Results and lessons from a hospital-wide initiative incentivised by delivery system reform to improve infection prevention and sepsis care

BackgroundAn academic safety-net hospital leveraged the federally funded state Delivery System Reform Incentive Payment programme to implement a hospital-wide initiative to reduce healthcare-associated infections (HAIs) and improve sepsis care.MethodsThe study period was from 2013 to 2017. The setting is a 770-bed urban hospital with six intensive care units and a large emergency department. Key interventions implemented were (1) awareness campaign and clinician engagement, (2) implementation of HAI and sepsis bundles, (3) education of clinical personnel using standardised curriculum on bundles, (4) training of key managers, leaders and personnel in quality improvement methods, and (5) electronic medical record-based clinical decision support. Throughout the 5-year period, staff received frequent, clear, visible and consistent messages from leadership regarding the importance of their participation in this initiative, performing hand hygiene and preventing potential regulatory failures. Several process measures including bundle compliance, hand hygiene and culture of safety were monitored. The primary outcomes were rates of central line-associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI) and sepsis mortality.ResultsFrom 2013 to 2017, the hospital-wide rates of HAI reduced: CLABSI from 1.6 to 0.8 per 1000 catheter-days (Poisson regression estimate: −0.19; 95% CI −0.29 to −0.09; p=0.0002), CAUTI from 4.7 to 1.3 per 1000 catheter-days (−0.34; −0.43 to −0.26; p<0.0001) and SSI after 18 types of procedures from 3.4% to 1.3% (−0.29; −0.34 to −0.24; p<0.0001). Mortality of patients presenting to emergency department with sepsis reduced from 9.4% to 2.9% (−0.42; −0.49 to −0.36; p<0.0001). Adherence to bundles of care and hand hygiene and the hospital culture of patient safety improved. Results were sustained through 2019.ConclusionA hospital-wide initiative incentivised by the Delivery System Reform Incentive Payment programme succeeded in reducing HAI and sepsis mortality over 5 years in a sustainable manner.

Achieving Triple Aim Outcomes: An Evaluation of the Texas Medicaid Waiver

The Texas Medicaid Waiver, via the Delivery System Reform Incentive Payment (DSRIP) program, has provided a path for Texas to achieve the Triple Aim through its focus on a defined population at the project and system levels, and financial payment policy based on outcomes. Both iterations of the DSRIP program (Waiver 1.0 and 2.0) have helped define populations, created regional collaboration that sets the stage for a true integrator, and provided financial incentives for improving population health, enhancing patient experience, and controlling costs. The flexible design of project menus and measure bundles in DSRIP encouraged a variety of projects, numerous measures of success and (often) overlapping populations of individual served to achieve the ultimate goal of the Triple Aim. This research outlines the major features of Texas DSRIP and demonstrates the Medicaid Waiver effectively contributed to measurable improvements in health, suggesting Texas safety net providers are moving closer to Triple Aim achievement.

Supporting Transformation through Delivery System Reform Incentive Payment Programs: Lessons from New York State

The New York Delivery System Reform Incentive Payment (DSRIP) waiver was viewed as a prototype for Medicaid and safety net redesign waivers in the Affordable Care Act (ACA) era. After the insurance expansions of the ACA were implemented, it was apparent that accountability, value, and quality improvement would be priorities in future waivers in many states. Despite New York's distinct provider relationships, previous coverage expansions, and local and state politics, it is important to understand the key characteristics of the waiver so that other states can learn how to better incorporate value-based arrangements into future waivers or attempts to limit spending under proposed Medicaid per-capita caps or block grants. In this article, we examine the New York DSRIP waiver by drawing on its design, early experiences, and evolution to inform recommendations for the future renewal, implementation, and expansion of redesigned or transformational Medicaid waivers.

The Simple Reality of Our Complex System: The Future of Health Care

The incredible complexity of the United States health care system can be connected to three simple outcomes: access, affordability, and quality. We should measure our progress against these three measures. While historic progress on access was made through implementation of the Affordable Care Act, the next area of focus for more results across all three measures is delivery system reform.