An Environmental Scan of Pay for Performance in the Hospital Setting: Final Report. Appendix B: Summary of Pay-for-Performance Design Principles

11/01/2007

This appendix builds on the summary of P4P design principles and recommendations presented in Chapter 1 of this report. Here we present and summarize the P4P design principles established by 26 organizations representing a variety of stakeholders, including purchasers, health care providers, policy organizations, accreditation organizations, health plans, and consumers. Table B.1 displays the P4P design principles for each of the 26 organizations. Table B.2 tallies the principles and recommendations across recommendations.

 
HEALTH CARE ORGANIZATIONS
HEALTH PLANS
P4P Design Principles/Recommendations
JCAHO
MedPAC
IOM
NQF Conference
Leapfrog 
IHA
Natl. Business Group on Health
eHealth Initiative Fdn.
Healthways/ Johns Hopkins
Pacific Business Group on Health
Alliance of Comm. Health Plans
AHIP
Medicare Specific                        
P4P in Medicare should be implemented using a phased approach that varies by setting, reward amount, and measures     X                  
Medicare should fund the program by setting aside a small share of payments in a budget-neutral approach   X                    
Congress should derive initial funding (3–5 years) largely from existing funds by creating provider-specific pools from a reduction in base Medicare funding for each class of providers     X                  
A consolidated pool should be formed from which all providers are rewarded when measures allowing for shared accountability are developed      X                  
A Medicare P4P program must not be budget neutral or subject to artificial Medicare payment volume controls                        
Medicare incentives should be financed with a new, dedicated stream of funding                     X  
Medicare should distribute all payments that are set aside to providers achieving quality criteria   X                    
Medicare should establish a process for continual evolution of measures   X                    
A Medicare P4P program should be phased in gradually starting with reporting on structural measures and moving to enhanced payment based on evidence-based clinical measures                        
Medicare should initially reward care that is of high clinical quality, patient centered, and efficient     X                  
Medicare should consider expanding the proportion of payment based on performance over time             X          
Medicare should initially reward both providers who improve performance significantly and providers who achieve high performance     X                  
Medicare should offer incentives to providers for the submission of performance data, and these data should be publicly available in ways that are meaningful and understandable to consumers     X                  
The program should be designed such that virtually all Medicare providers submit performance measures for public reporting and participate in P4P as soon as possible     X                  
CMS should design the program to include components that promote, recognize, and reward care coordination across providers     X                  
CMS should implement a monitoring and evaluation system for the program     X                  
A Medicare P4P program must be pilot tested across settings and specialties and phased in over an appropriate period                         
Incentives should eventually apply to all Medicare providers, including FFS and Medicare Advantage                     X  
Metrics                        
Programs should utilize accepted, evidence-based measures X X X X   X X   X X    
Measures should be pilot tested, validated, and vetted through a process that includes public comment and phased in        X                
The measurement set should include measures of clinical quality, patient experience, and infrastructure           X            
Measures need to be prioritized to address areas that are important to patients (such as those that prevent deaths, complications, and discomfort), as well as those that improve satisfaction, outcomes, and experience with care       X`                
Incentives should be based on existing measures and should emphasize clinical effectiveness                     X  
Measures adopted should be developed by nationally recognized measurement organizations and recommended by consensus-building organizations       X     X          
Metrics should be high volume, high gravity, and strongly evidence based; have a gap between current and ideal practice and good prospects for quality improvement; and have measurement reliability, validity, and feasibility                 X      
Program designers should include a sufficient number of metrics across a spectrum of health promotion activities to provide a balanced view of performance                 X X    
The development, validation, selection, and refinement of measures should be a transparent process that has broad consensus among stakeholders        X         X      
The development and selection of metrics should include participation by the patient community as well as by physicians and other providers                  X      
Distinct standards should be developed to evaluate performance relative to the most vulnerable patients: frail elderly and patients with chronic, debilitating, or life-threatening illness                        
Process measures, such as those used by the HQA, should be used                        
Process or intermediate outcome measures are preferred unless robust, well-accepted methods of risk adjustment can be applied to outcome measures                        
The focus should be on structure and process measures until evidence-based outcome measures are developed                        
Structure, process, and outcome measures should be utilized             X   X      
Outcome measures are the highest priority because of their central importance to patients       X                
Outcome measures must be subject to the best available risk adjustment for patient demographics, severity of illness, and co-morbidities           X            
Metrics should be selected from the following domains: patient centeredness, effectiveness, safety, and efficiency       X         X      
Metrics should include efficiency measures             X          
Efficiency measures should only be used when both the cost and the quality of a particular treatment are considered       X                
When measuring quality, focus on misuse and overuse as well as underuse             X          
Provide positive provider incentives for adoption and utilization of IT X   X X     X X X X    
Programs implemented by either the public or the private sector involving HIT should incentivize only those applications and systems that are standards based to enable interoperability and connectivity, and should address the transmission of data to the point of care X             X        
Programs should move from an individual disease management approach to cross-cutting measures           X            
Metrics should be stable over time                        
Metrics should be kept current to reflect changes in clinical practice                        
Each measure should remain in the set for at least three years but should be evaluated annually to adjust weighting and specifications as necessary           X            
Local measures should closely follow national metrics as long as they are reportable from electronic data sets                   X    
To prevent physician de-selection of patients, programs should use risk adjustment methods  X X             X      
To ensure fairness, performance data must be fully adjusted for sample size and case mix composition, including age/sex distribution, severity of illness, number of co-morbid conditions, patient compliance, and other features of the practice or patient population that may influence the results       X         X      
The responsibility for developing, maintaining, and revising measures must reside with the specialty organizations representing the providers in whose scope of practice the measure resides                        
Measures should be selected to ensure that all hospitals have an opportunity to participate and succeed                        
Measures should be uniform across all providers of imaging services and across payers                        
Measures used for P4P should meet higher standards than measures designed for other purposes       X                
Programs should reward accreditation or have an equivalent mechanism that rewards continuous attention to all clinical and support systems and processes X                      
                         
