SummaryBlue Cross Blue Shield of Michigan and Blue Care Network (its sister health maintenance organization) provide financial incentives and support to 18 provider-led regional collaborations designed to promote quality improvement. To stimulate provider participation and support the ongoing effectiveness of the collaboratives, the insurer pays financial incentives based on performance, finances key pieces of infrastructure, and compensates hospitals for the costs of data collection. Participating providers take ownership over all activities, including data collection and analysis through a registry, regular performance reports, and periodic meetings to review data and identify and share best practices. This incentive and support structure has generated very high levels of provider participation in the collaborations, which, based on results from the four longest-running initiatives, have significantly improved quality, reduced costs, and generated a positive return on investment.Moderate: The evidence generally consists of the percentage of hospitals participating in at least one collaborative, pre- and post-implementation comparisons of performance on key process and outcomes measures, estimates of the cost savings generated as a result of improvements on these measures, and/or comparisons of the performance of participating hospitals to nonparticipants and/or to regional and national benchmarks.
Developing OrganizationsBlue Care Network; Blue Cross Blue Shield of Michigan
Date First Implemented1997
A pilot test focused on coronary angioplasty began with six hospitals in 1997. Since that time, the program has expanded to include 18 separate initiatives, including 12 hospital-based and 6 professional collaborations. Key initiatives include: major general and vascular surgery (launched in 2005), bariatric surgery (2005), cardiac surgery (2005), cardiac imaging (2007), breast cancer (2006), percutaneous coronary intervention (1997), peripheral vascular interventions (2006), trauma care (2011), hospital medicine safety (2010), care transitions (2010), perioperative outcomes (2011), lean clinical redesign (2008), anticoagulation services (2009), two separate oncology initiatives (2010), radiation oncology (2012), hip and knee replacement (2012), and urology (2012).
Insurance Status > Commercial
Problem AddressedThe quality of health care remains suboptimal, with wide variations in performance across institutions and many patients experiencing avoidable adverse events. Suboptimal quality not only affects patients’ health, but also drives up costs. Regional collaborations of hospitals and/or physicians have the potential to improve quality and reduce costs, but such initiatives remain relatively uncommon, as providers often lack the incentive and infrastructure to systematically track and improve performance.
- Suboptimal and widely varying quality: Multiple studies have highlighted the potential to improve the quality of health care (particularly hospital care) by reducing significant variations in performance across facilities and preventing avoidable adverse events, such as surgical complications and unplanned readmissions.1,2,3,4
- Leading to higher costs: Preventable adverse events significantly raise the costs of health care services. For example, the cost to treat the typical surgical complication exceeds $10,000, and most of these costs are borne by payers and purchasers. Payments to hospitals for complicated stays (known as “outlier payments”), unplanned readmissions, and followup care after discharge for patients with complications account for 20 percent of the total costs associated with many inpatient procedures.5 Wide variations in costs that are unrelated (or inversely related) to quality also drive up health care expenses.
- Unrealized potential of provider-led collaborations: Regional, provider-led collaborations have significant potential to improve quality and reduce costs by bringing together hospitals and/or physicians from a given geographic area, providing them with detailed feedback on their performance versus that of peers, and supporting them in identifying and implementing best practices from the high-performing organizations.6 However, relatively few such collaborations exist, in part because providers often lack the time, incentive, and infrastructure to systematically monitor and improve performance. (Interest in such collaborations is growing; see the Use by Other Organizations section for more details.)
Description of the Innovative ActivityBlue Cross Blue Shield of Michigan and Blue Care Network provide financial incentives and support to 18 regional collaborations (known as Collaborative Quality Initiatives or CQIs) among hospitals and physicians in common, high-cost areas with wide variations in practice patterns. To stimulate provider participation and support the ongoing effectiveness of the collaboratives, the insurer pays financial incentives based on performance, finances key pieces of infrastructure, and compensates hospitals for the costs of data collection. Participating providers take ownership over all activities, including data collection and analysis through a registry, regular performance reports, and periodic meetings to review data and identify and share best practices. Key program elements are outlined below:
- Insurer-funded incentives and infrastructure: Blue Cross Blue Shield of Michigan provides financial incentives and funding for infrastructure to support the formation and ongoing success of each CQI, as outlined below:
- Coordinating centers: Blue Cross provides funding for a dedicated coordinating center for each CQI. Centers are typically housed and staffed by the University of Michigan Health System, with one center hosted at William Beaumont Health System. (Several other Michigan-based provider systems may host coordinating centers for future CQIs.) The clinical champion for the overall initiative oversees the center. (See the Planning and Development Process section for more details on the clinical champion, and see the sub-bullets under "provider-led quality improvement activities" for more details on coordinating center activities.)
