March 14th, 2011

The Common Thread Among Top-Performing Hospitals

A qualitative study just published in the Annals of Internal Medicine outlines some important distinctions between hospitals that have the lowest AMI mortality rates in the U.S and those that have the highest. The key factor? A supportive organizational culture. Here, study investigator Leslie Curry, PhD, MPH walks us through what that means and how the findings can be used to improve practice.

Q: What are the key components of a supportive organizational culture? Can you give us some concrete examples?

The participants in our study described five key components of an organizational culture that supports high-quality AMI care: shared organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, effective communication and coordination among groups, and problem solving and learning.

We heard many concrete examples of these features in the top-performing hospitals. For example, staff reported the vigilant pursuit of ways to improve care, a laser focus on innovation and problem solving without blame, earnest mutual respect for the expertise of diverse team members, and deliberate and systematic attention to the full continuum of AMI care.

Q: What are good first steps for building such a culture? 

Building a supportive culture requires first understanding the current culture and the ways in which it is impeding high performance. Key elements in the process of changing an organization’s culture include developing a shared vision for the organization’s objectives, adjusting formal structures and processes to support the desired culture, and working through key opinion leaders to introduce new ways of thinking about and conducting the organization’s work.

Q: What can an individual clinician do differently tomorrow to help shift his or her hospital’s culture?

I asked a clinician on our research team, Erica Spatz, MD, MS, to offer her insight:

Informed and engaged clinicians are central to a culture of quality. At the bedside, clinicians can promote quality by supporting a team approach to patient care. Effective teams communicate openly and exchange ideas. Nurses feel comfortable calling physicians in the middle of the night with a question; cardiologists share newly acquired knowledge with their staff; and clinicians from all phases of AMI care, from EMS to the ED to the cath lab, work together.

Taking a step back from the bedside, clinicians need to be informed about hospital efforts to improve quality — and getting involved in those efforts is even better. A first step is to demand data on outcomes. Most clinicians lack feedback. There is nothing like seeing how you and your hospital are performing compared to a rival hospital down the street or compared to a nationally recognized hospital. These data can help drive clinician-led quality improvement efforts. The success of such efforts can be gauged by internal process measures. But having timely, ongoing access to hospital-level 30-day mortality data can tell you whether you are shifting the quality culture.

Q: Most of the prior work on improving AMI mortality rates has focused on specific interventions, like door-to-balloon time and β-blocker use. How should we balance resources for those types of initiatives versus this one? 

A core finding in the D2B and β-blocker studies is that success depends on the presence of an organizational structure and culture that supports the recommended strategies (in the case of D2B, for instance, single call, or in the case of beta blockers, standing orders), so actually our findings here are not inconsistent. We believe that organizational support and culture are fundamental and that investment in these areas will ultimately enhance success both in process measures and in outcomes, such as mortality rates.

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