Defense Date


Document Type


Degree Name

Doctor of Philosophy



First Advisor

Marianne Baernholdt


Objective: The primary objective of this study was to examine the relationship between hospital structural characteristics and penalization status (penalized or not penalized) in any given hospital acquired condition (HAC) Reduction Program year, FY 2015 through 2018. Structural characteristics included hospital type, case mix index, average daily census, bed size, ownership, disproportionate share percentage, location, and American Nurses Credentialing Center Magnet status. The secondary objective of the study was to determine whether a hospital's penalization status across one or more HAC Reduction Program years is related to quality performance (Total HAC Score) in subsequent years. These objectives were achieved through retrospective, longitudinal, multivariate regression analysis using 4 publicly available data sources. Background: The intention of pay-for-performance programs, including the Centers for Medicare and Medicaid HAC Reduction Program, is to improve the quality of care delivered; however, the theoretical and conceptual basis of pay-for-performance programs and their efficacy in improving care are widely debated. This study was designed to address the gap in knowledge related to the efficacy of value-based reimbursement as a means of motivating providers and organizations to improve healthcare quality. Results: Higher average daily census, disproportionate share percentage, and case mix index were associated with increased likelihood of receiving a penalty in the HAC Reduction Program. Approximately half (49%) of who did not experience a penalty at all improved their Total HAC Score. 51% of hospitals with 1 year of penalty improved their Total HAC Score; 54% of hospitals with 2 years of penalty improved their Total HAC Score; 73% of hospitals with 3 years of penalty improved their Total HAC Score. Conclusions: Despite the inability of some hospitals to meet the benchmark to avoid penalty, the vast majority of hospitals improved their performance over time. This finding holds promise for value-based reimbursement as a means for improving HAC incidence.


© Emily Cochran

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