Assignment: Organizational Performance & Balancing Finance

Assignment: Organizational Performance & Balancing Finance ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Assignment: Organizational Performance & Balancing Finance I’m trying to learn for my Writing class and I’m stuck. Can you help? Assignment: Organizational Performance & Balancing Finance Prompt: Discuss the importance of balancing finance, quality, mission and its relevance to sustainability of organizational performance. Include at least one example that supports this concept. Requirements: APA-compliant, 500-word minimum unit_5___benzeryoungburgess2014jgimp4psustainability.pdf unit_5___health_care_quality_and_how_to_achieve_it.21.pdf See discussions, stats, and author profiles for this publication at: Sustainability of Quality Improvement Following Removal of Pay-forPerformance Incentives Article in Journal of General Internal Medicine · August 2013 DOI: 10.1007/s11606-013-2572-4 · Source: PubMed CITATIONS READS 20 73 7 authors, including: Justin K Benzer James F Burgess U.S. Department of Veterans Affairs Boston University 48 PUBLICATIONS 273 CITATIONS 163 PUBLICATIONS 2,533 CITATIONS SEE PROFILE SEE PROFILE Errol Baker David C Mohr U.S. Department of Veterans Affairs U.S. Department of Veterans Affairs 82 PUBLICATIONS 6,349 CITATIONS 85 PUBLICATIONS 1,206 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Advanced Imaging Utilization Trends View project Organizational Factors and Inpatient Medical Care Quality and Efficiency View project All content following this page was uploaded by Justin K Benzer on 14 October 2014. The user has requested enhancement of the downloaded file. SEE PROFILE Sustainability of Quality Improvement Following Removal of Pay-for-Performance Incentives Justin K. Benzer, PhD1,2, Gary J. Young, PhD1,3, James F. Burgess Jr PhD1,2, Errol Baker, PhD1,2, David C. Mohr, PhD1,2, Martin P. Charns, DBA1,2, and Peter J. Kaboli, MD, MS4,5 1 Center for Organization, Leadership, and Management Research (COLMR) at the VA Boston Healthcare System (152 M), Boston, MA, USA; Boston University School of Public Health, Boston, MA, USA; 3Northeastern University Center for Health Policy and Healthcare Research, Boston, MA, USA; 4Comprehensive Access and Delivery Research and Evaluation (CADRE) Center at the Iowa City VA Healthcare System, Iowa City, IA, USA; 5 Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA. 2 BACKGROUND: Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed. OBJECTIVE: To investigate sustainability of performance levels following removal of performance-based incentives. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010. INTERVENTION: VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Assignment: Organizational Performance & Balancing Finance Bonuses are distributed based on the attainment of these performance goals. MEASUREMENTS: Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives. RESULTS: Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained. LIMITATIONS: This is a quasi-experimental study without a comparison group; causal conclusions are limited. CONCLUSION: The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare’s value-based Electronic supplementary material The online version of this article (doi:10.1007/s11606-013-2572-4) contains supplementary material, which is available to authorized users. Received January 11, 2013 Revised May 17, 2013 Accepted July 18, 2013 purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives. KEY WORDS: inpatients; physician incentive plans; quality improvement; quality indicators; reimbursement; incentive; salaries ; fringe benefits. J Gen Intern Med DOI: 10.1007/s11606-013-2572-4 © Society of General Internal Medicine 2013 INTRODUCTION Pay-for-Performance (P4P) has become a central strategy for improving the quality of health care in the US, Canada, and the UK, and such programs have become widely adopted among private and public health insurance programs over the last decade.1–3 Of particular note, the Patient Protection and Affordable Care Act (ACA) mandates the adoption of P4P (i.e., value-based purchasing) for hospitals and physicians participating in the Medicare program. Although P4P programs vary markedly in their design, two common features are: 1) defined performance goals for selected quality measures, and 2) associated financial incentives that can be targeted to institutions, individuals or both. Despite the growing prevalence of P4P programs, numerous questions persist about their effectiveness in improving quality of care, particularly about sustainability once the incentive is removed. While some studies of P4P demonstrate positive improvements in quality of care,4 other studies report disappointing results, as documented in several reviews of the literature.5 Moreover, among studies that do indicate improvements in