuation at discharge. Patients who were hospitalized with reduced ejection fraction were pseudo-randomized to deliver interruptive or non-interruptive CDS alerts to providers based on the patients’ even or odd medical record number. The utilization rate was higher for interruptive alert versus non-interruptive alert hospitalizations for a sample of 958. This resulted in improved quality of care for heart failure patients.
AHRQ-funded; HS023683.
Citation: Blecker S, Austrian JS, Horwitz LI .
Interrupting providers with clinical decision support to improve care for heart failure.
Int J Med Inform 2019 Nov;131:103956. doi: 10.1016/j.ijmedinf.2019.103956..
Keywords: Clinical Decision Support (CDS), Decision Making, Heart Disease and Health, Cardiovascular Conditions, Medication, Medication: Safety, Patient Safety, Quality Improvement, Quality of Care
Kang SK, Garry K, Chung R
Natural language processing for identification of incidental pulmonary nodules in radiology reports.
The authors developed natural language processing (NLP) to identify incidental lung nodules (ILNs) in radiology reports for assessment of management recommendations using the electronic health records for patients who underwent chest CT before and after implementation of a department-wide dictation macro of the Fleischner Society recommendations. They concluded that NLP reliably automates identification of ILNs in unstructured reports, pertinent to quality improvement efforts for ILN management.
AHRQ-funded; HS024376.
Citation: Kang SK, Garry K, Chung R .
Natural language processing for identification of incidental pulmonary nodules in radiology reports.
J Am Coll Radiol 2019 Nov;16(11):1587-94. doi: 10.1016/j.jacr.2019.04.026..
Keywords: Imaging, Diagnostic Safety and Quality, Health Information Technology (HIT), Electronic Health Records (EHRs), Quality Improvement, Quality of Care
Hempel S, Miake-Lye I, Brega AG
AHRQ Author: Spector WD
Quality improvement toolkits: recommendations for development.
The authors convened a panel of health care stakeholders informed by a literature review that analyzed 44 publications and 27 toolkits. The panel formed 12 recommendations for content and 1 recommendation for toolkit development methods. The authors then established a set of key recommendations and suggestions addressing the content, development, and evaluation methods of quality improvement toolkits, together with a ready-to-use checklist.
AHRQ-authored.
Citation: Hempel S, Miake-Lye I, Brega AG .
Quality improvement toolkits: recommendations for development.
Am J Med Qual 2019 Nov/Dec;34(6):538-44. doi: 10.1177/1062860618822102..
Keywords: Quality Improvement, Quality of Care, Tools & Toolkits
Keller SC, Cosgrove SE, Arbaje AI
Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy.
This study examined roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy (OPAT). A qualitative study of patients and caregivers was conducted using 40 semistructured telephone interviews and 20 contextual inquiries for patients and caregivers. The participants had been discharged from two academic medical centers and put on OPAT. Four main roles were identified: communicator, advocate, learner-trainer, and lay health care worker. There was ambiguity shown among health care workers as well as patients and caregivers. Clearer delineation of roles as to who performs which tasks was indicated in the study.
AHRQ-funded; HS025782.
Citation: Keller SC, Cosgrove SE, Arbaje AI .
Roles and role ambiguity in patient- and caregiver-performed outpatient parenteral antimicrobial therapy.
Jt Comm J Qual Patient Saf 2019 Nov;45(11):763-71. doi: 10.1016/j.jcjq.2019.07.003..
Keywords: Patient-Centered Healthcare, Quality Improvement, Healthcare Delivery, Patient Self-Management, Care Management, Caregiving, Quality of Care, Patient Safety
Smith AB, Mueller D, Garren B
Using qualitative research to reduce readmissions and optimize perioperative cystectomy care.
This study examined the need for qualitative research on meaningful patient-reported outcomes (PROs) to prevent complications and readmissions after cystectomy. The investigators looked at the potential use of mobile communication devices (mHealth) to capture patients’ experiences and to improve outcomes. Interviews were conducted with 15 readmitted patients and 10 of their partners over 45 semi-structured in-depth interviews. The most common perspectives were that patients and their caregivers were overloaded with cystectomy education; they need to know what are normal post-operative symptoms; and that using mHealth would help with patient and caregiver education.
AHRQ-funded; HS024134.
Citation: Smith AB, Mueller D, Garren B .
Using qualitative research to reduce readmissions and optimize perioperative cystectomy care.
Cancer 2019 Oct 15;125(20):3545-53. doi: 10.1002/cncr.32362..
Keywords: Hospital Readmissions, Surgery, Health Information Technology (HIT), Quality Improvement, Quality of Care, Hospitals, Patient-Centered Healthcare
Andereck JW, Reuter QR, Allen KC
A quality improvement initiative featuring peer-comparison prescribing feedback reduces emergency department opioid prescribing.
This study compared opioid prescribing rates in emergency departments before and after a quality improvement initiative featuring peer-comparison feedback. All 117 ED prescribers at an urban academic medical center were provided regular feedback on their opioid prescribing rate compared to their de-identified peers. Pre-intervention rates were 8.6% compared to post-intervention at 4.8%.
AHRQ-funded; HS023011.
Citation: Andereck JW, Reuter QR, Allen KC .
A quality improvement initiative featuring peer-comparison prescribing feedback reduces emergency department opioid prescribing.
Jt Comm J Qual Patient Saf 2019 Oct;45(10):669-79. doi: 10.1016/j.jcjq.2019.07.008..
