Evidence-based protocols and processes—although important—may not be sufficient for achieving high hospital performance in care for patients with acute MI (AMI). Rather, clear values and goals to be the best play an important role, according to a qualitative study that appears in the March 15 issue of the Annals of Internal Medicine.
Mortality rates for patients with AMI vary substantially across hospitals, even when adjusted for patient severity; however, the study authors wrote that “little is known” about hospital factors that may influence this variation.
Leslie A. Curry, PhD, from Yale School of Public Health, Yale University School of Medicine in New haven, Conn., and colleagues assessed 11 U.S. hospitals that ranked in either the top or the bottom 5 percent in risk-standardized mortality rates for two recent years of data from the Centers for Medicare & Medicaid Services (CMS) (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. The CMS Hospital Compare website provided the information.
From December 2008 to December 2009, the researchers conducted “in-depth interviews” with 158 members of the various hospital staff who were most involved with AMI care, with an average of 14 interviews per hospital. Interviews were typically one hour in duration.
The investigators were seeking to identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.
They found that hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, as well as problem solving and learning.
While participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists and medication reconciliation), the researchers said these did not systematically differentiate high-performing from low-performing hospitals.
Yet, they noted that high-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital.
“The implication of our findings is that challenges for performance improvement in the broad outcome measure of RSMR [risk-standardized mortality rates] are complex and, in the absence of a supportive organizational culture, specific interventions may not be sufficient for achieving the highest performance in care for patients with AMI,” Curry and colleagues wrote. “Our findings differ from those of many previous studies, which identified specific determinants of high performance in other measures of AMI quality, such as beta-blocker use or door-to-balloon time.”
Based on the study process, the researchers provided three methods by which organizations might reduce risk for death within 30 days of admission for patients with AMI:
- Have clear values and goals to be the best, coupled with the strong engagement from staff members of diverse disciplines, senior management and staff, and focus attention and resources on the issue of quality of care.
- Strong communication and coordination among groups probably limit errors in transitions and enable a more reliable and safe environment at a hospital.
- Solve problems in a way that seeks and addresses root causes, a practice that was endemic in the top-performing hospitals, may ensure that difficulties in processes are addressed swiftly and routinely and reduce the risk inherent in the hospitalization and complex clinical care of patients with AMI.
The study was funded by the Agency for Healthcare Research and Quality, United Health Foundation and the Commonwealth Fund.