Session: Nurse Staffing, Nurse Human Capital And The Quality Of Hospital Care
Room: Phillips 203
Time: Tue 10:15-11:45

Presenter: Richard Lindrooth (University of Colorado, Denver. )

Discussant: Mark Smith (Health Economics Resource Center, VA)

Abstract

Objective: Public reporting of process measures can potentially provide hospitals with an incentive to improve hospital patient safety. Recent efforts, such as HospitalCompare, collect and report information on disease specific measures that are, though relatively easy to collect and disseminate, not necessarily indicative of a hospital's overall quality. Less is known about public reporting of process improvements that are specifically designed to prevent patient safety errors for which all patients may be at risk. We examine hospital adoption of a set of National Quality Forum-endorsed Safe Practices in the context of public reporting by the Leapfrog Group in 2004-2006.

Methods/Results: The Leapfrog Survey is merged with hospital information from the American Hospital Association's Annual Survey (AHA) and CMS Hospital Cost Reports (HCR). The Leapfrog survey is voluntary and thus we control for sample selection bias using a Heckman Selection model. The instruments include the hospital's response to voluntary HCR questions; the number and percent of large firms in the hospital's market area; and whether it was the first year Leapfrog has rolled out the survey. These variables reflect both the cost and benefits of reporting and are excellent predictors of response (F-tests greater than 45) but are not directly correlated with the degree of Safe Practice adoption based on over-identification tests.

We find that public reporting of Safe Practices helped spur a sizable number of poor performing hospitals to adopt the practices, but only if sufficient RN staff were already in place. A necessary condition for improving is having RN staffing levels of at least 0.23 per adjusted patient day (i.e. about 5 patients per RN). Much of the improvement is consistent with a hospital's incentive to participate in and perform well on the public reports, though a substantial portion of the improvement in scores is not explained by the data.

Having established that voluntary public reporting led to hospital adoption of Safe Practices, we examine whether adoption led to better outcomes. To accomplish this we merge in six patient safety indicators (PSI) calculated using the HCUP-SID inpatient discharge data set for hospitals in 8 states from 2000-2007. The sample period includes four years pre and post-Leapfrog rollout. Hospitals that are not in rollout regions are used as a control. We model the hospital's risk-adjusted PSI as a function of nurse staffing intensity and skill-mix; hospital ownership and payer mix; market characteristics; an indicator of whether the hospital was in a Leapfrog rollout-region; responded to the survey and the reported Safe Practice Score. We estimate a dynamic panel data model that allows for endogeneity of the Safe Practice score, survey response and lagged PSI using generalized method of moments based on Arellano and Bover (1995). We also use the instruments described above to help with identification. The results reveal that the PSIs dependent on the quality of nursing care show slight improvement with the adoption of Safe Practices. In contrast, PSIs that are dependent on the performance of multi-disciplinary teams are unaffected by Safe Practice adoption.

Key Terms

hospital quality, public reporting, adoption of process innovations

Authors:

Richard Lindrooth (University of Colorado, Denver) , John Welton (MUSC) , Dennis Scanlon (Penn State University) and Jayani Jayawardhana (MUSC)