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Importance: The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database., Objective: To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings., Design, Setting, and Participants: This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment., Intervention: A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018., Main Outcomes and Measures: The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention., Results: A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P < .001). There was a modest decrease in the mean number of EVTAs per patient among inlier physicians (1.83 [0.57] vs 1.78 [0.55]; P < .001) and a more substantial decrease among outlier physicians (4.40 [1.01] vs 3.67 [1.41] ; P < .001). Outliers in 2017 consisted of 90 physicians, of whom 71 (78.9%) reduced their EVTA use after the intervention. The number of EVTAs per patient decreased by a mean (SD) of 0.09 (0.46) procedures overall (median, 0.10 procedures [IQR, -0.10 to 0.30 procedures]; P < .001). The estimated cost savings associated with the decrease was $6.3 million in 2019., Conclusions and Relevance: In this quality improvement study, substantial variability in the number of EVTAs performed per patient was observed across the US. When physicians were provided with a 1-time peer-benchmarked performance report card, the timing of the intervention was associated with a significant decrease in the number of EVTAs performed per patient, particularly among outlier physicians. This quality improvement initiative was associated with reduced variability in EVTA use in the US and a substantial savings for Medicare.

Objective: The purpose of this study was to determine chief nursing officer (CNO) perspectives on how to sustain the infrastructure required for successful American Nurses Credentialing Center (ANCC) Magnet® redesignation., Background: American Nurses Credentialing Center Magnet designation is a prestigious achievement reflective of years of dedication, innovation, mentoring, and leadership support. As challenging as the initial attainment of Magnet status can be, sustaining the success and becoming redesignated is considered even more difficult by many CNOs. However, there have been no published reports indicating how to be successful in Magnet redesignation., Method: A grounded theory qualitative approach was used, and data were collected through telephone interviews with CNOs who had successfully attained at least 1 redesignation., Results: Fourteen CNOs participated; data were organized into 6 themes and 15 subthemes describing the critical elements for Magnet redesignation., Conclusion: Relationships among the 6 themes and subthemes are theorized in the form of a wheel with 6 spokes. When "set in motion," the wheel gathers momentum and all of the model elements become coalesced into the organizational ethos., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Organizations across the country are redesigning care delivery to improve quality and outcomes, enhance the patient experience, reduce costs, and, ultimately, produce better population health. Leaders from the American Organization for Nursing Leadership engaged key stakeholders to discuss the role nursing can play and the toolkit that will be introduced this year to guide nurse leaders in striving for value., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Since 2014, prostate cancer centers outside Germany (PCCoG) are eligible for certification according to the criteria set out by the German Cancer Society (DKG). These centers must fulfill the same requirements as their German counterparts. The article reports on the experiences of the first nine certified PCCoG, with a focus on their indicator results., Method: Following a descriptive analysis about primary case distribution, indicator definitions, and patient numbers, we compared indicator results for all 114 German PCC with all 9 PCCoG that have been certified for at least 3 years. Median centers' proportion was calculated and overall proportion for every indicator. Two-sided Cochran-Armitage tests were applied to detect trends over time., Results: The number of primary cases increased for both groups steadily from 2015 to 2017 as did fulfillment of most other indicators including PCa guideline-derived indicators. Requirements that proved to be hard to fulfill for PCCoG initially included psycho-oncological services (POS) and social service counselling (SCC). Fulfillment of POS requirements improved in the following years after initial certification in PCCoG. SCC rates remain low in PCCoG due to the different health system structures., Conclusion: Acquiring a certificate by the DKG is achievable for PCCoG. Candidate centers need to be aware that substantial effort is required to fulfill the criteria, but once this is done, typically an improvement of indicators and an increase in patient numbers can be observed. Different health-care systems need to be taken into consideration and the certification requirements adapted in different areas to allow country-specific implementation.

Infectious disease outbreaks pose major threats to human health and security. Countries with robust capacities for preventing, detecting and responding to outbreaks can avert many of the social, political, economic and health system costs of such crises. The Global Health Security Index (GHS Index)-the first comprehensive assessment and benchmarking of health security and related capabilities across 195 countries-recently found that no country is sufficiently prepared for epidemics or pandemics. The GHS Index can help health security stakeholders identify areas of weakness, as well as opportunities to collaborate across sectors, collectively strengthen health systems and achieve shared public health goals. Some scholars have recently offered constructive critiques of the GHS Index's approach to scoring and ranking countries; its weighting of select indicators; its emphasis on transparency; its focus on biosecurity and biosafety capacities; and divergence between select country scores and corresponding COVID-19-associated caseloads, morbidity, and mortality. Here, we (1) describe the practical value of the GHS Index; (2) present potential use cases to help policymakers and practitioners maximise the utility of the tool; (3) discuss the importance of scoring and ranking; (4) describe the robust methodology underpinning country scores and ranks; (5) highlight the GHS Index's emphasis on transparency and (6) articulate caveats for users wishing to use GHS Index data in health security research, policymaking and practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: To explore the utility and feasibility of implementing eight person-centred nursing key performance indicators in supporting community nurses to lead the development of person-centred practice., Background: Policy advocates person-centred health care, but few quality indicators exist that explicitly focus on evaluating person-centred practice in community nursing. Current quality measurement frameworks in the community focus on incidences of poor or missed opportunities for care, with few mechanisms to measure how clients perceive the care they receive., Methods: An evaluation approach derived from work of the Medical Research Council was used, and the study was underpinned by the Person-centred Practice Framework. Participatory methods were used, consistent with person-centred research., Results: Data were thematically analysed, revealing five themes: giving voice to experience; talking the language of person-centredness; leading for cultural change; proud to be a nurse; and facilitating engagement., Conclusions: The findings suggest that implementing the eight person-centred nursing key performance indicators (KPIs) and the measurement framework is feasible and offers a means of evidencing person-centredness in community nursing., Implications for Nursing Management: Person-centred KPI data, used alongside existing quality indicators, will enable nurse managers to evidence a high standard of care delivery and assist in the development of person-centred practice., (© 2020 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.)

