Learning from the best

Leslie Curry, PhD, has seen the best and the worst of U.S. hospitals. In an effort to pinpoint the characteristics of top-performing hospitals, Dr. Curry and colleagues visited 11 that ranked in either the top 5% or the bottom 5% in acute myocardial infarction (AMI) mortality rates, according to the Centers for Medicare and Medicaid Services. They interviewed 158 staff members, including administrators, nurses and hospitalists, about their practices and procedures related to heart attack care.

The interviews revealed notable differences, but not in the protocols that are usually targeted by improvement programs (such as use of rapid response teams or guidelines or hospitalists). “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,” the researchers concluded in a paper in the March 15 Annals of Internal Medicine.

Leslie Curry, PhD
Leslie Curry, PhD.

ACP Hospitalist recently spoke with Dr. Curry, who is a research scientist and lecturer in public health at Yale University, about what these findings mean for future improvement campaigns, lower-performing hospitals, and individual hospitalists.

Q: How did the results compare to your expectations?

A: We did expect to see some protocols and practices, because there's a lot of effort focused on figuring out how to improve AMI care and evidence that these things are important. We heard a fair amount about protocols and practices [but] these didn't distinguish between the high and low performers.

What was kind of a surprise was the intensity and degree to which people talked about more relational aspects of work. One of the things that was striking to us was the deliberate attention toward collaboration across the hierarchies. I can remember talking to this interventional cardiologist at one of these exceptionally performing hospitals who said very matter-of-factly that they look to the cath lab techs for solutions. They are just incredibly respectful of diverse opinions and engagement of frontline staff.

Q: Given what you found, what can the low-performing hospitals do to improve their performance?

A: It is more than practices and protocols. It's these aspects of diverse teams and collaboration and non-punitive environments. Of course, these are things that are much harder for people to imagine implementing; however, we report in the paper some individual and group behaviors and we believe if they are adopted and sustained over time they can influence the organizational environment. We've just finished the second phase of the study, a survey of a nationally representative sample of U.S. hospitals. That paper will report out practices and protocols and aspects of the environment that are statistically significant in terms of predicting performance.

Q: Did finances affect a hospital's ability to be a high performer?

A: Evidence indicated financial resources are part of the picture, but this does not explain the whole story. We couldn't assess that with this study because of the methodology, but we did include high-performing hospitals in low SES [socioeconomic] settings and low-performing hospitals in high SES settings. It is important to note that a lot of what we heard about is not necessarily expensive. It wasn't the most advanced techniques or equipment or technology that differentiated the hospitals. We might be able to do some things that improve quality without adding a lot to cost.

Q: What about hospitalists? Did they play a role?

A: We were fortunate to have a hospitalist on the team because diversity of perspectives is important. [See sidebar.] And we did hear about hospitalists, although this was not an explicit focus of the study. But there were positive comments to the effect that it was easier to get loose ends tied up because the hospitals had hospitalists. In one low-performing hospital, there was an interview that talked about turbulence in the hospitalist group, created in part by physician turnover when the hospital wasn't able to bring in enough hospitalists or retain them for long enough periods of time. It is my own sense the role of hospitalists has potential to be important, in particular in communication and collaboration across groups.

Q: What else can be done to make the low-performing hospitals more like the high-performing ones? Can individual physicians make a difference?

A: The physicians in the high-performing hospitals just had this incredible focus on quality and really were very open—if they made a mistake, putting it forth as a learning opportunity rather than blaming; this real sense of camaraderie to the end goal, looking to other staff like nurses and pharmacists and hospitalists to learn from.

Certainly there's a role for hospital leadership and management, and there may be a role for financial resources, but we learned that it is also about individuals and how they treat each other, the smooth information flow among groups, the willingness to share information, the ability to look at adverse events as an opportunity to learn—valuing innovation and creativity and trial and error.

Q: Could the differences you pinpointed be uncovered by physicians during a job interview?

A: On a job interview, I would try to pay attention to the climate—what it feels like being there. Are there conversations happening in the hallways? When we did these site visits, we saw really interesting public displays of data and of performance metrics. There may be signals within an organization's environment that could give somebody a sense of whether or not it's a place that really embraces this kind of collaborative learning, coordination and communication.