- Committees: Under the leadership of the clinician champion and with support from Blue Cross, each CQI typically establishes several committees that help run the initiative, including an executive committee made up of leaders from around the state and a writing/scientific committee that tests new ideas and approaches. Committees typically meet several times a year.
- Insurer payments for participation and performance: Blue Cross covers the bulk of the data-collection costs incurred by participating providers and ties a portion of its pay-for-performance (P4P) program to how well participants perform on key metrics tracked by the collaborative.
- Data-collection payments: Blue Cross pays participating hospitals based on a formula designed to cover roughly 80 percent of the costs of data collection. Payments typically range from $10,000 to $125,000 per hospital per CQI, depending on the size of the hospital.
- P4P payments: Blue Cross runs a Hospital P4P Incentive Program that pays up to the equivalent of 5 percent of each hospital's total reimbursement, with payments based on performance in a variety of areas. Approximately 15 percent of these payments—or almost 1 percent of total hospital reimbursement—is tied to performance on various metrics tracked by the CQIs. Because many hospitals participate in multiple initiatives, payments can range from $3,000 for a small hospital participating in only one CQI to $1.2 million annually for some large hospitals participating in multiple initiatives. To administer this program, the coordinating centers work with the consortium to develop a performance index based on level of engagement, accuracy of data, degree of quality improvement, and, for more mature CQIs, clinical outcomes. The center applies the scoring system and produces an indexed score for each hospital. In most cases, Blue Cross has access to only the aggregate score, not the detailed line items that go into it.
- Provider-led quality improvement activities: Participating hospitals and physicians take full ownership over and responsibility for a range of activities designed to stimulate quality improvement in the targeted area, as outlined below:
- Collection and evaluation of data through registry: Participating hospitals and physicians collect and submit relevant data to a program registry run by the coordinating center. In most cases, the coordinating center develops the registries and works with participating providers and outside experts to determine the appropriate data elements. In other cases, the collaborative makes use of registries run by professional societies, with some enhancements typically made at the local level. For example, the cardiovascular collaborative partners with the American College of Cardiology to use its National Cardiovascular Disease Registry.
- Regular performance feedback: Participants receive regular feedback (typically three or four times a year) on their risk-adjusted performance on hospital- and physician-specific measures, which is typically compared with peers, the Michigan average, and/or national averages and other benchmarks. Each collaborative uses different risk-adjustment models, outcome measures, and benchmarks. Measures generally focus on short- and long-term morbidity and mortality, although other relevant measures of effectiveness may also be used. Most CQIs begin by sharing de-identified data that allow participants to compare performance with unnamed peers or group averages. Over time, as trust builds, participants often decide to “name names” so as to facilitate more frank discussions during collaborative learning sessions (see below). Performance reports remain confidential and cannot be accessed by Blue Cross Blue Shield of Michigan; participants agree not to use the data outside of the collaborative (e.g., in advertising).
- Collaborative learning: Coordinating center staff schedule and run periodic meetings (usually each quarter) attended by at least one physician and the program coordinator from each participating hospital. (Typically 90 to 95 percent of participating hospitals send a representative.) During these sessions, participants discuss the most recent performance reports (which may be sent in advance or distributed at the session), as well as their experiences, including successes and failures with respect to quality improvement efforts. Sessions often uncover problems and identify solutions to major issues impeding performance, as outlined below:
- Bariatric surgery: Performance data uncovered wide variations in use of inferior vena cava filters (ranging from 0 to 35 percent, with 6 hospitals accounting for a large majority of filter placements), along with information showing that the filters did not achieve their intended purpose (to reduce the risk of pulmonary embolism) and increased the risk of other serious complications. Participants also received feedback on weight loss and functional status, which led to significant changes in practices at many hospitals.
- General and vascular surgery: Performance data and the collaborative learning sessions uncovered various strategies for preventing common complications, including appropriate use of antibiotics and the timely provision of prophylaxis to prevent venous thromboembolism.
