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The Association of Hospital Characteristics and Quality Improvement Activities in Inpatient Mediclal Services

Restuccia J, Mohr D, Meterko M, Stolzmann K, Kaboli PJ. The Association of Hospital Characteristics and Quality Improvement Activities in Inpatient Mediclal Services. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD.

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Research Objective: Despite the increasing attention to quality of US health care, relatively little is known about the extent to which hospitals engage in quality improvement activities (QIAs) or factors influencing extent of QIAs. The overall objective of this study was to identify the extent of QIAs in the inpatient medical services of an integrated delivery system, and examine the influence of 1. use of hospitalists, 2. use of other providers (nurse practitioners and physician assistants) and 3. goal alignment and commitment to quality of care in the adoption of QIAs. Study Design: We conducted a cross-sectional, descriptive study of QIAs using a survey administered to Chiefs of Medicine (COMs) at all 124 Department of Veterans Affairs (VA) acute care hospitals. We developed the survey instrument utilizing previously developed surveys of hospital QIAs and conducted pilot tests for face validity with seven VA physicians and one research methodologist. For the 27 QIA items, respondents rated the extent of use of the QIA using a Likert scale ranging from 0 for "not used at all", to 4 for "used hospital-wide" as well as an option for "Don't know/not sure." We conducted an exploratory factor analysis on the 27 QIAs and identified three factors: infrastructure, prevention, and information gathering. We conducted hierarchical regressions of QIA use for each factor and an overall factor from all 27 QIAs on facility contextual variables (operating beds, years in operation, occupancy rate, teaching status, urban/rural distinction, and geographic region), followed by use of hospitalists, use of other providers, and goal alignment/quality commitment. We entered the independent variables in ascending order based on expected magnitude of contribution to the overall model. Population Studied: Inpatient medicine services at all VA acute care hospitals. Principal Findings: Survey response rate was 95% (118/124). The overall QIA factor scale, consisting of all 27 QIAs, showed high internal consistency (k = 27; a = .94) as did the other scales: prevention (k = 10; a = .92) involving activities aimed at reducing negative incidents (e.g., central line infections, surgical site infections); information gathering (k = 9; a = .88) involving assessing performance and learning best practices (e.g., provider profiling, benchmarking); and infrastructure (k = 8; a = .89) involving QIAs focused on internal design activities (e.g., case management, clinical collaboratives). QIAs related to prevention were most frequently used (mean = 3.38) while information gathering (mean = 2.27) and infrastructure (mean = 2.25) were used less widely. With the exception of higher occupancy rate and infrastructure, contextual variables were not associated with QIAs. Hospitals using only hospitalists showed a positive association with all four QIA categories [overall QIAs (b = .61; p < .001); prevention (b = .61; p < .001); information gathering (b = .75; p = .01); infrastructure (b = .55; p = .03)] as did alignment/commitment [overall QIAs (b = .31; p < .001); prevention (b = .24; p < .001); information gathering (b = .28; p = < .001); infrastructure (b = .42; p < .001)]. Conclusions: Hospitalists on inpatient medicine services and goal alignment/quality commitment appear to facilitate implementation of QIAs. Implications for Policy, Delivery, or Practice: As hospitals look to respond to changes (e.g., pay for performance, accountable care organizations), this study suggests that use of hospitalists and efforts to communicate goals and align them throughout the organization may lead to greater implementation of QIAs.

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