Data Collection, Reporting, Feedback                        
Data should be collected without undue burden on providers X X             X     X
IT tools should be used whenever possible for data acquisition                         
Programs must reimburse physicians for any administrative burden for collecting and reporting data                        
Allow physicians to review, comment on, and appeal results prior to payment or reporting                        
Programs should have a mix of financial and non-financial incentives (e.g., public reporting) X       X   X   X      
Physician performance data must remain confidential and not subject to discovery in legal proceedings                        
Public reporting/recognition is essential     X X X X       X    
Performance data feedback should provide comparisons to peers and benchmarks                        
Educational feedback should be provided to providers X     X                
Physicians must have timely access to the comparative performance database to which they have contributed data, including the ability to benchmark their data                        
Programs should favor the use of clinical data over claims-based data                        
Programs should use administrative data and data from medical records                        
Measures should be feasible to collect using administrative data           X            
Performance data should be audited X     X                
Programs should use an auditable data collection method tested for reliability and accuracy       X                
Metric assessments and payments should be made as frequently as possible to better align rewards with performance X               X      
Hospital bonuses should be calculated every 6 months based on activity in the previous 6 months         X              
Data reporting must not violate patient privacy                        
P4P assessments should be done with sample sizes (denominators) large enough to produce statistically significant results                 X      
Incentives                        
Reimbursement must be aligned with the practice of high-quality, safe health care X X             X      
Incentives should be based on rewards, not penalties                 X      
Hospital rewards should be based on 50/50 sharing of savings from improvement         X              
Programs should reward providers based on improving care and exceeding benchmarks   X   X X       X X X  
A sliding scale of rewards should be established to allow for recognition of gradations in quality X                      
Programs must not reward physicians/hospitals based on rankings that compare them with other physicians/hospitals in the program       X                
Payments must exceed the total cost of implementation, including data collection and reporting costs                        
Incentives must be significant enough to drive desired behaviors and support CQI       X   X           X
Mechanisms must be established to allow performance awards for physician behaviors in hospital settings that produce cost savings                        
General Program Design                        
Funding for P4P initiatives should come from additional resources, not a redistribution of resources                        
Top performers should be eligible for market share through patient shift          X              
Programs should offer voluntary physician participation                        
Physicians and/or hospitals should be involved in the program design       X               X
Programs should encourage strong alignment between practitioner and provider goals  X                      
Providers must have the opportunity to understand the measures, analytical methodology, and use of data for public reporting before participating in a P4P program       X                
Most providers should be able to demonstrate improved performance   X             X      
When selecting areas of clinical focus/measures, programs should strongly consider consistency with national and regional efforts X               X X    
Programs should be consolidated across employers and health plans to make the bonuses meaningful and the program more manageable for physicians           X            
Programs should be designed to include practices of all sizes and levels of IT capabilities                        
Physician organizations rather than individual physicians should be the accountable entity in P4P programs                  X      
Initiatives need to be flexible enough to assess performance at both the individual and the group level                        
Accountability must occur at the individual physician level       X                
Payments should recognize systemic drivers of quality in units broader than individual provider organizations and practitioner groups X                      
The data or the program should be adjusted for patient non-compliance                 X      
Programs should incorporate periodic objective evaluations of impacts and make adjustments X     X                
As P4P methodologies develop, patient access to quality care should be facilitated and not impeded by reduced reimbursement                        
Programs should invest in sub-threshold performers who are committed to improvement X     X                