The successful implementation of a geriatric fracture program is dependent on engaging a multidisciplinary team. The goal of these programs is to address the unique needs of patients with geriatric fracture by providing the support necessary for return to their prefracture level of activities of daily living. Identifying the key stakeholders and clarifying their role in pre- and postoperative patient support are vital to the development of such an initiative. The purpose of this article is to discuss the steps to plan and implement a geriatric fracture program in a hospital and lessons learned from our experience initiating such a program.

Various approaches are used to measure the firms' performance. Grey relational analysis is one of the multiple attribute decision-making methods and data envelopment analysis is used to calculate the efficiency. Regarding the importance of water and wastewater companies' services, the present study, evaluates the performance and rank these companies by using grey relational analysis and data envelopment analysis approaches based on balanced scorecard criteria. Besides, balanced scorecard considers all levels of organization. In this research, statistical population includes thirty-five municipal water and wastewater companies in Iran for the year 2017. In order to ascertain grey relational grade, fuzzy normalization method was used then by subtracting normalized numbers from one, reference sequences obtained and in the next step, grey relational coefficient was calculated and finally, grey relational grade was determined by multiplying relative weight from Shannon entropy to relational coefficients. In order to assess companies' efficiency in data envelopment analysis, after ascertaining input and output indices, with the assumption of constant returns to scale and output-oriented viewpoint, the efficiency scores were calculated. Also, to rank efficient units Anderson-Petersen model implemented. Results demonstrated that, grey relational analysis is a more accurate method to measure the performance of water and wastewater companies., (Copyright © 2019. Published by Elsevier Ltd.)

Background: The National Surgical Quality Improvement Program (NSQIP) database is increasingly used for surgical research. However, it is unclear how well this database represents the breadth of work performed by different specialties., Methods: Using the 2017 NSQIP participant use file and the 2017 Medicare Physician/Supplier Procedure Summary file, we evaluated (1) what proportion of surgical work is captured by NSQIP, (2) what procedures and disciplines are undersampled, and (3) the overall concordance between the NSQIP sample and a national sample., Results: The NSQIP database reported at least one case for 4,463 out of the 5,272 Current Procedures Terminology codes in the Medicare file, potentially capturing 97.8% of surgical work across all 10 specialties. However, this proportion decreased to 72.1% when only procedures with at least 100 cases in NSQIP were considered. Limiting our analysis to only those procedures with 100 cases had markedly different effects by specialty. In part, this was owing to undersampling of minor procedures, which are more common in disciplines such as otolaryngology and urology. The overall association between the size of the NSQIP sample and the Medicare sample was 0.08., Conclusion: Although NSQIP has the potential to capture a diverse surgical caseload, some specialties and procedures are undersampled, limiting the ability for NSQIP to generate valid benchmarks. There was little correlation between the sample sizes in NSQIP and a national sample. Increasing sampling of underrepresented procedures and developing weights to scale NSQIP to a national sample would strengthen the program's ability to inform health outcomes research and provide valid comparisons across procedures and specialties., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation., Methods: Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed., Results: A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction., Conclusions: Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits., (© 2019 The Authors. International Journal of Clinical Practice published by John Wiley & Sons Ltd.)

The US Department of Health and Human Services has launched a large-scale plan that aims to "End the HIV Epidemic" (EtHE) in America, including ambitious goals and targets over the next 5 to 10 years.To be successful, the EtHE Plan will require timely dissemination of relevant metrics to inform the broad array of stakeholders who are in a position to act in support of the plan's goals. Metrics should include both population health outcome metrics and implementation metrics that track the deployment and uptake of specific intervention delivery strategies. In addition to the usual HIV care continuum metrics that include all people living with HIV in the denominator, metrics dedicated to those not yet reached (i.e., as the denominator) are essential to help target EtHE implementation efforts. Special attention is required around metrics and targets that inform and drive action on HIV-related health disparities.Well-chosen metrics and a well-designed dissemination system can serve as important tools to assess the progress of the EtHE Plan, and to identify and disseminate lessons learned quickly within and across jurisdictions aiming to end HIV as a local public health threat.

The population that undergoes pediatric surgical procedures in high-resource settings such as Canada primarily comprises healthy patients who undergo low-risk, elective surgeries and fewer higher-risk patients who require more complex surgeries. Given this variability, there is a relatively low incidence of traditionally measured "critical" outcomes within any single pediatric surgical system or even pediatric surgical subspecialty, rendering the currently available quality measurement tools inadequate to provide sensitive measures of quality. In an era when scalable solutions are required to improve health outcomes across entire populations, there is an urgent need for more holistic measures of a child's well-being to benchmark and measure changes in quality of care. This article discusses opportunities for enhanced performance measurement in pediatric surgery using a value-based framework to identify and measure patient and family outcomes of importance over the full care cycle, from initial presentation through surgery and recovery to sustainability of health. In suggesting new avenues for performance measurement, we highlight how these measures can be used to develop, evaluate and refine surgical system innovations such as bundled care pathways and perioperative care homes., (Copyright © 2019 Longwoods Publishing.)

