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Original Research |

What Distinguishes Top-Performing Hospitals in Acute Myocardial Infarction Mortality Rates?: A Qualitative Study

Leslie A. Curry, PhD; Erica Spatz, MD; Emily Cherlin, PhD, MSW; Jennifer W. Thompson, MPP; David Berg, PhD; Henry H. Ting, MD, MBA; Carole Decker, RN, PhD; Harlan M. Krumholz, MD, SM; and Elizabeth H. Bradley, PhD
[+] Article, Author, and Disclosure Information

From Yale School of Public Health, Yale University School of Medicine, and Yale-New Haven Hospital, New Haven, Connecticut; Mayo Clinic, Rochester, Minnesota; and St. Luke's Hospital, Kansas City, Missouri.

Acknowledgment: The authors thank the members of the team who participated in the hospital site visits and data collection: Tashonna R. Webster, PhD, MPH, MS; Jersey Chen, MD; Kate Goodrich, MD, MHS; Robert L. McNamara MD, MHS; Jeptha P. Curtis, MD; Adam Landman, MD, MS, MIS; Katherine Hearn, RN, MPA; Sarah A. Roumanis, RN; Susannah Bernheim, MD, MHS; Chohreh Partovian, MD, PhD; and Marian Mocanu, MD.

Grant Support: By the Agency for Healthcare Research and Quality (R01-HS-016929), United Health Foundation, and the Commonwealth Fund (20090565).

Potential Conflicts of Interest: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M10-2280.

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Leslie A. Curry, PhD, 60 College Street, Box 208034, New Haven, CT 06520-8034; email, leslie.curry@yale.edu.

Current Author Addresses: Drs. Curry and Bradley: 60 College Street, Box 208034, New Haven, CT 06520-8034.

Drs. Spatz and Krumholz: 1 Church Street, Suite 200, New Haven, CT, 06510.

Dr. Cherlin: 2 Church Street South, Suite 409, New Haven, CT 06520.

Ms. Thompson: 47 College Street, Suite 104, New Haven, CT 06510.

Dr. Berg: 146 McKinley Avenue, New Haven, CT 06515.

Dr. Ting: 200 First Street Southwest, Rochester, MN, 55905.

Dr. Decker: 4401 Womall Road, HI-5, Kansas City, MO, 64111.

Author Contributions: Conception and design: L.A. Curry, H.M. Krumholz, E.H. Bradley.

Analysis and interpretation of the data: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.

Drafting of the article: L.A. Curry, E. Cherlin, E.H. Bradley.

Critical revision of the article for important intellectual content: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.

Final approval of the article: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.

Administrative, technical, or logistic support: E. Cherlin, J.W. Thompson, E. Spatz.

Collection and assembly of data: L.A. Curry, E. Spatz, E. Cherlin, J.W. Thompson, D. Berg, H.H. Ting, C. Decker, H.M. Krumholz, E.H. Bradley.

Ann Intern Med. 2011;154(6):384-390. doi:10.7326/0003-4819-154-6-201103150-00003
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Background: Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation.

Objective: To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.

Design: Qualitative study that used site visits and in-depth interviews.

Setting: Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics.

Participants: 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.

Measurements: Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method.

Results: 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, and problem solving and learning. 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.

Limitation: The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed.

Conclusion: 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.

Primary Funding Source: Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.





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Rx for Hospitals
Posted on March 5, 2012
Hugh, Mann, Physician
Eagle Rock, Mo 65641
Conflict of Interest: None Declared

The hospital is a battlefield in which doctors and nurses fight sickness. Doctors are officers, and nurses are enlisted. Doctors have authority, issue orders, enjoy comforts, and receive rewards; while nurses lack authority, take orders, do dirty work, and receive blame. This gross inequality is counterproductive, because it hurts nurses, creates internecine conflict, subverts the hospital's mission, and subjects patients to suboptimal healthcare. The Hippocratic Oath should include the doctor-nurse relationship.

Conflict of Interest:

None declared

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