*Purpose: A Systems Improvement Agreement (SIA) is a voluntary and binding legal agreement between CMS and a Medicare certified hospital designed to address Condition level deficiencies and preclude Medicare decertification. Although widely deployed as a remedy to poor performance in thoracic transplant programs starting in 2010, there is no detailed analysis of the impact and sustainability of oversight mandated on program design and personnel. Here I provide a retrospective narrative review of two pulmonary transplant programs engaged in an SIA and identify both the positive implications of a supportive review process and the unintended consequences of external peer review.

*Methods: I reviewed the impact of the SIA on four criteria: (1) was the expert peer review process sufficient, accurate, and effective in identifying the “root cause” of poor performance, (2) were the implemented policy and personnel changes “institutionalized” and sustainable, (3) what were the total costs of SIA mandated procedures and policies, and (4) is there evidence that SIA mandated policy changes directly impacted improved performance.

*Results: Direct costs of the SIA were 860K with indirect costs exceeding 1.2 million. The expert peer review failed – as did the program – to identify inaccuracies in O/E outcomes which could have precluded program non-compliance with CMS outcome metrics. Both institutions failed to achieve aspirational compliance with two of five mandates within the Systems Improvement Agreement (patient “cohorts” and organizational design of ICU care). Two years after completing the SIA there were no substantial changes in either program as measured by direct program costs, additional personnel, or administrative redesign. At two years post review, program processes were compliant with CMS expectations and clinical outcomes were above the national average. The programs differed significantly in their emphasis on clinical versus administrative redesign. The SIA is an effective mechanism for informing hospital administration as to the need for organizational change and is an effective means of improving compliance. However, while failures in compliance are a significant predictor of poor performance there is little data to support the corollary that compliance creates quality programs. Commitment to this approach continues to support administrative rather than public health models of health care redesign. There is confusion as to individual versus institutional accountability in systems reviews and programs will likely demonstrate clear divergence between legitimate institutional and physician goals. Given the absence of ongoing oversight there is no organizational impetus for change sustainability in the absence of institutional culture change.

*Conclusions: Retrospective review suggests the SIA had little direct impact on subsequent program improvement and patient outcome beyond providing an important administrative platform for culture change.

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