 

   
P4P Design Principles/Recommendations

 

 
HEALTH CARE ORGANIZATIONS   
   
PHYSICIAN GROUPS
 
 
 
 

       

Hospital Groups  Patient Groups 
  IHA   AAFP ACP Mass. Medical Society ACC  Fdn. MGMA AMGA American Society  ACR Surgical Specialty Orgs* AHA AAMC  

Comm Hospital Assoc.

National Patient Advocacy Foundation   
Leapfrog  Data Collection, Reporting, Feedback                            
Medicare Specific                            
P4P in Medicare should be implemented using a phased approach that varies by setting, amount of reward, and measures                            
Medicare should fund the program by setting aside a small share of payments in a budget-neutral approach                            
Congress should derive initial funding (3–5 years) largely from existing funds by creating provider-specific pools from a reduction in base Medicare funding for each class of providers                            
 A consolidated pool should be formed from which all providers are rewarded when measures that allow for shared accountability are developed                             
A Medicare P4P program must not be budget neutral or subject to artificial Medicare payment volume controls             X       X      
Medicare incentives should be financed with a new, dedicated stream of funding                            
Medicare should distribute all payments that are set aside to providers achieving quality criteria                            
Medicare should establish a process for continual evolution of measures                            
A Medicare P4P program should be phased in gradually starting with reporting on structural measures and moving to enhanced payment based on evidence-based clinical measures       X                    
Medicare should initially reward care that is of high clinical quality, patient centered, and efficient                            
Medicare should consider expanding the proportion of payment based on performance over time                            
Medicare should initially reward both providers who improve performance significantly and providers who achieve high performance                            
Medicare should offer incentives to providers for the submission of performance data, and these data should be publicly available in ways that are meaningful and understandable to consumers                            
The program should be designed such that virtually all Medicare providers submit performance measures for public reporting and participate in P4P as soon as possible                            
CMS should design the program to include components that promote, recognize, and reward care coordination across providers                            
CMS should implement a monitoring and evaluation system for the program                            
A Medicare P4P program must be pilot tested across settings and specialties and phased in over an appropriate period                      X      
Incentives should eventually apply to all Medicare providers, including FFS and Medicare Advantage                            
Metrics                            
Programs should utilize accepted, evidence-based measures X   X X X X X   X X X      
Measures should be pilot tested, validated, and vetted through a process that includes public comment and phased-in                             
The measurement set should include measures of clinical quality, patient experience, and infrastructure                            
Measures need to be prioritized to address areas that are important to patients (such as those that prevent deaths, complications, and discomfort), as well as those that improve satisfaction, outcomes, and experience with care                            
Incentives should be based on existing measures and should emphasize clinical effectiveness                            
Measures adopted should be developed by nationally recognized measurement organizations and recommended by consensus-building organizations X                   X      
Metrics should be high volume, high gravity, and strongly evidence based; have a gap between current and ideal practice and good prospects for quality improvement; and have measurement reliability, validity, and feasibility                            
Program designers should include a sufficient number of metrics across a spectrum of health promotion activities to provide a balanced view of performance                            
The development, validation, selection, and refinement of measures should be a transparent process that has broad consensus among stakeholders        X                    
The development and selection of metrics should include participation by the patient community as well as by physicians and other providers                            X
Distinct standards should be developed to evaluate performance relative to the most-vulnerable patients: frail elderly and patients with chronic, debilitating, or life-threatening illness                           X
Process measures, such as those used by the HQA, should be used                            
Process or intermediate outcome measures are preferred unless robust, well-accepted methods of risk adjustment can be applied to outcome measures                 X          
The focus should be on structure and process measures until evidence-based outcome measures are developed                   X        
Structure, process, and outcome measures should be utilized       X   X   X            
Outcome measures are the highest priority because of their central importance to patients                            
Outcome measures must be subject to the best available risk adjustment for patient demographics, severity of illness, and co-morbidities X         X       X        
Metrics should be selected from the following domains: patient centeredness, effectiveness, safety, and efficiency                       X    
Metrics should include efficiency measures           X                
Efficiency measures should only be used when both the cost and the quality of a particular treatment are considered       X                    
When measuring quality, focus on misuse and overuse as well as underuse           X                
Provide positive provider incentives for adoption and utilization of IT X   X   X X X X     X     X
Programs implemented by either the public or the private sector involving HIT should incentivize only those applications and systems that are standards based to enable interoperability and connectivity, and should address the transmission of data to the point of care                            
Programs should move from an individual disease management approach to cross-cutting measures                            
Metrics should be stable over time X     X                    
Metrics should be kept current to reflect changes in clinical practice                 X   X      
Each measure should remain in the set for at least three years, but should be evaluated annually to adjust weighting and specifications as necessary                            
Local measures should closely follow national metrics as long as they are reportable from electronic data sets                            
