The patient safety, mortality, and effectiveness domains were each weighted at 30% and equity was weighted at 10% in the creation of a composite score for each institution. The 79 AMCs were divided into five groups according to composite scores for quality and safety, with group one being the five highest-performing AMCs and group five being the 14 lowest-performing ones.
TABLE 1. Characteristics of AMCs That Perform Highly in Quality and Safety
- Leaders who are dissatisfied with the current state of quality and safety;
- Chairs who accept responsibility for quality and safety within their departments;
- Employees who value each other’s critical knowledge and whose relationships are characterized by collaboration;
- Accountability, innovation, and redundancy at the unit level;
- Focus on results, human behavior, and work redesign as the keys to improvement;
- Service excellence added to the focus on quality and safety;
- Shared sense of purpose among hospital leaders that patient care comes first; and
- Strong alliance between the executive leadership and the clinical department chairs of the institution.
In phase two of the study, the authors selected three institutions from the top five–performing AMCs and three comparison institutions from the middle of the distribution for site visits by an expert team who were blinded to the performance scores of the institutions. The site visit was preceded by a review of documentation related to the quality program, leadership, goal setting activities, and board reports. During the site visit, the authors conducted formal interviews not only with key leaders, but also with front-line employees such as members of the residency programs and nursing staff.
During the interviews, multiple areas of leadership and organization were explored including leadership engagement, strategic planning and goal setting, accountability for quality and safety goals, interdisciplinary professionalism, the use of information technology, internal and external communication between the leadership and employees about quality and safety, and patient centeredness. Through inductive and iterative analysis of the interviews and documents, several themes were identified that distinguished the top performers from the average performers. Interestingly, although the site visit team was blinded, there was quick consensus about the status of the institutions as either top or average performers in all six cases, indicating a level of clarity in distinguishing these two groups.
Characteristics of a Top-ranked AMC
The placement of patient care as first among the competing missions of patient care, research, and education in AMCs was clearly evident at the top performing institutions. These institutions were dissatisfied with the current state of quality, safety, and service and were focused on the journey between the current state and the future ideal state toward which they were striving. Leaders of the top institutions were engaged with and visible to the front-line staff. Senior leadership reinforced patient-centered care with a strong but subtle pressure to conform to the values of safety, quality, and service. Clinical chairs and service chiefs accepted accountability for quality, safety, and service on their units and were focused on results through the setting and dissemination of measurements at all levels of the institution. Innovation at the unit level was encouraged, celebrated, and often self-started and sustained. Finally, interdisciplinary collaboration and multidisciplinary teams were the rule rather than the exception.
TABLE 2. Strategies to Improve Patient Safety
- Create a vision of patient centered care delivery;
- Modify organizational culture through effective leadership;
- Develop catalytic middle managers;
- Create cultural rites that emphasize patient centeredness;
- Promote accountability at every level of the organization; and
- Provide a formal curriculum in patient safety for medical students and housestaff.
In contrast to visits at top-performing institutions, the site visits at the average-performing institutions uncovered palpable conflict among the missions of patient care, education, and research. The clinical department chairs demonstrated inconsistency in their interest in the patient care missions, and the hospital leaders were either unable or unwilling to address this issue. Leaders were less engaged at the grass-roots level, and chairs often opted out of quality and safety initiatives, with leaders tending only to work with the more cooperative or engaged departments or chairs. Board members were much less engaged, and quality initiatives were not widespread. A sense of satisfaction with the current state of quality and safety was a prevailing theme.
Keys to Success
The authors suggest that their new composite scoring system represents an improvement over currently available institutional ratings on quality and safety, which include the well-known US News and World Report rankings, Health Grades, and Hospital Compare, citing the wide variety of patient-level measures used in their scoring system as its unique strength.4-6 The authors also acknowledge the weaknesses of their scoring system, including the absence of measurements for access to care and ambulatory care quality and coordination. Recently, a framework for healthcare organizations to develop and validate their own safety measurements has been described.7 It is important to note that this study did not address the educational activities of the AMCs. Because residents are frequently at the “sharp end” of healthcare delivery in AMCs, their attitudes and skills will affect patient safety and quality to a large degree. This relationship between resident education and involvement in patient safety activities and hospital outcomes should be studied further.
