Published in the May 2011 issue of Today’s Hospitalist
WHEN IT COMES TO REDUCING AMI MORTALITY, which approach produces the best results: proven strategies like increasing the use of beta-blockers and decreasing door-to-balloon times, or fuzzier factors like the “culture” of a hospital?
Most researchers have put their money on the former, focusing on efforts like rapid response teams and medication reconciliation. But a study published in the March 15 Annals of Internal Medicine found that hospital culture may be just as important in reducing AMI mortality rates.
Researchers found that while protocols and processes are important to lowering mortality, the broader environment “support from senior management, for instance, and open communication “within the hospital also plays an important role. While the concept may be more touchy-feely, it turns out that organizational culture is a key to quality improvement.
Same strategies, different results
Researchers started by looking at a group of 11 hospitals with either very low or very high 30-day AMI mortality rates. To determine what was working (or not working) in the effort to lower AMI mortality, researchers conducted on-site, in-depth interviews at these hospitals, averaging 14 interviews at each facility.
The team found that the hospitals in both groups used many of the same strategies, from consistently giving patients beta-blockers to using rapid response teams. But while these tactics have been shown to reduce AMI mortality rates, the study also found that hospitals that had the lowest mortality seemed to get a boost from many other, more amorphous attributes.
When researchers dug a little deeper, they found differences that went beyond a hospital’s processes and protocols. Those differences included factors like a hospital’s organizational values and goals, the involvement of senior management in QI initiatives, staff presence and expertise in AMI care, communication and coordination among groups, and approaches to problem-solving.
Leslie A. Curry, PhD, lead author of the study and a research scientist at the Yale Global Health Leadership Institute, says that those factors aren’t necessarily more important than protocols like beta-blocker administration. But her research found that the right culture can help hospitals much more successfully implement the tools they’re using to reduce mortality.
“We found that the protocols and processes that hospitals were using didn’t necessarily differentiate between the high- and low-performing hospitals in this study,” Dr. Curry says. “There’s no single solution to reducing AMI mortality.”
The importance of collaboration
To understand how hospital culture can affect AMI mortality, Dr. Curry says, it’s helpful to hear what clinicians had to say. A nurse at one high-performing hospital, for example, explained that the staff at her facility was constantly “resetting the bar” on quality. “We don’t accept anything other than the very best,” she explained. At lower-performing hospitals, by comparison, researchers didn’t find that same zeal for excellence.
To illustrate how senior management’s commitment to high-quality care can affect mortality rates, consider the medical director at a high-performing hospital. He explained that when there’s a quality problem, his facility’s leadership isn’t afraid to address people who are standing in the way of progress. Staff at lower performing hospitals, by comparison, said that resources for quality improvement were spotty and data weren’t used effectively to guide decision-making.
And in the area of communication, researchers heard that the staff at top-performing hospitals focused on working as a team and sharing information regularly and freely. Low-performing hospitals, on the other hand, tended to have irregularly scheduled meetings, and staff tended to not view themselves as part of a bigger team. Dr. Curry says that the stories from top-performing hospitals that impressed her the most described environments that don’t blame individuals for adverse events, and instead view problems as a chance to learn. “You hear a lot about nonpunitive environments,” she explains, “but the stories we heard were really compelling. These hospitals were saying, ‘We are not going to sit down and blame, but we are really going to problem- solve.’ ”
Staff at top-performing hospitals also described collaborations between high-level individuals and frontline staff. “We heard stories of a chief medical officer looking to frontline staff like cath lab techs or pharmacists to propose creative solutions,” Dr. Curry says. “This kind of empowerment showed a respect for a diversity of opinions that was striking.”
What to change?
While the results of the study are interesting, they stop short of giving hospitals a prescription for change. How do hospitals go about improving their culture, for example, so they can wring more out of the processes and protocols they put in place?
Dr. Curry acknowledges that the study doesn’t provide a clear path for hospitals that want to improve. To address this concern, her research group is completing a national quantitative study of a representative sample of U.S. hospitals to identify exactly what behaviors can make or break efforts to improve AMI mortality rates. “We are hoping that we’ll be able to point to more specific things hospitals can do, so we can say, ‘This is a statistically significant predictor of top performance or better performance.’ ”
The next logical step, she adds, is for other researchers to examine how cultural factors affect quality improvement efforts in other clinical areas like pneumonia or heart failure.
Edward Doyle is Editor of Today’s Hospitalist.