To prevent physician de-selection of patients, programs should use risk adjustment methods  X   X X   X X       X      
To ensure fairness, performance data must be fully adjusted for sample size and case mix composition, including age/sex distribution, severity of illness, number of co-morbid conditions, patient compliance, and other features of the practice or patient population that may influence the results X   X X     X       X      
The responsibility for developing, maintaining, and revising measures must reside with the specialty organizations representing the providers in whose scope of practice the measure resides                 X X        
Measures should be selected to ensure that all hospitals have an opportunity to participate and succeed                            
Measures should be uniform across all providers of imaging services and across payers                   X        
Measures used for P4P should meet higher standards than measures designed for other purposes                            
Programs should reward accreditation or have an equivalent mechanism that rewards continuous attention to all clinical and support systems and processes                            
Data should be collected without undue burden on providers X   X X         X X   X   X
IT tools should be used whenever possible for data acquisition        X                    
Programs must reimburse physicians for any administrative burden for collecting and reporting data X   X       X       X      
Allow physicians to review, comment on, and appeal results prior to payment or reporting X     X X   X       X      
Programs should have a mix of financial and non-financial incentives (e.g., public reporting)               X            
Physician performance data must remain confidential and not subject to discovery in legal proceedings                     X      
Public reporting/recognition is essential                           X
Performance data feedback should provide comparisons to peers and benchmarks     X                      
Educational feedback should be provided to providers X     X                    
Physicians must have timely access to the comparative performance database to which they have contributed data, including the ability to benchmark their data                 X          
Programs should favor the use of clinical data over claims-based data           X                
Programs should use administrative data and data from medical records X                          
Measures should be feasible to collect using administrative data                            
Performance data should be audited     X     X         X      
Programs should use an auditable data collection method that is tested for reliability and accuracy                            
Metric assessments and payments should be made as frequently as possible to better align rewards with performance     X                      
Hospital bonuses should be calculated every 6 months based on activity in the previous 6 months.                            
Data reporting must not violate patient privacy X     X                    
P4P assessments should be done with sample sizes (denominators) large enough to produce statistically significant results X   X X                    
Incentives                            
Align reimbursement with the practice of high quality, safe health care X   X X   X X   X   X     X
Incentives should be based on rewards, not penalties X   X X   X         X X   X
Hospital rewards should be based on a 50/50 sharing of savings from improvement                            
Programs should reward providers based on improving care and exceeding benchmarks X   X X       X     X      
A sliding scale of rewards should be established to allow for recognition of gradations in quality                            
Programs must not reward physicians/hospitals based on rankings that compare them with other physicians/hospitals in the program X                     X    
Payments must exceed the total cost of implementation, including data collection and reporting costs                 X          
Incentives must be significant enough to drive desired behaviors and support continuous quality improvement       X X       X          
Mechanisms must be established to allow performance awards for physician behaviors in hospital settings that produce cost savings                     X      
General Program Design                            
Funding for P4P initiatives should come from additional resources, not a redistribution of resources         X                  
Top performers should be eligible for market share through patient shift                             
Programs should offer voluntary physician participation X   X       X       X      
Physicians and/or hospitals should be involved in the program design X   X X     X       X      
Programs should encourage strong alignment between practitioner and provider goals          X             X    
Providers must have the opportunity to understand the measures and analytical methodology and use of data for public reporting before participating in a P4P program                 X          
Most providers should be able to demonstrate improved performance-focus on areas needing improvement X                          
When selecting areas of clinical focus/measures, programs should strongly consider consistency with national and regional efforts                 X          
Programs should be consolidated across employers and health plans to make the bonuses meaningful and the program more manageable for physicians     X                      
Programs should be designed to include practices of all sizes and levels of IT capabilities X   X                      
Physician organizations rather than individual physicians should be the accountable entity in PFP programs  X         X                
Initiatives need to be flexible enough to assess performance at both the individual and the group level                             
Accountability must occur at the individual physician level                            
Payments should recognize systemic drivers of quality in units broader than individual provider organizations and practitioner groups                            
Programs should be designed to acknowledge the united approach (team approaches, integration of services, continuity of care) X         X   X X          
Fair and accurate models for attributing care when multiple physicians treat the same patient must be implemented                            
The results of P4P programs should not be used against physicians in health plan credentialing, licensure, or certification X   X X                    
The data or the program should be adjusted for patient non-compliance X   X X                    
Programs should incorporate periodic objective evaluations of impacts and make adjustments       X X X                
As P4P methodologies develop, patient access to quality care should be facilitated and not impeded by reduced reimbursement                           X
Programs should invest in sub-threshold performers who are committed to improvement                            

