ORIGINAL CONTRIBUTION
Is Emergency Department Quality Related to
Other Hospital Quality Domains?
Megan McHugh, PhD, Jennifer Neimeyer, PhD, Emilie Powell, MD, MS, Rahul K. Khare, MD, MS, and
James G. Adams, MD
Abstract
Objectives: Systems theory suggests that there should be relatively high correlations among quality
measures within an organization. This was an examination of hospital performance across three types of
quality measures included in Medicare’s Hospital Inpatient Value-Based Purchasing (HVBP) program:
emergency department (ED)-related clinical process measures, inpatient clinical process measures, and
patient experience measures. The purpose of this analysis was to determine whether hospital
achievement and improvement on the ED quality measures represent a distinct domain of quality.
Methods: This was an exploratory, descriptive analysis using publicly available data. Composite scores
for the ED, inpatient, and patient experience measures included in the HVBP program were calculated.
Correlations and frequencies were run to examine the extent to which achievement and improvement
were related across the three quality domains and the number of hospitals that were in the top quartile
for performance across multiple quality domains.
Results: Achievement scores were calculated for 2,927 hospitals, and improvement scores were
calculated for 2,842 hospitals. There was a positive, moderate correlation between ED and inpatient
achievement scores (correlation coefficient of 0.50, 95% confidence interval [CI] = 0.47 to 0.53), but all
other correlations were weak (0.16 or less). Only 96 hospitals (3.3%) scored in the top quartile for
achievement across the three quality domains; 73 (2.6%) scored in the top quartile for improvement
across all three quality domains.
Conclusions: Little consistency was found in achievement or improvement across the three quality
domains, suggesting that the ED performance represents a distinct domain of quality. Implications
include the following: 1) there are broad opportunities for hospitals to improve, 2) patients may not
experience consistent quality levels throughout their hospital visit, 3) quality improvement interventions
may need to be tailored specifically to the department, and 4) consumers and policy-makers may not be
able to draw conclusions on overall facility quality based on information about one domain.
ACADEMIC EMERGENCY MEDICINE 2014;21:551–557 © 2014 by the Society for Academic Emergency
Medicine
T
he Centers for Medicare and Medicaid Services
(CMS) is changing the way that it pays for health
services.1 In an effort to improve the value of its
expenditures, CMS now reimburses providers based on
care quality, not just the quantity of services provided.
One important component of CMS’ value-based purchasing strategy is the Hospital Inpatient Value-Based
Purchasing (HVBP) program.2 Beginning October 2012,
CMS began withholding 1% of Medicare payments and
redistributing those funds back to hospitals based on
achievement or improvement on 12 process measures
and eight patient satisfaction measures (Table 1). Of the
12 process measures included in the first year of the
program, four are related to care delivered in the emergency department (ED): fibrinolytic therapy received
within 30 minutes of hospital arrival (acute myocardial
infarction [AMI]-7a), primary percutaneous coronary
intervention (PCI) received within 90 minutes of hospital
From the Center for Healthcare Studies (MM, JN, EP RKK), the Department of Emergency Medicine (MM, EP, RKK, JA), Northwestern University, Feinberg School of Medicine, Chicago, IL.
Received October 21, 2013; revisions received November 15 and November 17, 2013; accepted November 18, 2013.
The authors did not receive outside support or funding for this research. This work has not been published or presented
elsewhere.
The authors have no potential conflicts of interest to disclose.
Supervising Editor: Lowell Gerson, PhD.
Address for correspondence and reprints: Megan McHugh, PhD; e-mail: megan-mchugh@northwestern.edu.
© 2014 by the Society for Academic Emergency Medicine
doi: 10.1111/acem.12376
ISSN 1069-6563
PII ISSN 1069-6563583
551
551
552
McHugh et al. • ED QUALITY AND HOSPITAL QUALITY
arrival (AMI-8a), blood cultures performed in the ED
prior to initial antibiotic received in hospital (pneumonia
[PN]-3b), and initial antibiotic selection for communityacquired pneumonia (CAP) in immunocompetent
patients (PN-6).2,3 There is a growing interest in emergency medicine to understand factors influencing performance on these measures.4,5
Systems theory holds that high performance results
from a culture of excellence that permeates throughout
a hospital and that one should see correlation among
quality measures within an organization.6,7 However,
previous studies have found that hospitals that perform
highly on one dimension of quality (e.g., patient experience) do not necessarily perform highly on others (e.g.,
mortality).8–10 One could speculate that ED performance
represents a distinct dimension of hospital quality. EDs
are physically separate and have different reimbursement structures, management, and staffing than inpatient units. If ED performance is not related to hospital
performance, it signals a lack of consistency in quality
within an organization and that broad hospital quality
improvement initiatives may need to be tailored to individual departments.
