There is a 4 part question for the case study.

1. What were the sources for data and why were those chosen?
2. How did financial incentives contribute to the success of the improvement program? How else could financial incentives be used to drive results?
3. What resources and processes helped the health system improve quality, and who should have been on the QI team?
4. How could HTS design a physician incentive program to make the program more likely to continue in the future?

Below is the case study:

Holy Trinity Health System (HTS) is a large, acute-care, academic hospital with more than 400 beds, 800 physicians, and 1,500 nurses, therapists, technologists, and support personnel, serving more than 300,000 people from its surrounding area. Last year, leadership became suspicious that patient outcomes and satisfaction were getting worse; further, the states largest non-profit insurance company renegotiated their contract and included a quality-based incentive payment. HTS decided to implement a performance improvement project to enhance patient care and increase revenue.

First, the executive team notified all providers and staff of the new initiative. They created a quality improvement (QI) team consisting of people from different hospital departments. The QI team was given permission to talk to all HTS employees and contractors, gather all appropriate data, and target projects based on evidence.

The QI team was unsure where to start because of the immense scope of this initiative, so they contacted the IT department and had simple reports run on their administrative database. They also knew that the hospital participated in the annual Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey of patients, and they contacted internal resources to gain results from multiple years.

The CAHPS data was available first. The team created a Pareto chart to identify a limited number of survey questions that accounted for the lowest scores. Next, they plotted the results in a control chart and found that, of the selected measures, physician/patient communication had the most significant downward trend. To confirm that this measure was an issue, the QI team researched publicly available CAHPS data from the Centers for Medicare and Medicaid Services (CMS) and created a benchmark. As suspected, HTS was below the benchmark for this measure and getting worse.

The administrative data reports told a similar story. Readmission rates were higher than the state average, especially for patients being discharged to short-term rehab facilities or home care. This could have devastating financial impacts with the new quality-based incentive program.

Rather than review the clinical data, the QI team established a random population of patients and shadowed the discharge planners when the patients were released. Patients with more complex conditions and follow-up requirements were more likely to be readmitted than the rest of the population. The QI team realized this could be a simple risk-adjustment issue, but when complex patients were compared to equally complex patients in other facilities HTS was still worse.

After a series of interviews with patients, providers, and staff, the QI team implemented two new processes. The first was patient-facing: patients considered complex based on HTS proprietary risk scoring methodology were given a brief survey upon discharge. If the answers to the questions did not meet a passing grade, the planner was instructed to call the attending physician to review the post-discharge care plan and answer any additional questions. The second process was provider-facing: all physicians were required to sit down with patients prior to discharge, provide them with a written summary of their visit including discharge plans, and ask if they or their family members had any additional questions. Training programs were created to facilitate these interactions.

Both of these new processes were turned into internal metrics and added to the dashboard reports seen by providers, staff, and administrators. Finally, because of the staffing shortages that sometimes happen at HTS, the QI team created a helpline that providers and staff could call if they were unable to take the extra time to support a complex patient; utilization of the helpline was also tracked.

The QI team did a look-back on the 6-months prior to, and 6-months after, establishing these new processes and saw that readmissions decreased by 8% and patient satisfaction increased 2.5 points. Both items are elements within the quality-based insurance contract and will therefore translate into a system-wide bonuses. HTS revenues are projected to increase by $5M if they can sustain these quality improvements.