BACKGROUND/RATIONALE:
Despite the proliferation of quality improvement efforts, recent reviews have found mixed responses to these efforts. Growing research suggests that part of the gap between scientifically proven optimal practices in medicine and implementation of those practices may be related to organizational and structural characteristics including the culture of quality and patient safety at individual organizations. Incentives to improve quality of care may have little impact on provider behavior if there is low institutional commitment to providing high-quality care. Second, prior studies of P4P have not addressed the many unanswered questions concerning the most effective design of these programs.

OBJECTIVE(S):
Through related projects, this HSR&D Research Career Development award will investigate the effectiveness of quality improvement interventions and design and test different quality improvement interventions.

METHODS:
The first project evaluates the implementation of the medical home in the VA. We will perform an evaluation in VISN 4 using both qualitative and quantitative methods and focus on differences in PCMH implementation and effect across veteran subgroups, particularly vulnerable veteran populations. The second project will assess the relationship between pay-for-performance and the delivery of high-quality care in the setting of nursing homes. Using national data on all US nursing homes, this study examines changes in the quality of nursing home care when some states implemented pay for performance, examining: 1) whether pay-for-performance improves quality of care through changes in clinical quality measures, avoidable hospitalization rates, staffing levels, and number of deficiencies; 2) how the design of pay-for-performance affects improvement in quality of care, examining differences in the size of financial incentives and types of measures used in each program; and 3) the effect of pay-for-performance on disparities in care between facilities. The third project will design an intervention to help implementation of the medical home and effective use of team-based care. This project will assess task management and division of labor within provider teams. We will then design and implement an intervention to improve flow of patients through team members and ensure that providers work at the top of their provider licenses, testing whether this improves efficiency of care as well as provider and patient satisfaction with care.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
By using a combination of qualitative and quantitative methods as well as retrospective observational studies and prospective interventions these studies help shed light on how to design and more effectively implement quality improvement initiatives to improve quality of care for veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kullgren JT, Duey KA, Werner RM. A census of state health care price transparency websites. JAMA. 2013 Jun 19; 309(23):2437-8. [view]
2. Werner RM, Konetzka RT. Advancing nursing home quality through quality improvement itself. Health affairs (Project Hope). 2010 Jan 1; 29(1):81-6. [view]
3. Werner RM, Konetzka RT, Stuart EA, Polsky D. Changes in patient sorting to nursing homes under public reporting: improved patient matching or provider gaming? Health services research. 2011 Apr 1; 46(2):555-71. [view]
4. Park J, Werner RM. Changes in the relationship between nursing home financial performance and quality of care under public reporting. Health economics. 2011 Jul 1; 20(7):783-801. [view]
5. Popescu I, Werner RM, Vaughan-Sarrazin MS, Cram P. Characteristics and outcomes of America's lowest-performing hospitals: an analysis of acute myocardial infarction hospital care in the United States. Circulation. Cardiovascular quality and outcomes. 2009 May 5; 2(3):221-7. [view]
6. Werner RM, Goldman LE, Dudley RA. Comparison of change in quality of care between safety-net and non-safety-net hospitals. JAMA : the journal of the American Medical Association. 2008 May 14; 299(18):2180-7. [view]
7. Konetzka RT, Werner RM. Disparities in long-term care: building equity into market-based reforms. Medical care research and review : MCRR. 2009 Oct 1; 66(5):491-521. [view]
8. Werner RM, Norton EC, Konetzka RT, Polsky D. Do consumers respond to publicly reported quality information? Evidence from nursing homes. Journal of Health Economics. 2012 Jan 10; 31(1):50-61. [view]
9. Werner RM, Bradlow ET, Asch DA. Does Hospital Performance on Process Measures Directly Measure High Quality Care or Is It a Marker of Unmeasured Care? Health services research. 2008 Oct 1; 43(5p1):1464-1484. [view]
10. Lin GA, Redberg RF, Anderson HV, Shaw RE, Milford-Beland S, Peterson ED, Rao SV, Werner RM, Dudley RA. Impact of changes in clinical practice guidelines on assessment of quality of care. Medical care. 2010 Aug 1; 48(8):733-8. [view]
11. Werner RM, Konetzka RT, Stuart EA, Norton EC, Polsky D, Park J. Impact of public reporting on quality of postacute care. Health services research. 2009 Aug 1; 44(4):1169-87. [view]
12. Werner RM, Konetzka RT, Kruse GB. Impact of public reporting on unreported quality of care. Health services research. 2009 Apr 1; 44(2 Pt 1):379-98. [view]
13. Werner RM, Dudley RA. Making the 'pay' matter in pay-for-performance: implications for payment strategies. Health affairs (Project Hope). 2009 Sep 1; 28(5):1498-508. [view]
14. Polsky D, Marcus SC, Werner RM. Malpractice premiums and the supply of obstetricians. Inquiry : A Journal of Medical Care Organization, Provision and Financing. 2010 Jan 1; 47(1):48-61. [view]
15. Werner RM, Dudley RA. Medicare's new hospital value-based purchasing program is likely to have only a small impact on hospital payments. Health affairs (Project Hope). 2012 Sep 1; 31(9):1932-40. [view]
16. Asch DA, Werner RM. Paying for performance in population health: lessons from health care settings. Preventing chronic disease. 2010 Sep 1; 7(5):A98. [view]
17. Park J, Konetzka RT, Werner RM. Performing well on nursing home report cards: does it pay off? Health services research. 2011 Apr 1; 46(2):531-54. [view]
18. Werner RM, Canamucio A, Marcus SC, Terwiesch C. Primary care access and emergency room use among older veterans. Journal of general internal medicine. 2014 Jul 1; 29 Suppl 2:S689-94. [view]
19. Yong PL, Werner RM. Process quality measures and asthma exacerbations in the Medicaid population. The Journal of allergy and clinical immunology. 2009 Nov 1; 124(5):961-6. [view]
20. Werner R, Stuart E, Polsky D. Public reporting drove quality gains at nursing homes. Health affairs (Project Hope). 2010 Sep 1; 29(9):1706-13. [view]
21. Werner RM, Bradlow ET. Public reporting on hospital process improvements is linked to better patient outcomes. Health affairs (Project Hope). 2010 Jul 1; 29(7):1319-24. [view]
22. Werner RM, Konetzka RT, Kim MM. Quality improvement under nursing home compare: the association between changes in process and outcome measures. Medical care. 2013 Jul 1; 51(7):582-8. [view]
23. Chang VW, Asch DA, Werner RM. Quality of care among obese patients. JAMA : the journal of the American Medical Association. 2010 Apr 7; 303(13):1274-81. [view]
24. Werner RM, Bradlow ET. Relationship between Medicare's hospital compare performance measures and mortality rates. JAMA : the journal of the American Medical Association. 2006 Dec 13; 296(22):2694-702. [view]
25. Werner RM, Tamara Konetzka R, Liang K. State adoption of nursing home pay-for-performance. Medical care research and review : MCRR. 2010 Jun 1; 67(3):364-77. [view]
26. Alexander GC, Werner RM, Ubel PA. The costs of denying scarcity. Archives of internal medicine. 2004 Mar 22; 164(6):593-6. [view]
27. Polsky D, David G, Yang J, Kinosian B, Werner R. The Effect of Entry Regulation in the Health Care Sector: the Case of Home Health. Journal of public economics. 2014 Feb 1; 110:1-14. [view]
28. Reddy A, Shea JA, Canamucio A, Werner RM. The effect of organizational climate on patient-centered medical home implementation. American journal of medical quality : the official journal of the American College of Medical Quality. 2015 Jul 1; 30(4):309-16. [view]
29. Werner RM, Kolstad JT, Stuart EA, Polsky D. The effect of pay-for-performance in hospitals: lessons for quality improvement. Health affairs (Project Hope). 2011 Apr 1; 30(4):690-8. [view]
30. Werner RM, Canamucio A, Shea JA, True G. The medical home transformation in the Veterans Health Administration: an evaluation of early changes in primary care delivery. Health services research. 2014 Aug 1; 49(4):1329-47. [view]
31. Werner RM, Polsky D, Konetzka RT. The pay-off on nursing home report cards. Ldi Issue Brief [Electronic Resource]. 2011 Apr 1; 16(6):1-4. [view]
32. Werner RM, Chang VW. The relationship between measured performance and satisfaction with care among clinically complex patients. Journal of general internal medicine. 2008 Nov 1; 23(11):1729-35. [view]