- Site visits to audit data: Nurses at the coordinating center visit participating hospitals right after the program’s launch to train relevant staff on data-collection and submission methods. They conduct annual onsite “audits” to ensure that data are being entered accurately, providing ongoing support as needed.
- Other support: Coordinating center personnel periodically visit participating sites to provide support to the local physician leader. As part of these visits, staff may make suggestions in various areas, such as patient safety culture and care processes. These educational visits typically happen once or twice a year. In addition, coordinating center staff sometimes arrange for a team from one hospital to visit other high-performing hospitals to see how they capture data and engage in other quality improvement activities.
References/Related ArticlesShare DA, Campbell, DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):1-9. [PubMed]
Barnes GD, Birkmeyer N, Flanders SA, et al. Venous thromboembolism: a collaborative quality improvement model for practitioners, hospitals, and insurers. J Thromb Thombolysis. 2012;33:274-9. [PubMed]
Contact the InnovatorLauren Henrikson-Warzynski, MPA
Blue Cross Blue Shield of Michigan
Health Care Analyst, Value Partnerships
Mail Code 508B
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
Blue Cross Blue Shield of Michigan
Mail Code 508B
600 E. Lafayette Blvd.
Detroit, MI 48226-2998
ResultsThe incentive and support structure has generated very high levels of provider participation in the collaborations, which, based on results from the four longest-running initiatives, have significantly improved quality, reduced costs, and generated a positive return on investment (ROI). Data from the other CQIs are not yet available.
Moderate: The evidence generally consists of the percentage of hospitals participating in at least one collaborative, pre- and post-implementation comparisons of performance on key process and outcomes measures, estimates of the cost savings generated as a result of improvements on these measures, and/or comparisons of the performance of participating hospitals to nonparticipants and/or to regional and national benchmarks.
- Widespread participation: The vast majority of eligible hospitals typically participate in at least one CQI. For example, all eligible hospitals participate in the coronary angioplasty and cardiac surgery initiatives (33 hospitals in each), while 98 percent of eligible hospitals participate in bariatric surgery (39 hospitals) and 88 percent in major general and vascular surgery (52 hospitals). By design, CQIs tend to start small (with a pilot group of participants) and then expand over time as early success leads to enthusiasm and interest among non-participants.
- Higher quality: The four longest-running programs have achieved significant quality improvements, as outlined below:
- Lower morbidity in general and vascular surgery: Between 2005 and 2009, risk-adjusted morbidity rates in Michigan hospitals (virtually all of which participated) fell from 13.1 to 10.5 percent. By contrast, morbidity rates in other hospitals participating in the National Surgical Quality Improvement Program remained flat between 2005 and 2008, and decreased slightly in 2009. Although the trend toward improvement in both sets of hospitals met the test of statistical significance, improvement occurred at a meaningfully faster rate in Michigan hospitals. In 2009, overall morbidity in Michigan hospitals was significantly lower than in other hospitals (10.5 vs. 11.5 percent).7
- Fewer complications in bariatric surgery: Between 2008 and 2009, overall complication rates for patients undergoing bariatric surgery fell from 8.7 to 6.6 percent in participating hospitals. Over the same time period, risk-adjusted 30-day mortality decreased significantly, with the rate of improvement exceeding that in hospitals outside Michigan (which experienced improvements that were not statistically significant). Between 2007 and 2009, the proportion of bariatric surgery patients experiencing an emergency department (ED) visit within 30 days of initial discharge fell significantly, from 8 to 5 percent. Much of the improvement in complications and ED visits came as a result of reduced use of vena cava filters (from between 7 and 8 percent to less than 2 percent).7
- Lower mortality, fewer complications with coronary angioplasty: From 2002 through the third quarter of 2011, this collaborative resulted in significant reductions in hospital deaths (20 percent), emergent coronary artery bypass grafts (92 percent), contrast-induced nephropathy (38 percent), blood transfusions after angioplasty (38 percent), vascular complications (44 percent), stroke (18 percent), and door-to-balloon time for patients with ST segment elevation myocardial infarction or STEMI (42 percent). The proportion of patients with door-to-balloon-time below 90 minutes increased by 195 percent over the same time period.