We have previously described hospital performance
on the ED measures included in the HVBP program.11
However, to date, there has been no examination of the
extent to which ED performance mirrors performance
on other domains of hospital quality. We examined hospital achievement and improvement across the three
domains of hospital quality included in Medicare’s
HVBP program: ED-related clinical process measures,
inpatient clinical process measures, and patient experience measures. Our purpose was to determine whether
a hospital’s achievement and improvement on the ED
quality domain is related to achievement and improvement on the inpatient and patient experience quality
domains. Although several studies have investigated
hospital performance on publicly reported quality measures,12,13 this effort is unique in its focus on emergency
care, its examination of both achievement and improvement, and its use of measures included the new HVBP
program. Results have important implications for
department and quality improvement leaders, consumers, and policy-makers.
METHODS
Study Design
This was an exploratory, descriptive analysis of secondary data. Our institutional review board determined that
approval was not required because the study did not
involve human subjects.
Study Setting and Population
We obtained 2008 through 2010 performance data for
the four ED-related clinical process measures, eight
inpatient clinical process measures, and eight patient
experience measures from the CMS Web site Hospital
Compare (http://www.hospitalcompare.hhs.gov/). The
clinical process measures are chart-abstracted measures
that assess hospitals’ compliance on evidence-based
care related to AMI, heart failure, pneumonia, and
surgical care improvement. The patient experience measures are derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
survey, which was developed by the Agency for
Table 1
Measures Included in the Hospital Inpatient Value-Based Purchasing Program, Fiscal Year 2013
ED-related Clinical Process Measures
AMI-7a Fibrinolytic therapy received
within 30 minutes of hospital arrival
AMI-8a Primary PCI received within
90 minutes of hospital arrival
PN_3b Blood cultures performed in
the ED prior to initial antibiotic
received in hospital
PN_6 Initial antibiotic selection for
CAP in immunocompetent patient
Inpatient Clinical Process Measures
HF_1 Discharge instructions
SCIP_INF_1 Prophylactic antibiotic received within 1 hour
prior to surgical incision
SCIP_INF_2 Prophylactic antibiotic selection for surgical
patients
SCIP_INF_3 Prophylactic antibiotics discontinued within
24 hours after surgery ends
SCIP_INF_4 Cardiac surgery patients with controlled 6
AM postoperative serum glucose
SCIP_CARD_2 Surgery patients on a beta blocker prior to
arrival that received a beta blocker during the
postoperative period
SCIP_VTE-1 Surgery patients with recommended venous
thromboembolism prophylaxis ordered
SCIP-VTE-2 Surgery patients who received appropriate
venous thromboembolism prophylaxis within 24 hours
prior to surgery to 24 hours after surgery
Patient Experience
Measures
Nurses “‘always”
communicated well
Doctors “always”
communicated well
Patients “always” received
help as soon as they
wanted
Pain was “always” well
controlled
Staff “always” explained
Room was “always” clean
and room was “always”
quiet at night
Yes, staff “did” give patients
discharge information
Patients who gave a rating of
“9” or “10” (high)
Source: Federal Register 2011;76;26490–547. Additional information on measure specifications can be found in the measure specifications manual on CMS’ QualityNet website: http://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%
2FPage%2FQnetTier4&cid=1228771525863.
AMI = acute myocardial infarction; CAP = community-acquired pneumonia; CARD = cardiac; HF = heart failure; INF = infection;
PCI = percutaneous coronary intervention; PN = pneumonia; SCIP = surgical care improvement project; VTE = venous thromboembolism.
*ED-related measures.
ACADEMIC EMERGENCY MEDICINE • May 2014, Vol. 21, No. 5 • www.aemj.org
Healthcare Research and Quality, and asks patients
about their experience in the hospital. Although public
reporting of data on Hospital Compare is voluntary,
only hospitals that report their performance measures
are eligible for a full Medicare payment update. Ninetyseven percent of hospitals satisfactorily met the reporting requirements in 2010.14 We linked these data to the
2009 American Hospital Association Annual Survey,
which contains information on hospital characteristics
(e.g., size, ownership, region, teaching status) to compare the characteristics of the study hospitals with all
other general medical and surgical hospitals.