Journal Other

1. Werner RM, McNutt R. A new strategy to improve quality: rewarding actions rather than measures. JAMA : the journal of the American Medical Association. 2009 Apr 1; 301(13):1375-7. [view]
2. Konetzka RT, Werner RM. Applying market-based reforms to long-term care. Health affairs (Project Hope). 2010 Jan 1; 29(1):74-80. [view]
3. Werner RM, Asch DA. Clinical concerns about clinical performance measurement. Annals of Family Medicine. 2007 Mar 15; 5(2):159-63. [view]
4. Kullgren JT, Werner RM. Counterpoint: will public reporting of health-care quality measures inform and educate patients? No. Chest. 2011 Nov 1; 140(5):1117-20; discussion 1120-2. [view]
5. Werner RM. Does pay-for-performance steal from the poor and give to the rich? Annals of internal medicine. 2010 Sep 7; 153(5):340-1. [view]
6. Werner RM, Bradlow ET, Asch DA. Hospital performance measures and quality of care. Ldi Issue Brief [Electronic Resource]. 2008 Apr 1; 13(5):1-4. [view]
7. Werner RM. Hospital process measures: Only one piece of the quality improvement puzzle. AHRQ Advances in Patient Safety: New Directions and Alternative Approaches. 2009 Apr 29. [view]
8. Werner RM, Greenfield S, Fung C, Turner BJ. Measuring quality of care in patients with multiple clinical conditions: summary of a conference conducted by the Society of General Internal Medicine. Journal of general internal medicine. 2007 Aug 1; 22(8):1206-11. [view]
9. Werner RM. Will using Medicare data to rate doctors benefit patients? Annals of internal medicine. 2012 Apr 3; 156(7):532-3. [view]