- Better overall quality for cardiac surgery: Participating hospital performance on an 11-item composite quality measure (covering both mortality and key process measures) has improved with respect to national norms. At the beginning of the collaborative (2006–2007), the composite score for Michigan hospitals was statistically indistinguishable from national benchmarks. By 2008–2009, the performance of Michigan hospitals (all of which participated in the collaborative) ranked in the top 10 percent nationwide.7 In addition, the proportion of patients on prolonged ventilation has fallen significantly, from 19 percent in 2005 to 10.6 percent in 2010.
- Lower costs and positive ROI: Several of the longest-running CQIs have generated cost savings that far exceed program-related expenses, as outlined below:
- General and vascular surgery: The roughly 2.5-percentage point drop in morbidity rates translates into 2,500 fewer Michigan patients each year experiencing such complications. Based on an average cost of $11,000 per complication,5 the program saves an estimated $27.5 million a year. Payers typically are responsible for 75 percent of the cost of such complications, suggesting that Blue Cross and other payers save approximately $20 million, approximately four times the $5 million cost of administering the program.7
- Bariatric surgery: The reduction in use of vena cava filters likely saves payers more than $4 million a year (since payment for placing the filter averages $13,500), well above the cost of administrating the CQI. This figure does not include reductions in costs due to the avoidance of filter-related complications. In addition, the aforementioned decline in postdischarge ED visits saves payers an estimated $1 million a year.7
- Coronary angioplasty: Between 2008 and 2010, the collaborative saved $13.8 million as a result of reductions in blood transfusions, bypass surgery, contrast-induced nephropathy, vascular complications, and readmissions. Statewide savings (for Medicare, Medicaid, self-pay patients, and all commercial payers, including Blue Cross Blue Shield of Michigan and Blue Care Network) are estimated to be $102 million over this time period.
- Cardiac surgery: Between 2009 and 2010, statewide savings due to reductions in readmissions and cases of renal failure and prolonged ventilation totaled approximately $30.3 million.
Context of the InnovationBlue Cross Blue Shield of Michigan provides insurance to roughly 47 percent of Michigan’s approximately 10 million residents. The impetus for this program came from Dr. David Share (a medical consultant at the time and now Vice President of Value Partnerships at Blue Cross Blue Shield of Michigan), who in early 1996 met with two doctors then at the University of Michigan to learn about their prior experiences with the Northern New England Cardiovascular Disease Study Group, a regional collaboration formed in the late 1980s that focused on cardiac surgery. This effort featured use of a registry of data collected from six hospitals in distinct geographic markets to evaluate practice patterns and links between processes and outcomes. After learning of this group’s approach and success, Dr. Share decided to test a similar concept in the more competitive, densely populated Michigan market. In 1997, the Blue Cross Blue Shield of Michigan Foundation funded a collaboration of six hospitals focused on coronary angioplasty. This pilot test generated significant engagement and excitement, as the pooling of data allowed for more robust analysis and the generation of knowledge and statistical validity beyond what any hospital could do on its own. Relatively quickly, opportunities for improvement became clear, and by 2001 the collaborative had achieved significant improvements. This success convinced Blue Cross leaders that the same approach could yield substantial benefits in many other areas. The attraction stemmed in part from its ability to turn conventional research “on its head” by generating evidence in real-world practice environments, as opposed to doing so through randomized trials in controlled academic settings that may or may not be applicable in the real world.
Planning and Development ProcessAlthough the planning and development process for each CQI varies, key steps from the perspective of Blue Cross Blue Shield of Michigan include the following:
- Identification of target area: The best targets are common, high-cost clinical procedures and conditions that exhibit wide variations in practice patterns driven in large part by a still-developing evidence base.
- Recruitment of clinical champion: A successful collaboration begins with a clinical champion from the community who has the passion, skills, and experience to lead the effort. This individual must be a well-respected clinical leader within the state or region. For example, a University of Michigan researcher who is well known in Michigan and across the nation leads the bariatric surgery CQI. He was offered the position after approaching Blue Cross leaders about applying his experiences using a registry at Dartmouth to the Michigan market. In some cases, Blue Cross has found it difficult to find an appropriate clinical champion. For example, it took a while to identify and recruit someone deemed appropriate to lead the effort in joint replacement; recently a junior faculty member at the University of Michigan with significant enthusiasm and motivation has taken on this role.
- Collaborative dialogue with champion: Once a champion has been identified, program leaders at Blue Cross engage in a collaborative dialogue with this individual, explaining the Blue Cross approach and reviewing the essential elements of a CQI. This process includes sharing sample proposals from current projects and providing resources and tools related to setting up the initiative, including an organizational structure, budget, and estimates of its potential impact on quality and costs.
