In 2010 the pulmonary transplant program at the University of Kentucky entered a Systems Improvement Agreement (SIA) with CMS as a consequence of poor performance (1 and 3 year patient survival). The university successfully completed the SIA in early 2013.

We have 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) total costs of SIA mandated procedures and policies, and (4) evidence that SIA mandated policy changes directly impacted improved performance.

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. The institution failed to achieve 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 are no substantial changes in program design as measured by direct program costs, additional personnel, or administrative redesign. Patient survival is compliant with CMS expectations and remains above the national average.

The SIA is an effective mechanism for informing hospital administration as to the need for organizational change. In the absence of ongoing oversight there is no organizational impetus for change sustainability. Our review suggests the SIA had little impact on subsequent program improvement and patient outcome.

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