Hospital Perceptions of Medicare’s Sepsis Quality Reporting Initiative

Analysis

Interviews were audio recorded, transcribed, and loaded onto a secure server. We used NVivo 11 (QSR International, Cambridge, Massachusetts) for coding and analysis. We iteratively reviewed and thematically analyzed the transcripts for structural content and emergent themes, consistent with established qualitative methods.¹⁵ Three investigators reviewed the initial 20 transcripts and developed the codebook through iterative discussion and consensus. The codes were then organized into themes and subthemes. Subsequently, 1 investigator coded the remaining transcripts. The results are presented as a series of key themes supported by direct quotes from the interviews.

RESULTS

Sample Description

We performed 29 interviews prior to achieving thematic saturation. Each of the 8 strata from the sampling frame was represented by at least 3 hospitals. Hospitals in the final sample were diverse in total bed size, intensive care unit bed capacity, teaching status, and ownership (Table 2). The median interview length was 25 minutes (interquartile range, 20-32 minutes). Respondents included 6 quality coordinators, 6 quality managers, and 11 quality directors, with the remainder holding a variety of other quality-related titles. Most respondents worked in hospital quality departments, although 4 were affiliated with individual clinical departments (eg, emergency medicine and/or critical care services). Of the 9 respondents who reported their professional training, 8 were registered nurses. Eleven respondents reported participating in measure abstraction.

Perspectives on SEP-1

Respondents’ general perspectives on the SEP-1 program are outlined in Table 3, with several key themes emerging. Foremost was the sheer complexity of the measure compounded by its reliance on time-stamped clinical documentation, and in particular, the physical reassessment in individual medical notes. Respondents expressed frustration with the “all-or-none” approach to declaring sepsis treatment a “success,” which they noted was unfair and difficult to justify to their local clinicians. In part because of the time and effort required to comply with the measure and report results to CMS, several respondents noted that the measure is a uniquely burdensome addition to an already-crowded landscape of hospital quality programs. Despite the resources required to adhere to the measures’ standards and report results to CMS, respondents expressed a belief that the increased attention to sepsis is driving positive changes in hospital care and leading to improved patient outcomes.

Responses to SEP-1

Respondents identified several specific ways in which their hospitals responded to the SEP-1 mandate (Table 4), including investments in measurement, planning and coordinating sepsis-specific quality-improvement activities, improving the early identification of patients with sepsis, improving sepsis treatment and measure compliance, and addressing negative attitudes towards the implementation of the SEP-1 program.

Efforts to Collect Data for SEP-1 Reporting

Respondents reported challenges in reliably and validly measuring and reporting data for the SEP-1 program. First, patient identification and the measurement of treatment processes depends largely on manual medical record review, which is subject to variation across coders. This presents a particular challenge because the clinical definition of sepsis itself is in evolution,¹ creating the possibility that treating physicians could identify a given patient as having sepsis or septic shock based on the most up-to-date definitions but not based on the measure’s specifications or vice versa. Second, each case requires up to an hour of manual medical record review and patients who develop sepsis during prolonged hospitalizations can require several hours or more, which is an unprecedented length of time to spend abstracting data for a single measure.

In addressing these measurement challenges, investment in human resources is the rule. No respondent reported automating abstraction of all the SEP-1 data elements, underscoring concerns regarding the measurement burden of the SEP-1 program.^7,8,14 Rather, hospitals with sufficient financial resources frequently employ full-time data abstractors and individuals responsible for ongoing performance feedback, which facilitates the iterative revision of sepsis quality-improvement initiatives. In contrast, hospitals with fewer resources often rely on contracts with third-party vendors, which delays reporting and complicates efforts to use the data for individualized performance improvement.

Efforts to Coordinate Hospital Responses Across Care Teams

Complying with the measure involves the longitudinal coordination of multiple care teams across different units, so planning and executing local hospital responses required interdepartmental and multidisciplinary stakeholder involvement. Respondents were uncertain about the ideal strategy to coordinate these quality-improvement efforts, yielding iterative changes to electronic health records (EHRs), education programs, and data collection methods. This “learning by doing” is necessary because no prior CMS quality measure is as complex as SEP-1 or as varied in the sources of data required to measure and report the results. By requiring hospitals to improve coordination of care throughout the hospital, SEP-1 presents a quality-improvement and measurement challenge that may ultimately drive innovation and better patient care.