- Program leader review of proposal outline: The clinical leader submits a brief (one- or two-page) outline that describes the key elements of the proposed CQI. Blue Cross program leaders review this outline and, assuming it has the potential to generate significant improvement, work iteratively with the clinical leader to flesh out a more comprehensive proposal. By the time it has been fully developed, Blue Cross program leaders have effectively vetted (and fully support) the proposal.
- Formal review and approval: A broader committee at Blue Cross reviews the comprehensive proposal and decides whether to fund it. In the majority of cases, the careful vetting and iterative development process described above leads to approval.
- Provider-led launch and operation: After formal approval, Blue Cross plays a supporting role, primarily by funding the work of the CQI and providing administrative support and guidance during its development and implementation. The clinical leader works in collaboration with peers in the community (many of whom he/she already knows and/or has contacted during the proposal-writing process) to recruit participants and set up the coordinating center, registry, committees, and other key program elements.
Resources Used and Skills Needed
- Staffing: The program requires dedicated staff at Blue Cross Blue Shield of Michigan, the coordinating centers, and participating hospitals, as outlined below:
- Blue Cross: Blue Cross Blue Shield of Michigan has two physicians who serve as part-time “champions” of the program, along with a full-time program manager who supervises a staff of five full-time employees responsible for supporting the 18 CQIs. Support includes assisting in development of new CQIs, recruiting participants, collecting data, administering reward payments, and supporting the coordinating centers in their effort to ensure the active engagement of participants. In addition, the Blue Cross Blue Shield of Michigan clinical leads work closely with the CQI program directors to optimize the effectiveness and impact of the programs.
- Coordinating centers: As noted, each CQI has its own coordinating center. Each center is run by the physician champion (typically a practicing physician), who generally spends about a quarter of his/her time on the initiative. Centers also employ between five and eight full-time staff, typically made up of a project manager (usually a nurse), clinical epidemiologist, biostatistician, data analyst, data auditor/quality improvement expert (also generally a nurse), and information technology staff.
- Participating providers: As part of the participation agreement, hospitals commit to having three individuals participate (e.g., in meetings, data submission, etc.), including a clinical champion, administrative leader, and data coordinator. Most participating hospitals dedicate at least 0.5 full-time equivalents (FTEs) to data collection and coordination, with a few larger hospitals needing as many as 3 FTEs. In addition, hospital-based quality improvement staff may participate in CQIs as part of their regular duties.
- Costs: In fiscal 2012, Blue Cross Blue Shield of Michigan will invest roughly $36 million in the 18 ongoing collaborations, not including the P4P payments. The annual cost of each of these CQIs ranges from roughly $1 to $5 million.
Funding SourcesBlue Cross Blue Shield of Michigan Foundation
The Blue Cross Blue Shield of Michigan Foundation funded the first CQI (a pilot test focused on coronary angioplasty), which led to the development of the formal CQI program, now funded by Blue Cross Blue Shield of Michigan. Since that time, the Blue Cross Blue Shield of Michigan Foundation has funded pilot tests of other programs that were later formalized and ultimately integrated into the CQI program.
Tools and Other ResourcesBlue Cross Blue Shield of Michigan has developed a toolkit for the Blue Cross Blue Shield Association that assists in setting up a regional CQI. The toolkit is available by contacting the innovator.
More information on the individual CQIs is available at: http://www.valuepartnerships.com/hospital_initiatives/collaborations.shtml.
Getting Started with This Innovation
- Be willing to go outside comfort zone: Payers have historically been reluctant to get too involved in promoting quality improvement, fearing that the provider market is too competitive and/or that they do not have adequate leverage to do so. (See next bullet for more on leverage.) Often these explanations do not address the real, underlying reason for inactivity—that these types of quality improvement activities fall outside most payers’ “comfort zones.” However, few other organizations are in as good a position as payers to serve as a catalyst for provider-led quality improvement.
- Ensure adequate leverage: As noted, Blue Cross Blue Shield of Michigan provides insurance to nearly half of Michigan residents, giving the organization significant clout with providers and the confidence that any benefits derived will accrue primarily to its members and employer clients. Although some other markets have similarly dominant insurers, the payer market remains fragmented in many regions of the country. In these situations, regional coalitions of public and private payers and employers may be needed to sponsor this type of program.