Purpose: To describe a process to identify metrics that represent the impact of inpatient pharmacy services on patient outcomes across a health system., Summary: The authors describe a systematic process of identifying inpatient clinical outcome measures that could represent pharmacists' impact on patient outcomes and eventually be displayed in a dashboard within the electronic medical record (EMR). A list was generated through literature review, assessment of practices at other sites, evaluation of current pharmacy services, and collaboration with the quality department and System Pharmacy Clinical User Group. The project team narrowed the list through assessment against standardized criteria. An assessment tool was designed and distributed to stakeholders to prioritize clinical outcome measures for inclusion on the dashboard. The clinical outcome measures were transformed into metrics by determining measurement criteria, inclusion and exclusion parameters, and review time frame. After validation, the metrics are planned to be displayed on an inpatient pharmacy EMR dashboard. Exemption from institutional review board review was granted for this project., Conclusion: A systematic process was developed and used to identify inpatient clinical outcome metrics., (© American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Little is known about the role of organizational or administrative support in implementation of health promotion interventions, particularly outside of school settings. The purpose was to determine the change in fruit and vegetable (FV) intake among children living in residential children's homes (RCHs) and assess the relationships among change in organizational support, intervention implementation, and child nutrition outcomes. Data were collected from 29 RCHs and 614 children living in RCHs, as part of a group randomized design with delayed intervention, at three cross-sectional waves: 2004, 2006, and 2008. RCH staff made environmental changes to increase intake of FV. Implementation and organizational support data were collected from staff at the RCHs. Child FV intake were measured via 24-h dietary recalls. A two-way (condition by time) repeated measures ANOVA was conducted to test whether FV intake increased in response to the intervention. A two-level path analysis with a robust maximum likelihood estimator was used to explore the relationships among organizational support, intervention implementation fidelity, and child FV intake. There was a significant increase in FV intake within all RCHs from 2004 to 2006 (P = 0.022 for the intervention group, P = 0.015 for the control group). This increase was maintained in both groups from 2006 to 2008 (post-intervention mean servings: intervention = 3.2 vs control = 3.4). Increases in organizational support resulted in greater overall implementation fidelity. When RCH staff, supervisors, and the RCH CEO were perceived to be supportive of the intervention, more environmental changes were made to encourage eating FV. Fostering organizational support may improve implementation of interventions.

The incidence of pressure ulcers or injuries is a global healthcare issue and in the top six most common adverse events in healthcare. Pressure injuries also are symptomatic of wider system failure and poor care. Recognition of these injuries and prevention strategies must start in the emergency department. This article will detail best practice in relation to both assessment of these injuries and their prevention in the emergency department., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The objectives of this study were to benchmark roles that veterinary librarians at universities and colleges play in systematic reviews (SRs) and scoping reviews that are conducted by faculty and students at their institutions, to benchmark the level of training that veterinary librarians have in conducting SRs, to identify barriers to their participation in SRs, and to identify other types of literature reviews that veterinary librarians participate in., Methods: Sixty veterinary librarians in universities and colleges in Canada, the United States, England, Scotland, Ireland, Australia, and New Zealand were surveyed online about their roles and training in conducting SRs, barriers to participation in SRs, and participation in other types of literature reviews., Results: Veterinary librarians' highest participation was at an advising level in traditional librarian roles as question formulator, database selector, search strategy developer, and reference manager. Most respondents reported pretty good to extensive training in traditional roles and no or some training in less traditional roles. Sixty percent of respondents received few or no requests to participate in SRs, and only half of respondents had participated in SRs as a review team member. Sixty percent of respondents stated that their libraries had no policies regarding librarian roles and participation in SRs., Conclusions: The surveyed veterinary librarians participated in SRs to a lesser degree than human health sciences librarians, experienced low demand from veterinary faculty and students to participate in SRs, and participated as review team members at significantly lower rates than human health sciences librarians. The main barriers to participation in SRs were lack of library policies, insufficient training, and lack of time., Competing Interests: COMPETING INTERESTS The author has no competing interests to declare., (Copyright: © 2019, Authors.)

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision-making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence-based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness. Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks. Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country. As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study., (© 2019 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.)

Background: Considerable differences exist among the living donor Kidney Exchange Programmes (KEPs) that are in use and being built in Europe, contributing to a variation in the number of living donor transplants (Newsletter Transplant; International figures on donation and transplantation 2016). Efforts of European KEPs to exchange (best) practices and share approaches to address challenges have, however, been limited., Methods: Experts from 23 European countries, collaborating on the European Network for Collaboration on Kidney Exchange Programmes Cooperation on Science and Technology Action, developed a questionnaire to collect detailed information on the functioning of all existing KEPs in Europe, as well as their opportunities and challenges. Following a comparative analysis, results were synthesized and interpreted by the same experts., Results: The practices, opportunities and challenges reported by 17 European countries reveal that some of the 10 operating programs are mature, whereas others are in earlier stages of development. Over 1300 transplants were performed through existing KEPs up to the end of 2016, providing approximately 8% of their countries' living kidney donations in 2015. All countries report challenges to either initiating KEPs or increasing volumes. Some challenges are shared, whereas others differ because of differences in context (eg, country size, effectiveness of deceased donor program) and ethical and legal considerations (eg, regarding living donation as such, nonrelated donors, and altruistic donation). Transnational initiatives have started in Central Europe, Scandinavia, and Southern Europe., Conclusions: Exchange of best practices and shared advancement of national programs to address existing challenges, aided by transnational exchanges, may substantially improve access to the most (cost) effective treatment for the increasing number of patients suffering from kidney disease.