Keywords: Emergency Department, Opioids, Medication, Practice Patterns, Quality Improvement, Quality of Care
White CM, Coleman CI, Jackman K
AHRQ series on improving translation of evidence: linking evidence reports and performance measures to help learning health systems use new information for improvement.
This paper analyzed ways to enhance usability of AHRQ’s Evidence-based Practice Center (EPC) reports. The reports are often lengthy and difficult for users to navigate. A quality measure index was created to allow health systems to more efficiently access relevant information. A test was created where two tables were embedded in an EPC report. The first identified quality measures covered by the report descriptively. The second contained page numbers in the executive summary which hyperlinked to those pages with the quality measures. An exercise with two health system-targeted scenarios was then created. The participants were timed how long it took to find answers to scenario questions and gave feedback. It was found that it took 63.4% less time to find quality measure information with the hyperlinked indexing tables than without. The participants felt that the tables were easy to use and more user friendly to health systems.
Jt Comm J Qual Patient Saf 2019 Oct;45(10):706-10. doi: 10.1016/j.jcjq.2019.05.002.
Citation: White CM, Coleman CI, Jackman K .
AHRQ series on improving translation of evidence: linking evidence reports and performance measures to help learning health systems use new information for improvement.
Jt Comm J Qual Patient Saf 2019 Oct;45(10):706-10. doi: 10.1016/j.jcjq.2019.05.002..
Keywords: Implementation, Evidence-Based Practice, Health Systems, Learning Health Systems, Patient-Centered Outcomes Research, Provider Performance, Quality Measures, Quality Improvement, Quality of Care
Childers CP, Dworsky JQ, Russell MM
Association of work measures and specialty with assigned work relative value units among surgeons.
The authors assessed whether objective work measures are associated with a surgical procedure's assigned work relative value units (RVUs) and whether differences exist by surgical specialty. Thier cross-sectional study used data from the 2016 and 2017 Participant Use files of the American College of Surgeons National Surgical Quality Improvement Program; the 2017 Centers for Medicare & Medicaid Services physician fee schedule was a secondary data source. The authors found that objective work measures appeared to be associated with assigned work RVUs, predominantly with operative time. They recommend that registry data be used to augment and inform the generation and updating processes of the work RVUs.
AHRQ-funded; HS000046.
Citation: Childers CP, Dworsky JQ, Russell MM .
Association of work measures and specialty with assigned work relative value units among surgeons.
JAMA Surg 2019 Oct;154(10):915-21. doi: 10.1001/jamasurg.2019.2295..
Keywords: Surgery, Quality Improvement, Quality of Care
Jones KJ, Skinner A, Venema D
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Researchers evaluated the implementation and outcomes of evidence-based fall-risk-reduction processes when those processes are implemented using a multiteam system (MTS) structure. They found that multiteam systems that effectively coordinate fall-risk-reduction processes may improve the capacity of hospitals to manage the complex patient, environmental, and system factors that result in falls.
AHRQ-funded; HS024630; HS021429.
Citation: Jones KJ, Skinner A, Venema D .
Evaluating the use of multiteam systems to manage the complexity of inpatient falls in rural hospitals.
Health Serv Res 2019 Oct;54(5):994-1006. doi: 10.1111/1475-6773.13186..
Keywords: Falls, Hospitals, Inpatient Care, Quality of Care, Quality Improvement, Patient Safety, Prevention, Risk
McGee MF, Kreutzer L, Quinn CM
Leveraging a comprehensive program to implement a colorectal surgical site infection reduction bundle in a statewide quality improvement collaborative.
This study’s objective was examine the implementation and associated clinical outcomes of a comprehensive colorectal surgical site infection (SSI) reduction bundle in a large statewide quality improvement collaborative. This multifaceted bundle includes guided implementation, data feedback, mentorship, process improvement training/coaching, and targeted-implementation toolkits. Bundle adherence outcomes were examined pre- and post-implementation. Among 32 hospitals, there was a 2.4-fold relative increase in patients completing at least 75% of bundle elements. The largest gains were in wound closure re-gowning/re-gloving, use of clean closing instruments, and preoperative chlorhexidine bathing. Adherence showed a significant decrease in superficial SSI rates.
AHRQ-funded; HS024516.
Citation: McGee MF, Kreutzer L, Quinn CM .
Leveraging a comprehensive program to implement a colorectal surgical site infection reduction bundle in a statewide quality improvement collaborative.
Ann Surg 2019 Oct;270(4):701-11. doi: 10.1097/sla.0000000000003524..
Keywords: Surgery, Healthcare-Associated Infections (HAIs), Patient Safety, Quality Improvement, Quality of Care
Schwarzkopf R, Behery OA, Yu H
Patterns and costs of 90-day readmission for surgical and medical complications following total hip and knee arthroplasty.
Unplanned readmissions following elective total hip (THA) and knee (TKA) arthroplasty as a result of surgical complications likely have different quality improvement targets and cost implications than those for nonsurgical readmissions. In this study, the investigators compared payments, timing, and location of unplanned readmissions with Center for Medicare and Medicaid Services (CMS)-defined surgical complications to readmissions without such complications.
AHRQ-funded; HS022882.
Citation: Schwarzkopf R, Behery OA, Yu H .
Patterns and costs of 90-day readmission for surgical and medical complications following total hip and knee arthroplasty.
J Arthroplasty 2019 Oct;34(10):2304-07. doi: 10.1016/j.arth.2019.05.046..
Keywords: Orthopedics, Surgery, Hospital Readmissions, Adverse Events, Quality Improvement, Quality of Care, Medicare, Hospitals