Study Protocol
We limited our analysis to hospitals that met the criteria
for the HVBP program. Hospitals must be acute care
hospitals paid under the Inpatient Prospective Payment
System (IPPS). An exception was made for acute care
hospitals in Maryland, which are not paid under the
IPPS, but are included in the program. Additionally,
between 2009 and 2010, hospitals must have reported
data from at least 100 HCAHPS surveys and data for at
least four clinical process measures with at least 10 eligible cases.
We calculated scores for each performance measure
according to the method used by CMS for the HVBP
program, the details of which are described in the program’s Final Rule published in the Federal Register on
May 6, 2011.2 In brief, for each performance measure,
hospitals receive an achievement score between 1 and
10 based on how much their current performance score
exceeds the median for all hospitals. If the score is
below the median, the hospital receives an achievement
score of 0. Additionally, hospitals also receive an
improvement score between 1 and 10 based on how
much the score on the performance measure improved
from the previous (i.e., baseline) year. If performance
did not improve, the hospital receives an improvement
score of 0. Under the HVBP program, the final performance score is the higher of the achievement or
improvement score. However, because we were interested in looking at both achievement and improvement,
we investigated both scores separately.
In administering the HVBP program, CMS calculates
a composite score for all clinical process measures
included in the program. We applied CMS’ composite
score methodology separately to the four ED measures,
the eight inpatient measures, and the eight patient experience measures for both achievement and improvement, to create six composite scores. For each hospital,
we summed total points earned for the performance
measures and divided by the total number of points for
which the hospital was eligible. Eligible points is equal
to 10 (the highest possible score on a performance measure) times the number of performance measures for
which the hospital reported at least 10 cases. Following
CMS’s methodology, we then multiplied by 100. Each
hospital had two composite scores (achievement and
improvement) for each quality dimension. The scores
ranged from 0 to 100.
There are two important differences between CMS’
methodology and our approach. First, CMS uses a 9month performance period for the current and baseline
553
time periods. However, due to the way data are
reported in Hospital Compare, we used 12-month periods. October 2008 through September 2009 represented
our baseline period, and October 2009 through September 2010 was our current period. These were the most
recent data available from Hospital Compare at the time
of our analysis. Second, CMS uses a minimum of four
clinical process measures to calculate program composite scores. Because there are only four ED-related performance measures, we did not set a minimum for the
calculation of the ED quality dimension scores.
Data Analysis
For both achievement and improvement, we calculated
the distribution of hospitals by performance quartile. We
calculated the number of hospitals that scored within the
top quartile for the ED quality domain and then calculated whether those hospitals were also in the top quartile for the inpatient and patient experience domains.
Because we were interested in the association
between quality domain scores, but we did not want to
assume one-way causal effect (e.g., ED achievement is
dependent on inpatient achievement), we used correlations and scatterplots to explore the relationship
between the raw composite scores on the three quality
domains. We ran the analyses separately for achievement and improvement. Analyses were performed using
Stata 10.0.
RESULTS
Number of Hospitals in the Analysis
We determined that 3,030 hospitals met the criteria for
the HVBP program. A total of 103 low-volume hospitals
were dropped from the analysis because they either did
not report, or reported fewer than 10 cases, for every
ED measure. The final sample for our analysis related to
achievement included 2,927 hospitals. Because 85 of
those hospitals did not report enough cases in the baseline period to receive improvement scores, our analyses
related to improvement included 2,842 hospitals. Compared to all general medical and surgical hospitals in
the United States, the hospitals in the analysis included
fewer small hospitals.
Correlations and Frequencies
There was a positive, moderate correlation between the
ED and inpatient achievement scores (Figure 1). The
correlation coefficient was 0.50 (95% confidence interval
[CI] = 0.47 to 0.53). Of the 731 hospitals that scored in
the top quartile for ED achievement, 382 (52.3%) scored
within the top quartile for inpatient achievement
(Table 2).
All other correlations were weak (0.16 or less). Only
198 hospitals (6.7%) scored in the top quartile for
achievement on both the ED and patient experience
areas. Similarly, there was little overlap on high performance for improvement. Of the 678 hospitals that
scored in the top quartile for ED improvement, only 254
(37%) scored in the top quartile for inpatient improvement and only 187 (28%) scored in the top quartile for
patient experience improvement. Only 96 hospitals
(3.3%) scored in the top quartile across all three
554
McHugh et al. • ED QUALITY AND HOSPITAL QUALITY
achievement dimensions, and only 73 (2.6%) scored in
the top quartile for all three domains of improvement.