Purpose of Review: To review the developments within paediatric anaesthesia and describe the various factors that have contributed to the improvements in anaesthesia-related outcomes in children., Recent Findings: During the years substantial improvements in paediatric anaesthesia-related outcomes has derived from safety advances in equipment, drugs, human factor analysis, professional standardization and organization, subspecialty care and regionalization. However, universally agreed outcome measures are lacking., Summary: Despite a steadily and significant improvement in paediatric anaesthesia-related outcomes over the years further and future improvements are still necessary in areas such as adverse-event reporting and long-term neurocognitive outcomes with much more focus on patient/family-centred outcomes. Clinical experts and stakeholders should meet and agree on a consensus to identify indicators that could act as outcome measures in future large-scale prospective observational studies and clinical trials. Such an approach will foster benchmarking and continuous quality assessment and improvement at individual, institutional, interinstitutional, regional, national and international levels and facilitate larger scale clinical research. Furthermore, it will attain a high public health importance and will facilitate comparisons between healthcare provision models leading to optimization of perioperative care delivery.

Background: Over the past decade, biopharmaceutical companies have been progressively establishing global frameworks across their capabilities. It is well recognized that the Medical Information (MI) department is a key externally facing function that needs to maintain a consistent focus on optimizing its capabilities of addressing product medical inquiries worldwide., Methods: In the United States, a consortium named Pharma Collaboration for Transparent Medical Information, phactMI, a collaboration of pharmaceutical company MI departments dedicated to supporting health care professionals in their commitment to provide quality patient care, has provided a forum to benchmark and share best practices across the companies. In May 2017, phactMI conducted a survey inclusive of 25 biopharmaceutical companies to gain insight into the globalization of respective MI departments and relevant trends., Results: We found increased trends in various aspects of globalization across large, mid, and small size companies, and identified key drivers for success. Overall, 16 of the 25 companies had globalized their MI department, 5 had only partially globalized, and the remaining 4 had not globalized., Conclusion: The findings of this survey will further help inform the MI community as to globalization approaches for a successful outcome.

Aim: This study aimed to introduce a set of administrative key performance indicators (KPIs) for Early Psychosis Services., Methods: The study design was longitudinal with data retrieved from a 4-year period between January 2009 and December 2013 included in the study. Descriptive statistics and t tests were used to evaluate the KPIs., Results: Results in the 1 year before early psychosis (EP) intervention and 1-year postintervention were calculated for most items, and entry and exit scores were calculated for involuntary treatment orders (ITOs) and Health of the Nation Outcome Scale (HoNOS) scores. There was a 54% reduction in mental health emergency department presentations representing a cost saving of $62 524.00 (AUD). There was also an improvement in the number and duration of mental health admissions with a financial saving of $1 653 534.00 (AUD). Patients improved on all HoNOS scores from entry to exit from the services. ITOs were reduced by approximately 29% on discharge from the service., Conclusions: Administrative data can provide useful KPIs to measure the effectiveness of EP teams and allow benchmarking with similar services., (© 2018 John Wiley & Sons Australia, Ltd.)

Electronic clinical quality measures (eCQMs) that capture data from electronic health records promise accurate and timely measurement, but their use has been limited in payment. The Comprehensive Primary Care initiative sponsored by the Centers for Medicare & Medicaid Services used eCQMs as part of a shared savings incentive. To assess performance, the authors developed benchmarks for 11 measures and compared performance of initiative and benchmark practices. Initiative practices outperformed benchmark practices on 8 measures in 2015 (between 6.3 and 17.7 percentage points) and 9 measures in 2016 (between 1.7 and 20 percentage points). Initiative practices improved significantly on 7 measures from 2015 to 2016 (between 3.3 and 8.6 percentage points). For 3 measures, the improvement was greater than benchmark practices that reported the same measures in a 2-year period (between 1 and 8.9 percentage points). The authors conclude that eCQMs can be used for payment.

Feedback from patients about the care they have received is an integral part of quality in health care. This article looks at the extent to which patient feedback impacts the performance of clinicians and provision of clinical care. A non-systematic literature search was conducted in a narrative form on five electronic databases, including English language peer-reviewed articles published within the last 18 years. The effects of patient feedback on clinicians' performance are mixed. The reviewed studies either reported no effects, small non-statistically significant improvements or few statistically significant changes in clinical practice. More policy-level actions and effective organizational leadership are required for the goal of incorporating patient feedback in quality improvement to promote patient centredness in care delivery to be fully realized.