Conference Presentations

1. Werner RM. Benefits and pitfalls of public reporting of quality measures: what the infection control community might expect in an era of public reporting. Paper presented at: International Conference on Healthcare-Associated Infections; 2010 Mar 18; Atlanta, GA. [view]
2. Werner RM. Benefits and pitfalls of quality improvement initiatives: an overview. Presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2011 Apr 2; Dallas, TX. [view]
3. Werner RM, Park J, Konetzka RT, Norton E, Polsky D. Changes in market share in response to public reporting: effects of education. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
4. Gutierrez JC, Marcus SC, Terwiesch C, Werner RM. Characterizing primary care provider activity in routine practice. Paper presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD. [view]
5. Polsky D, Werner RM, Konetzka RT, Stuart E. Cream-skimming of low-risk patients after initiation of public reporting: evidence from nursing homes. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
6. Werner RM. Do consumers respond to publicly reported quality information? Evidence from nursing homes. Paper presented at: Harvard Medical School Department of Health Care Policy Monthly Meeting; 2010 Nov 1; Boston, MA. [view]
7. Werner RM. Does public reporting cause cream skimming? Paper presented at: AcademyHealth Annual Research Meeting; 2010 Jun 27; Chicago, IL. [view]
8. Robinson E, Asch DA, Werner RM. Effect of area-level factors on pay-for-performance hospital measures. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
9. Park J, Werner RM, Konetzka RT. Effect of public reporting on nursing home financial performance. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
10. Werner RM. Evaluating pay-for-performance initiatives. Paper presented at: Institute of Medicine Roundtable on Value and Science-Driven Health Care; 2011 Jun 1; Washington, DC. [view]
11. Reddy A, Asch DA, Canamucio A, Werner RM. Impact of loss of interpersonal continuity on patient experience of care and ambulatory quality of care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 26; San Diego, CA. [view]
12. Popescu I, Werner R, Sarrazin MV, Cram P. Is poor hospital adherence to AMI process measures associated with increased patient mortality? An analysis of CMS clinical and administrative data. Paper presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 10; Pittsburgh, PA. [view]
13. Park J, Werner R. Nursing home quality and financial performance. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
14. Rubenstein LV, Fihn SD, Werner RM, Kerr EM, Hickam DH, Rosenthal GE. PACT demonstration labs: multi-level partnerships in action. Presented at: VA HSR&D / QUERI National Meeting; 2012 Jul 18; National Harbor, MD. [view]
15. Casalino L, Belman M, Doran T, Werner R. Pay for performance, public reporting and disparities: what do we know? Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
16. Werner RM. Providing accountability through public reporting: intended and unintended consequences. Paper presented at: Minnesota Health Services Research Annual Conference; 2010 Mar 2; St. Paul, MN. [view]
17. Goldman D, Ostroff S, Petersen L, Werner RM. Public reporting of quality and safety measures, pay for performance and no pay for adverse outcomes: timely interventions to improve performance and accountability or insufficiently tested strategies with potential unintended consequences? [roundtable]. Presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
18. Werner RM. Quality improvement initiatives: Putting promise into practice. Paper presented at: VA HSR&D Career Development Annual Meeting; 2009 Feb 11; Baltimore, MD. [view]
19. Yong P, Werner RM. Relationship between process quality measures and acute care utilization for people with asthma enrolled in Medicaid. Paper presented at: AcademyHealth Annual Research Meeting; 2009 Jun 28; Chicago, IL. [view]
20. Kruse G, Werner RM, Polsky D, Stuart E. The impact of hospital pay-for-performance on hospital and Medicare costs. Paper presented at: AcademyHealth Annual Research Meeting; 2012 Jun 25; Orlando, FL. [view]
21. Reddy A, Canamucio A, Werner RM. The impact of patient-centered medical home transformation within Veterans Health Administration on patient experience of care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2014 Apr 26; San Diego, CA. [view]
22. Werner RM, Konetzka T, Stuart E, Norton E. The impact of public reporting on quality of post-acute care. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
23. Werner R, Konetzka RT, Kruse G. The impact of public reporting on unreported quality of care. Paper presented at: AcademyHealth Annual Research Meeting; 2008 Jun 8; Washington, DC. [view]
24. Polsky D, David G, Werner RM. The influence of competitive markets on improving quality of care through public reporting: the case of home health care. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2011 Jul 11; Toronto, Canada. [view]
25. Schapira MM, Huo H, Werner RM. The Relationship Between Patient Experience, Care Quality, and No Show Rates in the Outpatient Primary Care Setting. Paper presented at: Society of General Internal Medicine Annual Meeting; 2016 May 14; Hollywood, FL. [view]

DRA: Aging, Older Veterans' Health and Care, Health Systems
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none