In just one decade, the Institute of Medicine has changed the landscape of American healthcare with its consecutive reports To Err is Human: Building a Safer Healthcare System in 1999 and Crossing the Quality Chasm: A New Health System for the 21st Century in 2001.1,2 These reports presented a vision and agenda for how healthcare needs to be radically transformed in order to meet the six attributes of ideal care: safe, effective, timely, efficient, equitable, and patient centered. This vision is easy to agree on yet hard to implement, and hospitals across the nations continue to struggle to create an intelligently and effectively designed system in what was once a “systemless” array of professional autonomy, nonstandardized practice, and free enterprise.
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The leaders of academic medical centers (AMCs), with their competing missions of education and research, face additional challenges compared to their non-AMC colleagues, because such vast improvements in the safety and delivery of patient care cannot be achieved without prioritizing the safety and quality mission in parallel with the research and educational mission.
The Future of AMCs
Given the importance of these issues, a study published by Keroack and colleagues in Academic Medicine is notable for calling attention to the challenges AMCs face in the future.3 This study represents the first attempt to quantify, through a composite score of a wide variety of patient-level data, the quality and safety of care delivered in AMCs. In addition, the authors augmented their score by performing blinded site visits to validate their patient-level data with experiential observations and interviews. Such qualitative data allowed them to identify organizational themes that separate the high-performing from the low-performing medical centers. These data can help leaders in average-performing AMCs answer the important questions: “What are we doing wrong?” and “How can we move the big dots in the right direction?”
Keroak and colleagues collected measurements on four of the six attributes of quality health care: patient safety, mortality, clinical effectiveness, and healthcare equity. Because consensus around measurements for patient centeredness and outpatient care were not available at the time of the study, the authors did not include these measures in their analysis. Seventy-nine AMCs in the University HealthSystem Consortium (UHC), an organization of 97 university teaching hospitals across the United States, were included in the study.
Safety measures were determined by evaluating preventable complications known as patient safety indicators (PSIs) as determined by the Agency for Healthcare Research and Quality (AHRQ). Such measures are abstracted from hospital discharge information and include conditions such as nosocomial infections, falls, and wrong-site surgery. Mortality measures were determined by evaluating risk-adjusted mortality rates for selected inpatient diagnoses. For the area of clinical effectiveness, the authors used compliance with the Joint Commission (JC) Core Measures and 14-day surgical readmission rates for the same condition or surgical complication as their measure of quality. Finally, equity of care was evaluated by analyzing JC Core Measure diagnoses looking for disparities of care across gender, race, and socioeconomic status.
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.
A learning organization is defined as one that actively creates, captures, transfers, and mobilizes knowledge to allow adaptation to a changing environment.8,9 Thus, the key aspect of organizational learning is the interaction that takes place among individuals.10 A learning organization does not rely on passive processes in the hope that organizational learning will take place through serendipity or as a byproduct of normal work. Instead, it actively promotes, facilitates, and rewards collective learning.8-12 Successful companies have utilized techniques of organizational learning for years to maximize efficiency and productivity.
Recently, healthcare organizations have also identified organizational learning as a critical component of their success. This study begins to identify the characteristics that several top AMC performers have in the domains of quality and patient safety, and, as such, will be useful to academic medical centers as they continue in their quest for improvements in patient care.
All physicians need to increase their understanding of how system redesign and reducing waste and complexity can improve the care we deliver to our patients. Moving beyond simply understanding these changes, we need to be leaders in organizational change and exemplify the principles of accountability, transparency, and professionalism. For those of us in AMCs, we need to remind ourselves that the tripartite mission of research, education, and patient care has developed a fourth dimension—quality and safety—that we must not only practice, but teach. It’s about time.
Dr. Von Feldt is associate professor of medicine in the rheumatology division at the University of Pennsylvania School of Medicine in Philadelphia and a TR board member. Dr. Myers is assistant professor of clinical medicine in the division of general internal medicine and the patient safety officer at the Hospital of the University of Pennsylvania.
- Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C.: National Academy Press; 2001.
- Corrigan J, Kohn L, Donaldson M, Eds. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press; 1999.
- Keroack MA, Youngberg BJ, Cerese JL, Krsek C, Prellwitz LW, Trevelyan EW. Organizational factors associated with high performance in quality and safety in academic medical centers. Acad Med. 2007;82(12):1178-1186.
- McFarlane D, Murphy J, Olmsted M, Drozd E, Hill C. America’s best hospitals 2007 methodology. Available online at www.usnews.com/usnews/health/best-hospitals/methodology_report.pdf. Last accessed May 12, 2008.
- Health Grades I. Hospital report card mortality and complication based outcomes 2007 methodology white paper. Available online at www.healthgrades.com/media/DMS/pdf/HospitalReportCardsMortalityComplications2008.pdf. Last accessed May 12, 2008.
- Department of Health and Human Services. Hospital compare: A quality tool for adults, including people with Medicare. www.hospitalcompare.hhs.gov/hospital. Last accessed May 12, 2008.
- Pronovost PJ, Berenholtz SM, Needham DM. A framework for healthcare organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.
- Argyris C, Schon D. Organizational Learning: A theory of action perspective (Series on Organization Development). Addison-Wesley, New Jersey; 1978.
- Nonaka I. A dynamic theory of organizational knowledge creation. Organ Sci. 1994;5(1):14-37.
- Schein E. Organizational Culture and Leadership. San Francisco: Jossey-Bass Wiley, 1992:3-27.
- Gilmore T, Shea G. Organizational learning and the leadership skill of time travel. J Management Development. 1997;16:302-311.
- Druckman D, Singer J, Van Cott H, Eds. Organizational culture. In Enhancing Organizational Performance. Committee on Techniques for the Enhancement of Human Performance, Commission on Behavioral and Social Sciences and Education, National Research Council, National Academy Press, Washington, D.C. 1997:65-96.