Background: Despite the wealth of knowledge on hospital performance, the majority of health facilities in the Maghreb don't have yet a Balanced Scorecard for its measurement., Objective: Elaborate, through a systematic review of the biomedical literature, a Balanced Scorecard for hospital performance, consisting of indicators of quality of care, highly recommended and suitable for the professional and managerial contexts of Greater Maghreb health systems., Materials and Methods:   This is a "systematic review" study on the topic of indicators to measure hospital performance. A documentary query combining the "Mesh Major Topic" for the two following descriptors "hospitals" and "health quality indicators", has been applied to the "Medline" database over a period of ten years (2004-2013). A focus group composed of clinicians, managers and representatives of civil society, was formed for the selection of a Balanced Scorecard of health facilities in Maghreb, composed of 20 systemic indicators., Results: An in-depth reading of 166 articles included in the study identified 926 quality of care assessment indicators. It is in one of three cases "systemic" indicators applicable to multi-purpose health facilities, and in one case of two, it is"process"indicators focused on a health care activity. Following the work of the focus group, a Balanced Scorecard for hospital performance was developed in a consensual manner. Among these indicators, 18 explored the "care" dimension (average length of stay, bed occupancy rates, turnover beds rates, occupational blood exposure rates, unplanned admission rates, discharge rates, prolonged admissions rates, antibiotic prescription rates, mortality rates, health care-associated infection rates, readmission rates, pressure ulcer rates, patient / staff ratio, staff turnover rates, maintenance of medical records, time sending of the report of hospitalization, staff burnout rates, patients' satisfaction rates), and two indicators were related to training functions and research (number of hours of staff training, publication rates)., Conclusion: The use, by health care facilities, of this Balanced Scorecard, based on the current data from the literature and adapted to the specific professional context of Greater Maghreb, would be a preliminary condition for the start-up of a strategy to measure and improve hospital performance in the Maghreb countries.

Quality is complex and difficult to define, and institutions and organisations often have their own definitions, measurements and assurance processes. The Care Excellence Framework (CEF), developed and used at University Hospitals of North Midlands NHS Trust, is a unique, integrated framework of measurement, clinical observation, patient and staff interviews and benchmarking. It also has an internal accreditation system that provides assurance from ward to board based on the five Care Quality Commission (CQC) domains and reflects CQC standards. The CEF has been established in its existing form since autumn 2016 and has been used in all areas of the organisation. This article provides an overview of the development and use of the CEF in an acute care setting, demonstrates how the framework acts as an internal accreditation system, and shows how it can encourage staff to undertake effective change and transform care from ordinary to excellent., Competing Interests: None declared, (©2018 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Objective: Critical care transport (CCT) supports regionalization of medical care. Focus on the quality of CCT care prompted the development of the Ground and Air Medical qUality in Transport (GAMUT) Quality Improvement collaborative database which tracks consensus quality metrics. The Institute of Medicine recommends benchmarking of comparative data to accelerate improvement. Herein, we report the strategies and rationale for GAMUT QI Collaborative benchmarking., Methods: The GAMUT database includes >350 programs internationally with >200,000 annual patient contacts. Evidence-based literature review performed in May 2016 and October 2017 identified benchmarking strategies were evaluated and summarized, specific to the GAMUT metrics. Statistical analyses include simple statistics and weighted expectation calculations for benchmark examples (Pearson chi-square with Bonferroni adjusted post-hoc z tests)., Results: Evidence-based literature search yielded 70 articles, and 31 were selected for inclusion in our evidence table. 5 evidence-based benchmark strategies were considered: average (mean), average (median), adjusted benchmark (based on expected outcome), Achievable Benchmark of Care (ABC), and Delphi. ABC threshold establishes a higher target (90th percentile) forcing more programs to achieve higher performance., Conclusion: Benchmarking is not well-suited for a single strategy and requires customized consideration based on each metric, though adjusted benchmark and ABC generally set higher performance benchmarks., (Copyright © 2018 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Physician performance and peer comparison feedback can affect physician care quality and patient outcomes. This study aimed to understand family physician perspectives of the value of performance feedback in quality improvement (QI) activities. This study analyzed American Board of Family Medicine open-ended survey data collected between 2004 and 2014 from physicians who completed a QI module that provided pre- and post-QI project individual performance data and peer comparisons. Physicians made 3480 comments in response to a question about this performance feedback, which were generally positive in nature (86%). Main themes that emerged were importance of accurate feedback data, enhanced detail in the content of feedback, and ability to customize peer comparison groups to compare performance to peers with similar patient populations or practice characteristics. Meaningful and tailored performance feedback may be an important tool for physicians to improve their care quality and should be considered an integral part of QI project design.

Background: In 2016 the U.S. Congress directed the Centers for Medicare & Medicaid Services (CMS) to implement the 21st Century Cures Act to fix a flaw in the Hospital Readmissions Reduction Program (HRRP). One section of the Act is intended to remove bias in calculating penalties for hospitals treating large percentages of low socioeconomic status (SES) patients. A study was conducted to analyze the effect of the introduction of SES hospital peer groups on the number and distribution of the hospitals being penalized., Methods: The CMS analysis files for the fiscal year 2017 HRRP final rule and Disproportionate Share Hospital adjustments were used to assign hospital peer groups. The median excess readmission ratios for hospital peer groups were calculated, and the resulting pattern of hospital penalties within peer groups was analyzed., Results: The findings suggest that because CMS assigns individual HRRP penalties on six clinical conditions but proposes to assign hospitals to a single SES peer group based on all admissions, it will ignore substantial differences in the distribution of peer group medians across these conditions. For surgical cases, as expected, hospitals with fewer patients had higher readmission rates, while for medical cases, hospitals with fewer patients had fewer readmissions. These findings may result in distortion of the peer group adjustment intended to correct for SES., Conclusion: Hospital peer groups may create unintended redistributions of penalties through distortion of peer group medians. An observed relationship between lower-volume hospitals and fewer readmissions for medical conditions requires additional research to establish its basis., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices., Methods: From October through December 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and nonanonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, and faculty effort and compensation. Responses reflected a calendar year from July 1, 2015, to June 30, 2016., Results: Of 107 eligible U.S. allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for EM residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was clinical effort, 66.9%; education effort, 12.7%; administrative effort, 12.0%; and research effort, 6.9%. Median faculty salary was $277,045., Conclusions: Academic EM programs are characterized by significant productivity in clinical operations, education, and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than nonacademic programs that do not necessarily share the additional missions of research and education and may have dissimilar working environments., (© 2017 by the Society for Academic Emergency Medicine.)