quality measures, almost no attention has been paid to whether such improvements are sustainable over time,6 especially if the performance goals and incentives are removed. The sustainability of performance levels is a key consideration, as it may not be desirable or practical to Benzer et al.: Sustainability of QI after Removing Incentives maintain performance-based incentives indefinitely. For example, removal of performance-based incentives may seem warranted when performance for a measure rises to the upper end of the performance scale (i.e., topped out) (e.g., aspirin in acute myocardial infarction), or is otherwise at a level that is not likely to be exceeded in the current clinical environment. In the design of Medicare’s hospital value-based purchasing (VBP) program, considerable debate regarding topped out measures occurred, resulting in a decision to exclude process measures that have attained this status.7 Another reason for removing performance-based incentives is to expand the reach of a P4P program to a new range of clinical conditions or areas of focus. Assignment: Organizational Performance & Balancing Finance Performancebased incentives may be routinely removed from some measures for specified time periods and assigned to other measures to limit the total number of performance measures under evaluation at any point in time. Despite the importance of sustainability for current healthcare policy, there is limited research on the sustainability of performance levels.8–10 There has been no research on the removal of incentives for inpatient medicine quality measures such as those included in Medicare’s VBP. A multi-year P4P initiative within the Veterans Health Administration (VA) that included adoption and removal of performance-based incentives for selected quality measures provides the opportunity to conduct such research using a quasi-experimental study design. The objective of this study was to evaluate the empirical support for a hypothesis that performance gains realized during a P4P program would decrease after the removal of the performance-based incentives. JGIM payments to front-line clinicians and other employees. The unit of analysis for the study was the VA medical center (N=128). Performance Measures Since 2004, VA has tracked over 30 performance measures relevant to acute coronary syndrome (ACS), heart failure (HF), and pneumonia (PNU). Following The Joint Commission standards, sampling has been conducted for all patients with these three conditions. Performance measures were developed based on published scientific evidence and established clinical guidelines. The performance measurement system for these quality measures is standardized and includes specified data collection protocols (Appendix A; available online). Performance measure guideline adherence is measured through VA’s External Peer Review Program, an independent chart review of randomly selected patients who meet specified inclusion and exclusion criteria. Goals for each performance measure are set annually by the VA central office, and incentives are awarded based on achievement of those goals. Performance goals have also been raised for some measures as the mean performance level has risen over time. In addition, for seven of these measures, the performance-based incentives were removed between 2007 and 2009, but continued to be measured and reported for at least a year. Although no explicit criteria existed for the removal of incentives, high performance level was likely a factor. For six of the seven performance measures, mean performance was over 90 % prior to removal of the incentives. We focused on these seven quality measures, and for each indicated the percent of hospitalized patients who satisfied the inclusion/exclusion criteria and received guideline concordant care. METHODS Setting The Veterans Health Administration (VA), US Department of Veterans Affairs, is the largest integrated healthcare provider in the US, with more than 8.5 million enrollees in 2012. VA medical centers are organized into regional networks managed by a network director, use a common electronic medical record, and a P4P quality measurement and reporting system.Assignment: Organizational Performance & Balancing Finance 11 For purposes of P4P, VA’s central office sets performance goals in consultation with clinical leaders and reported performance scores to medical centers quarterly. As such, this system-level intervention entailed both public reporting and financial incentives. With respect to public reporting, performance data were available to both clinicians and managers quarterly, and were also included in publicly available annual reports. Performance bonuses were distributed, based on the attainment of performance goals, to both regional network and facility-level senior managers, who, in turn, had discretion to