A new Yale University study looks at why there is such a big difference in the mortality rates among patients treated for heart attacks in hospitals across the country. The study appears in the March issue of the Annals of Internal Medicine.

Until now, little has been known about the factors that may influence this variation in death rates. The Yale team reviewed 11 hospitals through interviews and site visits. Those selected were among the best and worst performers, as rated by the federal agency that administers Medicare and Medicaid.

"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," said Leslie A. Curry, Ph.D., research scientist at the Yale Global Health Leadership Institute (http://www.yale.edu/ghli) and lead author on the paper. "We were particularly interested in the roles of social interactions and organizational culture, which are difficult to measure using common research approaches like surveys."

Hospitals in the high- and low-performing groups differed substantially in five ways: organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination, and problem solving.
"Our research shows that the key facets to safety and quality in hospitals may not be new gadgets," says Elizabeth Bradley, Ph.D., faculty director at the Yale Global Health Leadership Institute, professor of public health and senior author on the paper. "The essential ingredients are not expensive. If we could implement our findings in more hospitals, we could improve quality without adding to costs."

Staff in the best hospitals reported strong communication and coordination across disciplines and departments. In low-performing hospitals, sporadic involvement of senior management was common, in part due to frequent turnover, and management did not create an environment that encouraged taking responsibility for performance problems. Curry says that achieving high performance may require long-term investment and concerted efforts to create an organizational culture that supports full engagement in quality, strong communication and coordination among groups, and capacity for problem solving and learning across the organization.

"What we found was that 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," says Harlan Krumholz, M.D., professor of medicine and cardiology at Yale School of Medicine. "This study begins to address our need to know what it takes to be an outstanding performer."

The study was funded by the Agency for Healthcare Research and Quality, the Commonwealth Fund, and the United Fund.