More than 50 years ago, Shriners Hospitals for Children expanded their philanthropy to include care for burned children. In so doing, the effects of their work weightily expanded from rehabilitation and quality of life outcomes to include survival proper. As the first facility dedicated to the care of burned children, originally designated the Shriners Burn Institute, the Galveston hospital remains the cornerstone of this endeavor. Shriners maintains charitable pediatric hospitals, provide care irrespective of the patient's or the family's ability to pay, and promote research. The sole criterion for admission at Shriners Hospitals for Children is the determination by a surgeon at a Shriners hospital that "the child's trouble may be corrected or improved." This philanthropic effort to provide medical care for children is one expression of the human commonality recognized by Shriners. In this article, we provide some background information on how this hospital came into existence as well as a global summary of its interventions toward greater survival and more complete rehabilitation of burned children. Based on the findings presented herein, we assert that there is less suffering and less loss of life due to childhood burns today than in previous years. We attribute much of this improvement to the simple voluntary collective decision by Shriners to provide alms for burned children.

In any particular region, determining an adequate, quantifiable geriatrician full-time equivalent required to run geriatric medicine services comprehensively - that is spanning both inpatient and outpatient settings - remains an imperfect science. Whilst workforce planning may be addressed through 'demand versus supply' simulations, 'specialist-to-patient ratios' (SPRs) may be a useful additional workforce metric. There has never been a yardstick SPR, which 'defines' a satisfactory level of geriatrician manpower in any particular Australian hospital catchment. Here, a new methodology is proposed (tailored specifically to Australian geriatrics), illustrating how we may begin to transparently deduce such a national benchmark SPR. Allowing for some empiricism, the method presently favours an SPR approximating '0.4 full-time equivalent of geriatrician time per 10 000 head of population' in regions with 'average' population age distribution; this level of manpower may afford specialist assessment of targeted patients (widely capturing geriatric cases from acute to community settings). Further discussion on workforce planning methodologies is warranted., (© 2017 AJA Inc.)

Objectives Internationally, there has been considerable debate about the role of data in supporting quality improvement in health care. Our objective was to understand how, why and in what circumstances the feedback of aggregated patient-reported outcome measures data improved patient care. Methods We conducted a realist synthesis. We identified three main programme theories underlying the use of patient-reported outcome measures as a quality improvement strategy and expressed them as nine 'if then' propositions. We identified international evidence to test these propositions through searches of electronic databases and citation tracking, and supplemented our synthesis with evidence from similar forms of performance data. We synthesized this evidence through comparing the mechanisms and impact of patient-reported outcome measures and other performance data on quality improvement in different contexts. Results Three programme theories were identified: supporting patient choice, improving accountability and enabling providers to compare their performance with others. Relevant contextual factors were extent of public disclosure, use of financial incentives, perceived credibility of the data and the practicality of the results. Available evidence suggests that patients or their agents rarely use any published performance data when selecting a provider. The perceived motivation behind public reporting is an important determinant of how providers respond. When clinicians perceived that performance indicators were not credible but were incentivized to collect them, gaming or manipulation of data occurred. Outcome data do not provide information on the cause of poor care: providers needed to integrate and interpret patient-reported outcome measures and other outcome data in the context of other data. Lack of timeliness of performance data constrains their impact. Conclusions Although there is only limited research evidence to support some widely held theories of how aggregated patient-reported outcome measures data stimulate quality improvement, several lessons emerge from interventions sharing the same programme theories to help guide the increasing use of these measures.

Background: To determine alignment of proposed international standard outcomes sets for ophthalmic conditions to metrics currently reported by eye hospitals., Methods: Mixed methods comparative benchmark study, including eight eye hospitals in Australia, India, Singapore, Sweden, U.K., and U.S. All are major international tertiary care and training centers in ophthalmology. Main outcome measure is consistency of ophthalmic outcomes measures reported., Results: International agreed standard outcomes (ICHOM) sets are available for cataract surgery (10 metrics) and macular degeneration (7 metrics). The eight hospitals reported 22 different metrics for cataract surgery and 2 for macular degeneration, which showed only limited overlap with the proposed ICHOM metrics. None of the hospitals reported patient reported visual functioning or vision-related quality of life outcomes measures (PROMs). Three hospitals (38%) reported rates for uncomplicated cataract surgeries only. There was marked variation in how and at what point postoperatively visual outcomes following cataract, cornea, glaucoma, strabismus and oculoplastics procedures were reported. Seven (87.5%) measured post-operative infections and four (50%) measured 30 day unplanned reoperation rates., Conclusions: Outcomes reporting for ophthalmic conditions currently widely varies across hospitals internationally and does not include patient-reported outcomes. Reaching consensus on measures and consistency in data collection will allow meaningful comparisons and provide an evidence base enabling improved sharing of "best practices" to improve eye care globally. Implementation of international standards is still a major challenge and practice-based knowledge on measures should be one of the inputs of the international standardization process.