distribute bonus Acute Coronary Syndrome (ACS) & & & Cardiology Involvement: High or moderate-high risk patients with cardiology involvement within 24 hours of arrival, or if acute myocardial infarction (AMI) during inpatient stay, within 24 hours of initial electrocardiogram (ECG) or first positive troponin, whichever is earlier. Troponin Returned: First troponin result returned within 60 min of order. Diagnostic Catheterization: High or moderate-high risk patients who received a diagnostic catheterization prior to discharge. Heart Failure (HF) & ACE-I or ARB: For patients with ejection fraction less than 40 %, presence of an angiotensin-converting JGIM & Benzer et al.: Sustainability of QI after Removing Incentives enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) prior to admission (i.e., a continuous care metric targeting the quality of care in the outpatient setting). Weight Monitoring: Documentation of instruction for monitoring weight prior to admission (i.e., a continuous care metric targeting the quality of care in the outpatient setting). Pneumonia (PNU) & & Timely Antibiotic: Initial antibiotic dose administered no earlier than 15 min prior to or no later than 240 min following hospital arrival. Pneumococcal Immunization: Receipt of pneumococcal immunization prior to admission (i.e., a continuous care metric targeting the quality of care in the outpatient setting). Patient Sample 313,600 VA patient records were peer reviewed between FY2004 and FY2010 across the seven measures. Sample sizes for a single year ranged from 3,588 for HF: ACE-I or ARB in FY2010 to 13,777 for HF: Weight monitoring in FY2009. For each performance measure, the average numbers of patients sampled per facility per quarter are reported in Table 1. between four to nine study sites. These sites had more than 50 % missing data, whereas all other sites averaged 1 % missing data. Sensitivity analyses with and without the high missing data sites demonstrated that conclusions would not differ based on the decision to include or exclude sites. The sites with substantial missing data were excluded. For the remaining sites, we imputed missing data using maximum likelihood estimation during analyses. Latent growth models implemented with MPLUS Version 5.2 were used to estimate slopes across years. A piecewise latent growth model was used for each performance measure to estimate an intercept and slopes for each year in the model, accounting for autocorrelations across time periods (Appendix B; available online). Assignment: Organizational Performance & Balancing Finance A significant slope indicates that the rate of change is significantly different from zero. For example, PNU: Timely Antibiotic was measured from FY2005 to FY2009 so analyses estimate the slopes for each of the 5 years. This model permits evaluation of changes in performance between years where the performance goal changed, years where the performance goal remained constant, and years during which the performance goal was removed. A significant negative slope in the year following incentive removal indicates that performance was not sustained. Power is a concern because the absence of a significant negative slope will be interpreted as sustained performance. Thus, we performed power calculations. Analyses had 86 % power to detect whether the slope was at least ?2 % in the year following incentive removal. Statistical Analyses RESULTS Quarterly performance data were obtained from FY2004 to FY2010 from VA administrative data. Each measure was a percentage score representing the number of patients meeting the performance criteria divided by the total number of eligible patients. Medical centers served as their own controls in analyses. Missing data were an issue for Table 1 presents the introduction and removal of the performance-based incentives for each performance measure. Only two measures (PNU: Timely Antibiotic and ACS: Diagnostic Catheterization) had a true baseline period where reporting for the measure occurred before the adoption of performance-based incentives. Performance- Table 1. Performance Goals for Each Quality Measure (FY2004–FY2010) Measure Acute Coronary Syndrome Cardiology Involvement Troponin Returned Diagnostic Catheterization Heart Failure ACE-I or ARB Weight Monitoring Pneumonia Timely Antibiotic Pneumococcal Immunization N FY2004 FY2005 FY2006 FY2007 FY2008 FY2009 FY2010 17 15 15 N/A N/A Baseline 82 % 75 % 90 % 87 % 85 % 90 % 87 % 89 % none 91 % 95 % N/A none none N/A none none N/A 11 25 N/A 90 % 90 % 90 % 90 % 90 % 90 % 90 % none none none none none N/A 18 20 N/A 85 % Baseline 85 % 73 % 85 % 80 % 85 % none none none none N/A N/A Percentage scores indicate the performance standard for that year. N/A indicates that the measure was not assessed that year. “Baseline” indicates the measure was collected, but was not incentivized for that