Inpatient Quality Dimension Score
A. ED and Inpatient Dimension Scores - Achievement
100
90
80
70
60
50
40
30
20
10
0
DISCUSSION
0
10
20
30
40
50
60
70
80
90
100
ED Quality Dimension
B. Inpatient and Patient Experience Dimension Scores - Achievement
Patient Experience Quality
Dimension Score
100
80
60
40
20
0
0
10
20
30
40
50
60
70
80
90
100
90
100
Inpatient Quality Dimension Score
Patient Experience Quality
Dimension Score
C. ED and Patient Experience Dimension Scores - Achievement
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
ED Quality Dimension Score
Inpatient Quality Dimension
Score
on Scor
D. ED and Inpatient Dimension Scores - Improvement
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
ED Quality Dimension Score
80
90
100
Patient Experience Quality
Dimension Score
E. Inpatient and Patient Experience Dimension Scores - Improvement
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
100
Inpatient Quality Dimension Score
Patient Experience Quality
Dimension Score
F. ED and Patient Experience Dimension Scores - Improvement
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
50
60
70
80
90
100
ED Quality Dimension Score
Figure 1. Scatterplots for the ED, inpatient, and patient experience quality dimensions, achievement, and improvement
scores
Our investigation of hospital performance using measures included in Medicare’s new HVBP program
revealed a positive, moderate correlation for achievement on the ED and inpatient measures. One would
generally expect to see a strong positive relationship
between ED and inpatient performance, as hospital
quality is ultimately overseen by a single hospital board
of directors, and resources that enhance quality (e.g.,
electronic health records) are often consistently available (or unavailable) across departments. However, our
findings also show a weak relationship between
achievement on the ED and patient experience measures. These findings are consistent with other studies
showing a weak relationship between process of care
and patient experience measures.8,15 This is the first
study to investigate whether improvement on the ED
quality domain is related to improvement on other quality domains. We found that the three quality domains
do not necessarily improve in tandem.
There are several implications of our findings for policy-makers, hospital leaders, and consumers. First, for
policy-makers, our results lend support to the notion
that value-based purchasing programs should include
measures that represent multiple dimensions of performance. If ED measures were excluded from Medicare’s
Hospital Inpatient VBP program, a different group of
hospitals would have achieved the highest relative performance (and therefore the highest rewards). Although
hospitals report that submitting multiple quality measures can be burdensome,2 our findings indicate that
including measures from multiple dimensions provides
a more complete picture of hospital quality.
Second, few hospitals achieve high performance
across the three quality dimensions, and almost half of
hospitals did not qualify as top performers in any
dimension. This highlights a broad opportunity for
improvement. Hospital and department leaders should
review their scores on the measures included in the
HVBP program, identify the dimensions of performance
that are weakest, and focus attention in those areas,
with the goal of improvement. Further, our findings
have implications for hospital boards, who are ultimately responsible for hospital quality.16,17 Given that
quality is one of many topics that boards discuss during
their meetings,18 they may be inclined to review few
measures. Our results suggest that they should request
information on quality across departments and consider
the consistency of quality across the organization.
