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High Performers: New Study Seeks to Identify Common Traits of Top Providers

Under contract with the Centers for Medicare & Medicaid Services (CMS), Health Services Advisory Group, Inc. (HSAG) is conducting a special study on “Identification and Synthesis of Components Essential to Achieving ‘High Performer’ Status in Various Provider Types.” The objective of this study is to identify the unique characteristics of high performing health care providers. Specific knowledge of these characteristics could greatly aid quality improvement organizations (QIOs) in their efforts to design and implement health care quality improvement strategies for hospitals, nursing homes, home health agencies, and physician offices across the United States.

One step in this process was for HSAG to conduct a “state of the art” review of the medical literature and other sources to synthesize already available information that has been used to identify and characterize health care providers that perform exceptionally well on Seventh Scope of Work (7th Sow) health care process indicators. Of particular interest were the hospital process indicators for management of pneumonia, heart failure, and acute myocardial infarction.

The literature review focused on these research questions:

• What statistical methods, based on existing quality indicators, have been used for profiling and ranking institutions, and for classifying their performance?
• Do these methods discriminate among institutions?
• Are they meaningful to decision makers?
• To what extent have clinical conditions and related performance measures from the current 7th SoW been the subjects of published research identifying high performance in hospitals, nursing homes, home care agencies, and physician offices?
• What organizational attributes or quality improvement practices are suggestive of institutional high performance?

In the High Performers “State of the Art” report, which was released in February 2004, nine “dimensions” of quality improvement were identified that represent categories of organizational characteristics and quality improvement practices thought to be associated with institutional high performance. Those dimensions are: culture; structure; strategy; leadership; systems; customer and market; measurement, analysis and knowledge management; human resources; and business results.

The report concludes that neither the published medical literature nor material from quality rating organizations directly addressed the Special Study’s focus on hospitals that are high performing in their management of the three conditions from the 7th SoW. However, four principles have been developed that will guide HSAG in proceeding to a final definition of high performer and the construction of the algorithm to identify them.

These principles are:

1. Hospitals that provide the same service should be held to the same standard, regardless of size or geographic location.
2. Performing well on an indicator on which others perform poorly (a “hard” indicator), while performing as well as any on an indicator on which others do well (an “easy” indicator), is basic to a definition of high performance.
3. Performing well on “hard” indicators is more important than performing well on “easy” indicators.
4. High performance must incorporate sustained excellence over time.

According to the report, it is becoming clear that what matters is not whether a hospital possesses the knowledge of quality improvement principles, tools, and techniques, but the extent to which progress is made in implementing them. Complexity theory suggests that understanding can only be achieved when organizational attributes are studied in concert, rather than individually.

The information synthesized in this report reaffirms CMS’s position that there is an underlying need within the health care system to design a scientifically sound and credible structure by which high performing health care providers can be defined, identified, and studied. Furthermore, the report establishes that designing such a structure is highly feasible.

For more information, download the February 2004, High Performer “State of the Art” Report (PDF, 414K).

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