- Target common, high-cost areas prone to performance variation: The best targets will be high-cost procedures and interventions where performance varies significantly across providers, suggesting ample room for improvement.
- Identify strong clinician champion: The clinician champion plays a critical role. This individual must be well respected, knowledgeable, and passionate about quality improvement. In many cases, running a CQI becomes a way for the champion to leave a mark on the profession that goes beyond everyday clinical practice. Blue Cross leaders have found that it is better to delay the launch of an initiative if an appropriate champion cannot be found.
- Take early steps to elicit trust: The program will not work in the absence of trust between all key stakeholders—the sponsor, the clinical champion, the coordinating center, and the participating providers. To that end, the sponsor should take several concrete steps designed to elicit trust, including giving participants complete ownership over all data and quality improvement activities, and using data to inform and educate rather than to judge (particularly in the early stages of an initiative).
Sustaining This Innovation
- Aim for high levels of participation over time: Although smaller pilot tests are sometimes necessary to prove the concept and generate early successes, the large sample sizes and statistical power associated with having many participants allow for more robust assessment of relationships between processes and outcomes, and of the effects of quality improvement interventions.
- Consider adding P4P bonus payments: In a fee-for-service payment environment, hospitals and physicians could potentially be penalized financially as a result of some of the improvements generated by this program. For example, fewer complications and readmissions might result in lower revenues. (However, hospitals often lose money on more complicated patients even with the higher revenues.) To keep hospitals motivated, consider adding a P4P component that provides additional payments to those that perform well on various metrics. Although Blue Cross got some push-back after introducing P4P incentives as part of the CQIs (which run somewhat counter to the “nonjudging” nature of the program), most hospitals readily accepted them, because they represented bonus payments above and beyond what they already received. Some hospitals that initially did not score well (and hence received little if any P4P bonuses) have, however, registered complaints. Program leaders suggest focusing first on rewarding active participation and high levels of engagement, with a gradual movement to use of performance metrics as the consortium matures and its quality improvement agenda begins to yield benefits.
- Recognize that credibility grows over time: Once Blue Cross established itself as a credible sponsor, the ability to hit the ground running increased, as did the willingness of providers to share identified data openly with each other and to tackle former “sacred cows.” For example, participants in the recently launched urology collaborative quickly agreed to tackle the appropriateness of radical prostatectomy (a common, lucrative procedure for many urologists).
Use By Other OrganizationsThis Blue Cross Blue Shield of Michigan program has served as a catalyst and/or resource for the development of a number of other regional, provider-led quality improvement collaborations that are in various stages of planning and development, including the Tennessee Surgical Quality Collaborative. This interest has been driven by frequent presentations from CQI physician leaders and participants, and the publishing of roughly 10 to 12 peer-reviewed journal articles by the CQIs each year. Interest is growing among statewide specialty societies and guilds throughout the country, and a handful of other payers have also expressed interest. The program has received international attention in the last few years, with a few CQI representatives presenting their results outside the United States, including in Kyoto, Japan, in late 2011.
Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370–6. [PubMed]
Ghaferi AA, Birkmeyer JD, Dimick JB. Variation in hospital mortality associated with inpatient surgery. N Engl J Med. 2009;361(14):1368–75. [PubMed]
Leape LL, Brennan TA, Laird N, et al. The nature of adverse events in hospitalized patients: results of the Harvard Medical Practice Study II. N Engl J Med. 1991;324(6):377–84. [PubMed]
O’Connor GT, Plume SK, Olmstead EM, et al. A regional prospective study of in-hospital mortality associated with coronary artery bypass grafting: the Northern New England Cardiovascular Disease Study Group. JAMA. 1991;266(6):803–9. [PubMed]
Dimick JB, Weeks WB, Karia RJ, et al. Who pays for poor surgical quality? Building a business case for quality improvement. J Am Coll Surg. 2006;202(6):933–7. [PubMed]
O’Connor GT, Plume SK, Olmstead EM, et al. A regional intervention to improve the hospital mortality associated with coronary artery bypass graft surgery. JAMA. 1996;275(11):841–6. [PubMed]
Share DA, Campbell, DA, Birkmeyer N, et al. How a regional collaborative of hospitals and physicians in Michigan cut costs and improved the quality of care. Health Aff (Millwood). 2011;30(4):1-9. [PubMed]
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Original publication: June 06, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 06, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.