year. “None” indicates that the performance-based incentive was removed. N=Average number of patients per hospital per quarter JGIM Benzer et al.: Sustainability of QI after Removing Incentives DISCUSSION In this observational cohort study evaluating P4P over 7 years in 128 VA hospitals, we found evidence of improvement in performance measures following the adoption of performance-based incentives, and that after removal of the incentives, performance neither further improved nor deteriorated. As the US makes a substantial investment in P4P, both financially and intellectually, it is imperative that researchers capitalize on opportunities to learn about the potential effectiveness of such programs on quality of care. Current national policy discussions involve both use of quality measures and choices regarding when to retire measures. Our findings have important implications for Medicare’s value-based purchasing program as we focused on the same types of hospital inpatient measures included in the Medicare program. Our study contributes to a growing literature on P4P for which there is a lack of consistent evidence regarding the effectiveness of such programs. Assignment: Organizational Performance & Balancing Finance The mixed findings in the a Acute Coronary Syndrome 1 Performance (%) 0.9 0.8 Diagnostic Catheterization 0.7 Troponin Returned 0.6 Cardiology Involvement 0.5 0.4 2004 b 2005 2006 2007 2008 Fiscal Year (Oct-Sep) 2009 2010 2011 Heart Failure 1 0.95 Performance (%) 0.9 0.85 Weight Monitoring 0.8 ACEI or ARB 0.75 0.7 0.65 0.6 2004 c 2005 2006 2007 2008 Fiscal Year (Oct-Sept) 2009 2010 2011 Pneumonia 1 0.9 Performance (%) based incentives were removed between 2–4 years following adoption. Rates of change for each measure are shown by quarter in Fig. 1 for the latent growth models. The three ACS measures are displayed together in Fig. 1a, the two HF measures in Figure 1b, and the two PNU measures in Fig. 1c. Each line represents the overall trend for a single year regarding the rate of change after removal of the performance-based incentives, as indicated by the arrows in Figure 1. The overall mean score changes for the period where performance-based incentives were adopted and the period where performance-based incentives were removed are summarized in Table 2. Prior to the removal of incentives, we found that performance significantly improved for six of the seven measures. The most dramatic improvement occurred with the PNU: Timely Antibiotic measure, where performance improved from 64 % to 82 % in 2 years following the adoption of performance-based incentives. The only measure that did not demonstrate significant improvement was the heart failure: ACE-I measure. Results did not support the hypothesis that performance decreased after incentives were removed. Six of the seven measures did not demonstrate a significant slope in the year following incentive removal. The seventh measure, weight monitoring, demonstrated a significant positive slope in the year following incentive removal. However, a significant negative slope was observed in the following year and a non-significant slope in the third post-removal year. Given that the design provides adequate power to detect changes in performance, results indicate that performance was sustained for all measures following removal of incentives. 0.8 0.7 Pneumococcal Immunization 0.6 Timely Antibiotic 0.5 0.4 2004 2005 2006 2007 2008 Fiscal Year (Oct-Sep) 2009 2010 Figure 1. Graph of latent growth model analyses for seven performance measures. Dependent variable is the number of patients who receive guideline-adherent care divided by the number of eligible patients. Trend lines are estimated for each year to demonstrate how the trend changes over time. Arrows indicate the point at which incentives are either introduced or removed. Dashed lines indicate periods in which performance-based incentives were removed. Significant slopes are indicated by larger point size lines. literature suggest that the effectiveness of P4P likely depends on contextual factors that researchers have yet to fully explicate with conceptual frameworks and empirical testing. In this vein, the particular implementation of P4P in the VA and the nature of the VA system may have improved the likelihood of performance sustainability. As noted, performance-based incentives in the VA are awarded to facilities and their managers, who decide whether and how to distribute them to clinicians. This type of incentive arrangement is similar to those established by Medicare and private health plans for purposes of contracting with JGIM Benzer et al.: Sustainability of QI after Removing Incentives Table 2. Overall Change in Performance Measures from Initial to Final Measureme … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10

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