The use of evidence-based protocols and processes didn't vary widely between hospitals that ranked in the top 5% and bottom 5% for 30-day mortality rates for heart-attack patients, according to a study in the Annals of Internal Medicine—leading researchers to posit that organizational structure that supports long-term investment in concerted quality-improvement efforts is a key factor in high performance.
Culture of quality may boost outcomes: study
Such a structure features "physician champions" of quality-improvement efforts for treating heart attacks, empowered nursing staff and pharmacist involvement in patient care. Other factors included the open and consistent use of quality data, and using adverse events as opportunities for non-punitive learning.
"No single practice or set of practices emerged as key to reducing (heart-attack) mortality," wrote the researchers, who from December 2008 to December 2009 interviewed 158 hospital staff members from seven hospitals ranked in the top 5% for AMI 30-day mortality rates by the CMS Hospital Compare website and four hospitals in the bottom 5%. They interviewed on average of 14 people at each hospital and examined work processes, social interaction and organizational culture—items that they said "are difficult to measure quantitatively."
The researchers noted that hospitals were not blinded as to why they were selected, so there may have been a more-negative bias to the responses from staff at low-performing hospitals. Still, common characteristics could be found in the low-performing hospitals, including high turnover of senior management, a lack of physician presence in quality-improvement efforts, limited roles for nurses and pharmacists and a tendency to engage in finger-pointing rather than constructive problem-solving.
The report was written by researchers from the Yale School of Public Health, Yale University School of Medicine and 906-bed Yale-New Haven (Conn.) Hospital; as well as researchers from the Mayo Clinic in Rochester, Minn., and 391-bed St. Luke's Hospital, Kansas City, Mo. It was funded by the U.S. Agency for Healthcare Research and Quality, the United Health Foundation and the Commonwealth Fund. The report noted that these funding sources had no role in the study.
While cautioning that "this qualitative study generates hypotheses but could not test them," the authors concluded, "Studies that focus on guidelines, hospitalists, rapid response teams, and other clinically oriented advances should consider the importance of the additional characteristics of top-performing hospitals identified in this study."
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