Background: Composite measures, which aggregate performance on individual measures into a summary score, are increasingly being used to evaluate facility performance. There is little understanding of the unique perspective that composite measures provide., Objective: To examine whether high/low (ie, high or low) performers on a composite measures are also high/low performers on most of the individual measures that comprise the composite., Methods: We used data from 2 previous studies, one involving 5 measures from 632 hospitals and one involving 28 measures from 112 Veterans Health Administration (VA) nursing homes; and new data on hospital readmissions for 3 conditions from 131 VA hospitals. To compare high/low performers on a composite to high/low performers on the component measures, we used 2-dimensional tables to categorize facilities into high/low performance on the composite and on the individual component measures., Results: In the first study, over a third of the 162 hospitals in the top quintile based on the composite were in the top quintile on at most 1 of the 5 individual measures. In the second study, over 40% of the 27 high-performing nursing homes on the composite were high performers on 8 or fewer of the 28 individual measures. In the third study, 20% of the 61 low performers on the composite were low performers on only 1 of the 3 individual measures., Conclusions: Composite measures can identify as high/low performers facilities that perform "pretty well" (or "pretty poorly") across many individual measures but may not be high/low performers on most of them.

In recent years, accountable care organizations (ACOs) have become more prevalent in the United States. This study describes the origins, implementation, and early results of Minnesota's Medicaid ACO payment model, the Integrated Health Partnership (IHP) demonstration project. We describe the structure of the program and present preliminary evaluation results to document the state's important work and to provide lessons for other states interested in implementing Medicaid ACOs. The IHP program has expanded in size over time, the state has reported significant savings, and evidence exists of capacity building among participating providers. We identify factors that may have contributed to the program's early success, but more work is needed to investigate the specific drivers of quality improvement and savings within Minnesota's ACO program and to compare the design and effects of the IHP with other Medicaid and Medicare ACO programs. We conclude with comments about the future of the state's Medicaid ACO program and situate Minnesota's findings within the context of the broader ACO movement., (Copyright © 2017 by Duke University Press.)

Treatment delays in patients with acute myocardial infarction (AMI) are related to increased morbidity and mortality. Hence, identifying determinants of delay may help reduce time to treatment. Importantly, limited data suggest that there may be sex-related disparities in benchmark timelines. Although guidelines advocate the use of the first medical contact (FMC) rather than hospital admission as the moment from which delays to treatment should be monitored, the latter is still often used for quality purposes. We aimed to identify factors associated with treatment delays, with an emphasis on sex-related disparities. We reviewed data on 3,658 patients with AMI from 2 contemporary, consecutive multicenter surveys. Measured delays were FMC-to-electrocardiogram >10 minutes in ST-elevation MI (STEMI) and non-STEMI, FMC-to-primary percutaneous coronary intervention >90 minutes in STEMI, and invasive angiography >72 hours after admission in non-STEMI patients. Timely electrocardiogram was performed in 48% of patients with STEMI and in 39.8% of non-STEMI patients without significant sex-related differences. Independent determinants of delay included atypical chest pain (CP) and presentation during daytime. In patients with STEMI, 37.5% had primary percutaneous coronary intervention in less than 90 minutes without significant sex-related disparities. Independent determinants of delay included atypical CP, night presentation, and diabetes. In non-STEMI patients, independent determinants of delayed invasive approach were female sex, age >75 years, atypical CP, and renal failure. In conclusion, significant treatment delays in patients with AMI are still frequent in contemporary practice, highlighting the need for improvement and guidelines implementation. Predictors of delay identified in our study may facilitate targeting of interventions to improve adherence to guidelines., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: This paper describes the development of quality indicators for an external statutory and cross-sectoral quality assurance (QA) procedure in the context of the German health care system for adult patients suffering from schizophrenia, schizotypal and delusional disorders (F20-F29)., Methods: Indicators were developed by a modified RAND/UCLA Appropriateness Method with 1) the compilation of an indicator register based on a systematic literature search and analyses of health care claims data, 2) the selection of indicators by an expert panel that rated them for relevance and for feasibility regarding implementation. Indicators rated positive for both relevance and feasibility formed the final indicator set., Results: 847 indicators were identified by different searches. Out of these, 56 were selected for the indicator register. During the formal consensus process the expert panel recommended another 45 indicators so that a total of 101 indicators needed to be considered by the panel. Of these, 27 indicators rated both relevant and feasible were included in the final set of indicators: this set included 4 indicators addressing structures, 19 indicators addressing processes and 4 indicators addressing outcomes. 17 indicators of the set will be reported by hospitals and 8 by psychiatric outpatient facilities. Two indicators considered to be cross-sectoral will be reported by both sectors., Discussion: F20-F29 and its treatment show some specific features which so far have not been addressed by any procedure within the statutory QA program of the German health care system. These features include: Schizophrenia and related disorders a) are potentially chronic conditions, b) are mainly treated in outpatient settings, c) require a multi-professional treatment approach and d) are treated regionally in catchment areas. These specific features in combination with the peculiarities of some legal, political and organizational characteristics of the German health care system and its statutory QA program have strongly influenced the development of indicators. The result was a seemingly "imbalanced" set of indicators with a greater number of indicators for inpatient than for outpatient care despite the fact that clinical reality is otherwise., Conclusions: The circumstances of the German health care system that restricted the development of this cross-sectoral QA procedure addressing care for F20-F29 are also most likely to emerge with the development of cross-sectoral QA procedures for other (potentially) chronic conditions that are mainly treated in the outpatient setting by multi-professional teams or by networks of different providers. In order to be able to develop a QA procedure that mirrors the reality of service provision for (potentially) chronic diseases such as F20-F29 we need to explore further current and new data sources, diminish sectoral borders, and implement health care responsibility on the level of catchment areas., (Copyright © 2017. Published by Elsevier GmbH.)

