Outcomes/Effectiveness Research

Organizational culture distinguishes top-performing hospitals in patient outcomes from heart attack

Hospitals with the lowest mortality rates for patients with acute myocardial infarction (AMI) or heart attack don't differ much from hospitals with high mortality rates in their use of evidence-based protocols and processes. Organizational culture is what distinguishes the top-performing hospitals, according to a new study. The difference in risk-standardized mortality rates (RSMRs) between the highest- and lowest-performing hospitals in the study was approximately 33 percent (average of 13.3 vs. 19.4).

The researchers found that staff at the high-performing hospitals shared organizational values of providing exceptional, high-quality care. In these hospitals, senior management exhibited unwavering commitment to high-quality AMI care through providing adequate financial and nonfinancial resources, by using quality data in their strategic planning, and by fostering staff accountability for poor performance and recognition for high performance.

Low-performing hospitals were more likely to have the sporadic involvement of senior management and allocate insufficient resources to accomplish quality goals. High-performing hospitals were more likely to have physician-champions for quality AMI care, empower their nurses, and involve pharmacists in patient care. Low-performing hospitals typically were inconsistent in treating nurses as valued members of a team, and had narrowly defined roles for pharmacists. Finally, coordination among teams and units and innovative problem-solving by front-line staff were routine in the high-performing hospitals.

The researchers listed hospitals by their AMI 30-day RSMRs from the Centers for Medicare & Medicaid Services' Hospital Compare database for 2005 to 2006 and 2006 to 2007. Hospitals that were in either the top or bottom 5 percent for both time periods were selected. The researchers conducted site visits at 11 hospitals (7 high-performing and 4 low-performing), interviewing a total of 158 staff members (physicians, nurses, administrators, and other clinical staff) who were most involved in AMI care. The study was funded in part by the Agency for Healthcare Research and Quality (HS16929).

More details are in "What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study," by Leslie A. Curry, Ph.D., Erica Spatz, M.D., Emily Cherlin, Ph.D., M.S.W., Harlan M. Krumholz, M.D., S.M., Elizabeth H. Bradley, Ph.D., and others in the March 15, 2011, Annals of Internal Medicine 154(6), pp. 384-390.

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