High-Value Care Tools to Understand Institutional Culture and Inform Value-Improvement Efforts

From the 2021 HVPAA National Conference

Kimberly O’Hara (University of Colorado School of Medicine and Children’s Hospital Colorado), Angela Moss, Emily Albrecht, David Chung, Nicole Clifton, Elizabeth LaGuardia, Jennifer Reese, Michael Tchou

Background

Low-value care contributes to increased costs and patient harm. Consequently, there has been a focus on education to increase the practice of high-value care (HVC). Yet our understanding of the impact of organizational HVC culture on practice behaviors in pediatrics is limited. Assessing cultural influences could better guide curricular innovation and faculty development to improve value-based care.

Objective

To better understand the culture of HVC by using a combination of two previously validated tools

Methods

We first surveyed pediatric residents and pediatric hospital medicine (PHM) faculty at a free-standing children’s hospital using the previously validated HVC Culture Survey (HVCCS) designed to assess HVC culture among frontline providers. Next, using a published HVC Rounding Tool, 8 hospitalists measured the content and frequency of HVC discussions on PHM team rounds. The primary outcome measured was percent of patient encounters with any HVC topic discussed. These hospitalists underwent training on the Tool in April 2019; they then conducted paired observations, where two hospitalists assessed 150 patient encounters from May – July 2019. After establishing inter-rater reliability, individual hospitalists observed rounds from August 2019 until February 2020. Clinical teams were blinded to what was being observed.

Results

The HVCCS revealed PHM faculty and residents rated HVC culture similarly, with better culture scores for leadership and health system messaging and lower scores for data transparency and access (Figure 1).

For paired observations, we achieved 90% positive agreement between rounds observers. In 255 subsequent patient encounters, the mean frequency of at least one HVC discussion during rounds was 56% (Figure 2). The most commonly observed topic was if the patient required ongoing hospitalization, while praising a team member for not doing an unnecessary treatment and narrowing medication lists were the least common (Table 1).

Conclusions

To our knowledge, this work is the first application of the HVCCS in pediatrics and highlights a need for greater data transparency around cost. These results, coupled with our observations of actual behaviors, emphasize that more data and HVC discussions, specifically around medications and praising providers, on rounds may further promote HVC culture. The combination of the HVCCS and bedside observations identified multiple specific targets for future education interventions. Next steps include curricular and professional development that address these areas for improvement and using these instruments at other institutions.

Clinical Implications

This work revealed that greater data transparency and a stronger emphasis on discussing certain quality, cost, and patient value topics during rounds may foster an institutional culture focused on high-value medicine and ultimately improve patient care. Discussions around narrowing medication lists for home and balancing both the benefits and harms of care are critical.

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