Objective: To determine if the release of health care report cards focused on physician practice quality measures leads to changes in consumers' awareness and use of this information., Primary Data Sources: Data from two rounds of a survey of the chronically ill adult population conducted in 14 regions across the United States, combined with longitudinal information from a public reporting tracking database. Both data were collected as part of the evaluation for Aligning Forces for Quality, a nationwide quality improvement initiative funded by the Robert Wood Johnson Foundation., Study Design: Using a longitudinal design and an individual-level fixed effects modeling approach, we estimated the impact of community public reporting efforts, measured by the availability and applicability of physician quality reports, on consumers' awareness and use of physician quality information (PQI)., Principal Findings: The baseline level of awareness was 12.6 percent in our study sample, drawn from the general population of chronically ill adults. Among those who were not aware of PQI at the baseline, when PQI became available in their communities for the first time, along with quality measures that are applicable to their specific chronic conditions, the likelihood of PQI awareness increased by 3.8 percentage points. For the same group, we also find similar increases in the uses of PQI linked to newly available physician report cards, although the magnitudes are smaller, between 2 and 3 percentage points., Conclusions: Specific contents of physician report cards can be an important factor in consumers' awareness and use of PQI. Policies to improve awareness and use of PQI may consider how to customize quality report cards and target specific groups of consumers in dissemination., (© Health Research and Educational Trust.)

Obtaining genetic testing insurance authorizations for patients is a complex, time-involved process often requiring genetic counselor (GC) and physician involvement. In an effort to mitigate this complexity and meet the increasing number of genetic testing insurance authorization requests, GCs formed a novel partnership with an industrial engineer (IE) and a patient services associate (PSA) to develop a streamlined work flow. Eight genetics clinics and five specialty clinics at the University of Michigan were surveyed to obtain benchmarking data. Tasks needed for genetic testing insurance authorization were outlined and time-saving work flow changes were introduced including 1) creation of an Excel password-protected shared database between GCs and PSAs, used for initiating insurance authorization requests, tracking and follow-up 2) instituting the PSAs sending GCs a pre-clinic email noting each patients' genetic testing insurance coverage 3) inclusion of test medical necessity documentation in the clinic visit summary note instead of writing a separate insurance letter and 4) PSAs development of a manual with insurance providers and genetic testing laboratories information. These work flow changes made it more efficient to request and track genetic testing insurance authorizations for patients, enhanced GCs and PSAs communication, and reduced tasks done by clinicians.

Background: Audit and feedback (AF) interventions that leverage routine administrative data offer a scalable and relatively low-cost method to improve processes of care. AF interventions are usually designed to highlight discrepancies between desired and actual performance and to encourage recipients to act to address such discrepancies. Comparing to a regional average is a common approach, but more recipients would have a discrepancy if compared to a higher-than-average level of performance. In addition, how recipients perceive and respond to discrepancies may depend on how the feedback itself is framed. We aim to evaluate the effectiveness of different comparators and framing in feedback on high-risk prescribing in nursing homes., Methods: This is a pragmatic, 2 × 2 factorial, cluster-randomized controlled trial testing variations in the comparator and framing on the effectiveness of quarterly AF in changing high-risk prescribing in nursing homes in Ontario, Canada. We grouped homes that share physicians into clusters and randomized these clusters into the four experimental conditions. Outcomes will be assessed after 6 months; all primary analyses will be by intention-to-treat. The primary outcome (monthly number of high-risk medications received by each patient) will be analysed using a general linear mixed effects regression model. We will present both four-arm and factorial analyses. With 160 clusters and an average of 350 beds per cluster, assuming no interaction and similar effects for each intervention, we anticipate 90% power to detect an absolute mean difference of 0.3 high-risk medications prescribed. A mixed-methods process evaluation will explore potential mechanisms underlying the observed effects, exploring targeted constructs including intention, self-efficacy, outcome expectations, descriptive norms, and goal prioritization. An economic analysis will examine cost-effectiveness analysis from the perspective of the publicly funded health care system., Discussion: This protocol describes the rationale and methodology of a trial testing manipulations of theory-informed components of an audit and feedback intervention to determine how to improve an existing intervention and provide generalizable insights for implementation science., Trial Registration: NCT02979964.

Medical triage is the process of determining the priority of patients' treatments based on the severity of their condition. Triage provides the healthcare provider the ability to identify the most urgent cases first, with the goal of maximizing each individual patient's outcome. When resources are challenged, such as in a disaster, the healthcare provider's goal becomes to maximize overall population survival. In this context, the triage process must identify patients who require resources urgently, as well as those who have the best chance of survival. The revised triage process must include an "expectant management" category, to identify patients for whom further resuscitation is delayed, as they have a poor chance of survival and require significant resources. The paradigm shift that is required in these circumstances can be challenging for pediatric healthcare providers. Many may find themselves unable to change the decision-making process that would favor overall survival and best outcome for the most members of a population, while potentially not addressing the most sick or injured because they have low chances of survival. We hypothesized that participating in a multiprofessional ethics-based educational session regarding making difficult triage decisions may improve participants' perceived ability to use the "expectant" triage category in a disaster setting. Participants took part in an ethics-based educational session and completed a pre- and postsurvey. Results demonstrated a significant change in the participants' self-perceived comfort level using the disaster triage tools and improved their confidence to use the expectant triage category in a disaster setting.