Our findings also have important implications for
consumers. Our results suggest that the level of quality
a consumer will encounter during an ED-initiated hospital stay is likely to vary during that single stay. While
quality of care may be high in the ED, this will not necessarily be consistent across the inpatient stay and measures of patient experience. Further, the variation in
achievement across the three quality domains illustrates
how difficult it may be for consumers to choose a hospital based on publicly available quality data. Assuming a
Top quartile
(n = 697)
Second
quartile
(n = 735)
Third quartile
(n = 761)
Bottom
quartile
(n = 734)
Top quartile
(n = 731)
Second
quartile
(n = 735)
Third quartile
(n = 716)
Bottom
quartile
(n = 745)
Patient experience
quality dimension
215
187
126
98
66
164
139
185
183
196
182
184
198
382
179
Second Quartile (n = 710)
198
Top Quartile
(n = 731)
Top quartile
(n = 785)
Second
quartile
(n = 713)
Third quartile
(n = 685)
Bottom
quartile
(n = 659)
Top quartile
(n = 708)
Second
quartile
(n = 679)
Third quartile
(n = 734)
Bottom
quartile
(n = 721)
Patient experience
quality dimension
Inpatient quality
dimension
Improvement
Domain
217
221
195
98
216
208
168
139
Third Quartile
(n = 7313)
293
207
163
140
136
169
152
148
196
149
165
165
190
254
213
185
185
160
150
165
176
175
164
Third Quartile
(n = 680)
ED Quality Dimension
Second Quartile
(n = 743)
187
Top Quartile
(n = 678)
B. Distribution of Hospitals, by Quality Domain and Improvement Quartile
Inpatient quality
dimension
Achievement
Domain
ED Quality Dimension
Table 2
A. Distribution of Hospitals, by Quality Domain and Achievement Quartile
237
202
163
139
173
164
183
221
Bottom Quartile (n = 741)
336
210
140
69
215
174
185
181
Bottom Quartile (n = 755)
162
143
199
204
Top Quartile
(n = 731)
185
183
175
188
Top Quartile
(n = 731)
175
191
195
155
Third Quartile
(n = 716)
151
186
172
170
Second Quartile (n = 735)
174
168
167
225
Third Quartile
(n = 716)
Inpatient Quality Dimension
153
204
189
189
Second Quartile (n = 735)
Inpatient Quality Dimension
172
188
175
186
Bottom Quartile
(n = 745)
221
183
176
165
Bottom Quartile
(n = 745)
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consumer is willing to review quality scores, he or she
may have difficulty deciding between hospitals that have
high patient experience scores versus those with high
clinical quality scores.
Our results raise an important question about why
hospitals perform strongly (or greatly improve) on one
quality domain, but not in others. In this effort, we did
not explore the link between organizational culture or
resources and performance; however, the absence of a
strong correlation among the measures calls into question the notion that a culture of excellence can permeate
through an organization, raising performance in all
areas.6,19 Instead, targeted approaches in each quality
domain may be necessary. Specifically, the ED may
require separate and tailored quality initiatives to earn
the highest quality improvement or achievement. This is
an important topic for future research.
Another possible explanation for the absence of a
strong correlation is that our implicit assumption about
hospital leaders’ attention to the three dimensions may
be incorrect. Hospital leaders may be focused on
aspects of quality that they believe are more meaningful
(e.g., resuscitation performance, hospital-acquired conditions) than the measures included in the HVBP program. Importantly, the Institute of Medicine defined six
domains of quality, and the measures currently included
in the HVBP program do not encompass all six
domains.20 Instead, the program measures provide
insight only into selected aspects of performance.
LIMITATIONS
Our findings should be viewed in light of several limitations. First, as noted above, we used a 12-month period
rather than a 9-month period of performance. Doing so
likely resulted in the inclusion of certain small hospitals
that would not have met the reporting criteria sample size
(at least four measures with 10 eligible cases) for the
HVBP program had we used a 9-month reporting period.
Second, in the 2011 Federal Register final rule for the
HVBP program, several commenters expressed concern
that 10 eligible cases per clinical process measure (the
minimum threshold used by CMS and in this analysis)
may be insufficient to produce reliable measure scores.
CMS maintains that an independent analysis found that
10 cases was sufficient to produce reliable scores.2 Still,
it is possible that some of our estimates in this analysis
were unstable.
Third, the four ED-related process of care measures
were selected because of their relevance to care provided in the ED.3 However, not all cases for a particular
measure represent care provided in the ED. For example, initial antibiotic selection (PN-6) is sometimes performed in an inpatient unit rather than the ED. That
may explain the larger correlation between the ED and
inpatient measures.21 Using the Hospital Compare data,
there was no way for us to limit our analysis to patients
who received care in the ED.
CONCLUSIONS
With the exception of a moderate positive relationship
between performance on the ED and inpatient quality
McHugh et al. • ED QUALITY AND HOSPITAL QUALITY
domains, we found little consistency between achievement and improvement across the three quality
domains included in Medicare’s new Hospital Valuebased Purchasing program. Most hospitals that demonstrated high achievement or improvement in one quality
domain did not demonstrate high achievement or
improvement in the other domains. Our findings suggest that 1) there are broad opportunities for hospitals
to improve, 2) patients may not experience consistent
quality levels throughout their hospital visit, 3) quality
improvement interventions may need to be tailored specifically to the department, and 4) consumers and policy
makers may not be able to draw conclusions on overall
facility quality based on information about one domain.
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