NQF Conference

*American Academy of Ophthalmology, American Academy of Otolaryngology, American Association of Neurological Surgeons, American Association of Orthopedic Surgeons, American College of Surgeons, American Society of Cataract and Refractive Surgery, American Society of Plastic Surgeons, American Urological Association, Congress of Neurological Surgeons, Society for Vascular Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Gynecologic Oncologists, Society of Surgical Oncology, and The Society of Thoracic Surgeons.

Table B.2. Summary of P4P Design Principles and Recommendations

Principles and Recommendations
Number of Orgs Supporting(n=26)
Metrics for P4P Programs:
 
 
                        • Evidence based  19
                        • Risk adjust to mitigate impact of patient non-compliance, avoid                           physician de-selection of patients, and ensure fairness 11
                        • Comprehensive in scope 5
                        • The development, validation, and selection of measures should                            include all  stakeholders  5
                        • Recommended by consensus-building organizations 4
                        • Keep current to reflect changes in clinical practice  4
                        • Focus on clinical areas needing improvement 4
                        • Stable over time 3
                        • Focus on misuse and overuse as well as underuse 2
                        • Developed, maintained, and revised by specialty organizations 2
                        • Include the patient community in the selection process 2
                        • Should meet higher standards than metrics used for other purposes 2
                        • Select such that all hospitals may participate 1
                        • Evaluate performance relative to the most-vulnerable patients (frail                          elderly and patients with chronic, debilitating, or life-threatening illness) 1
                        • Move from an individual disease management approach to                            cross- cutting measures 1
                        • Reward accreditation or similar process  
Process measures:                         • Should be included in P4P programs 1
Outcome measures                         • Risk adjust  8
                        • Should be included in P4P programs  
                        • Are not sufficiently developed  
                        • Give the highest priority  11
Structural measures                         2
                        • Should be included in P4P programs 1
                        • Should include HIT adoption and utilization measures  
                        • Should require HIT systems to be standards based and provide data                         at the point of care 15
    Efficiency measures                       
                        • Should be included in P4P programs 15
                        • Use only when both the cost and the quality of a treatment are                           considered 2
Patient experience measures                          
                        • Should be included in P4P programs 5
Data Collection, Reporting, Feedback:    
                        • Avoid undue burden on providers 12
                        • Include public reporting  8
                        • Allow providers to review, comment on, and appeal results prior to payment or reporting 6
                        • Audit performance data   
                        • Sample sizes must be large enough to produce statistically significant results 5
                        • Assess performance and make payments as frequently as possible to align rewards and performance 4
                        • Data reporting must not violate patient privacy  
                        • Give providers feedback with benchmarking data 3
                        • Favor the use of clinical data over administrative data  
                        • Use both clinical data and administrative data 3
                        • Choose measures that are feasible to collect using administrative data 2
                        • Performance data must remain confidential and not subject to                           discovery in legal proceedings 1
Incentives:    
                        • Reward high-quality, safe health care 13
                        • Base rewards on improving care and exceeding benchmarks 12
                        • Base incentives on rewards, not penalties 9
                        • Provide incentives significant enough to drive desired behaviors and support improvement 7
                        • Payment must exceed the cost of implementation (collecting and                            reporting data)  
                        • Do not base incentives on provider ranking 5
                        • Establish gain-sharing mechanisms   
                        • Base hospital rewards on a 50/50 shared savings with payers 4
                        • Top performers should be eligible for increased market share through patient shift (steering/tiering) 1
                        • Establish a sliding scale of rewards to recognize gradations in quality 1
General Program Design:    
                        • Providers should be involved in the program design 7
                        • Acknowledge team approaches, integration of services, care                           coordination 6
                        • Consider consistency with national and regional efforts 5
                        • Incorporate periodic evaluation of impacts and make adjustments 5
                        • Encourage strong alignment of physicians and hospitals 4
                        • Programs should be voluntary 2
                        • Give providers an opportunity to understand the measures,                           methodology, and reporting requirements before they participate in                            P4P 2
                        • Invest in sub-threshold performers who are committed to improvement  
                        • Funding should come from additional resources, not a redistribution of resources 2
                        • Include providers of all sizes and levels of IT capabilities  2
                        • Consolidate programs across employers and health plans  
                        • Design to mitigate the impact of patient non-compliance 2
                        • Patient access should not be impeded by reduced reimbursement  
                        • Implement fair and accurate attribution rules for providers 2
Medicare-Specific Recommendations:                         • Program should not be budget neutral 2
                        • Program should be budget neutral 2
                        • Use a phased approach 1
                        • Reward care that is of high clinical quality, patient centered, and                            efficient 1
                        • Reward improvement and high performance 1
                        • Require public reporting 1
                        • Reward care coordination 1
                        • Include a monitoring and evaluation system 1
                        • Provide incentives for FFS and Medicare Advantage providers 1
                        • Establish a process for continual evolution of measures 1
                        • Distribute all funds that are set aside to providers achieving quality                            criteria 1
                        • Consider expanding the proportion of payment based on                            performance over time  
                        • Pilot test across settings 1

