improvement (Pathway 2) provided by accountability/selection (Pathway 1). Motivation for process improvement may be influenced by good publicity, higher payments, or access to larger markets.

A number of Pathway 1 motivations relating to medication safety have already been implemented on a trial basis:

  • Public recognition. Since 1999, the Centers for Medicare and Medicaid Services (CMS) has produced comparative performance reports for Medicare providers. These reports are available online through the CMS website. In Hospital Compare (DHHS, 2005), many of the measures used are medication-related. For heart attack patients, for example, the measures include percent of patients given angiotensin-converting enzyme (ACE) inhibitors, percent given aspirin at arrival, percent given aspirin at discharge, percent given beta-blockers at arrival, percent given beta-blockers at discharge, and percent given thrombolytic medication.

  • Preferred provider status. The Leapfrog Group (Leapfrog, 2005) is a consortium of buyers of health care. Members have agreed to base their purchase of health care on principles that encourage quality improvement on the part of providers. The Leapfrog Group introduced three safety practices, one of which—the use of computerized provider order entry (CPOE)— directly relates to medication safety; the other two are evidence-based hospital referral and staffing of intensive care units with doctors who have specialized clinical care training. A fourth leap has also been added, consisting of the National Quality Forum’s (NQF) 30 safe practices (NQF, 2003), many of which are medication-related.

  • Rewarding investment in information technology. Bridges to Excellence is an employer-led group aimed at improving the quality of care by recognizing and rewarding health care providers for implementing high-quality care delivery processes (BTE, 2003). For instance, through the Physician Office Link (POL), Bridges to Excellence rewards practices (in specific geographic areas) according to the number of modules implemented from a schedule monitored by the National Committee for Quality Assurance (NCQA, 2004). These include (1) clinical information systems/ evidence-based medicine (electronic capabilities for prescriptions and texts, use of electronic systems for prescribing and checking for safety and efficiency, contents of patient information in electronic health records (EHRs), and use of EHRs for decision support), (2) patient education and support, and (3) care management.

  • Pay for performance. Good performance by hospitals participating in the first year of a joint Premier Inc.–CMS demonstration project (Premier, 2005b) has made hospitals eligible for increased payments of $8.85 million (Premier, 2005a). The initiative covers five conditions (acute myocardial infarction, coronary artery bypass graft, heart failure, community

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