A study by Yale University researchers concluded that hospital culture and organization of care, including factors like the values and goals of the organization, and senior management involvement, may explain the wide range in mortality rates among patients treated for heart attacks in US hospitals.

You can read about the findings, and how the researchers conducted their systematic qualitative review, based on site visits and 158 interviews with hospital staff involved in acute myocardial infarction (AMI) care at 11 hospitals throughout the US, in the March issue of the Annals of Internal Medicine.

The researchers noted that previous studies have found rates of death for patients with heart attack or acute myocardial infarction (AMI) vary substantially across hospitals in the US, even when patient severity is taken into account, and little is known about the hospital factors that might explain such variation.

Lead author Dr Leslie A. Curry, a research scientist at the Yale Global Health Leadership Institute, told the press that:

"Previous research looked at whether hospital characteristics like urban location, teaching status, geographical region, and socio-economic status of patients are related to acute myocardial infarction (AMI) mortality rates, but these factors don't explain much of the variation in mortality."

For their study, Curry and colleagues selected the US hospitals that were in the top and bottom 5% of AMI mortality rates for 2005-2006 and 2006-2007 as ranked by the federal agency that administers Medicare & Medicaid Services.

Using a qualitative systematic constant comparative method, a multidisciplinary team of researchers examined the information collected from site visits and in-depth interviews conducted with hospital staff in 2009.

The methods they used to examine the data is more suited to the analysis of qualitative information that comes from what people say freely in interviews in response to questions, or what researchers observe during visits.

With this kind of research, the concepts and hypotheses emerge from the data itself.

The method is different to a quantitative survey where all the questions and the types of answers permitted are worked out in advance so that responses can be analyzed statistically.

Curry said:

"We were particularly interested in the roles of social interactions and organizational culture, which are difficult to measure using common research approaches like surveys."

They found substantial differences between the hospitals with the lowest and highest mortality rates for AMI patients. These differences were in five areas: Organizational values and goals, Senior management involvement, Broad staff presence, and expertise in AMI care, Communication and coordination, and Problem solving. Surprisingly, they found that systems for AMI care made little difference, as they noted in their paper:

"Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals."

Hence they concluded that:

"High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI."

Senior author Dr Elizabeth Bradley, professor of public health and faculty director at the Yale Global Health Leadership Institute, said the key to safety and quality does not have to be expensive; it's not necessarily about having "new gadgets":

"If we could implement our findings in more hospitals, we could improve quality without adding to costs," said Bradley.

The staff in the hospitals with the lowest mortality rates among AMI patients said communication and coordination across disciplines and departments was strong, whereas in the hospitals with high mortality rates, senior managers were involved only sporadically, partly because of high turnover, and they did not encourage people to take responsibility for performance problems.

Curry said long-term investment and concerted efforts are often needed to create high performing organizations that encourage members to engage with and be concerned about quality, where communication and coordination among groups is strong, and where there is capacity for solving problems and learning across the organization.

Co-author Dr Harlan Krumholz, professor of medicine and cardiology at Yale School of Medicine, agreed, explaining that they found the best hospitals "were distinguished by a combination of factors that related to how they organized and managed the care and the performance of the teams".

Grants from the Agency for Healthcare Research and Quality, the Commonwealth Fund, and the United Fund helped pay for the research.

The authors acknowledged that the use qualitative methods meant it was not possible to do statistical analyses, and this could be viewed as a limitation of the study.

"What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study."
Leslie A. Curry, Erica Spatz, Emily Cherlin, Jennifer W. Thompson, David Berg, Henry H. Ting, Carole Decker, Harlan M. Krumholz, and Elizabeth H. Bradley.
Ann Intern Med 15 March 2011 154:384-390;

Additional source: Yale.

Written by: Catharine Paddock, PhD