 

Measure
Organizations Collecting/Utilizing Measures
  Joint Commission CMS1 HQA2 CMS-RHQDAPU3 Premier4
SCIP5
STS6 ACC7 ACE8 GWTG9 IHI10 Leapfrog11 NSQIP12 AHRQ13 CDC14 NQF En-dorsed IOM Domain
AMI:                                  
Aspirin at Arrival X X X X X       X   X         X Effective
Aspirin at Discharge X X X X X       X   X         X Effective
ACEI or ARB for LVSD X X X X X       X X X         X Effective
Smoking Cessation Advice/Counseling X X X X X       X X X         X Effective
Beta Blocker at Discharge X X X X X       X X           X Effective
Beta Blocker at Arrival X X X X X       X   X         X Effective
Mean Time to Thrombolysis/Fibrinolysis                                 Effectiv
Thrombolytic/Fibrinolytic Received Within 30 Minutes of Arrival X X X X X       X             X Effective
Mean Time to PC                                 Effectiv
PCI Within 120 Minutes of X X X X X       X             X Effective
Smoking Cessation Advice X X X X X       X X           X Effective, Patient Ctrd.
Beta Blocker at Discharge                   X             Effective
Inpatient Mortality                           X     Safe
30-Day Mortality (Medicare Patients)                                 Saf
30-Day All-Cause Risk Standardized Readmission                                  Effectiv
Pneumonia:                                  
Oxygenation Assessment X X X X X                     X Effective
Pneumoccocal Vaccination X X X X X                     X Effective
Blood Cultures Within 24 Hours Prior to or After Arrival—ICU Patients                                 Effectiv
Blood Culture Before First Antibiotic Received X X X X X                     X Effective
Smoking Cessation Advice X X X X X                     X Effective, Patient Ctrd.
Antibiotic Timing (Median) X                               Effective
Initial Antibiotic Received Within 8 Hours of Arrival                                 Effectiv
Initial Antibiotic Received Within 4 Hours of Arrival X X X X X                     X Effective
Initial Antibiotic Selection for CAP in Immunocompetent Patient                                 Effectiv
Initial Antibiotic Selection for CAP in Immunocompetent—ICU Patient                                 Effectiv
Initial Antibiotic Selection for CAP in Immunocompetent—Non-ICU Patient                                  Effectiv
Influenza Vaccination X X X X X                     X Effective
Inpatient Mortality                           X   X Effective
30-Day Pneumonia Mortality   X X                      

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