Yale School of Public Health, Yale University School of Medicine, Yale-New Haven Hospital, Connecticut, USA.
Ann Intern Med. 2011 Mar 15;154(6):384-90. doi: 10.7326/0003-4819-154-6-201103150-00003.
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.
To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates.
Qualitative study that used site visits and in-depth interviews.
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.
158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals.
Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method.
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.
The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed.
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.
Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.
即使对患者的严重程度进行了调整，不同医院之间急性心肌梗死（AMI）患者的死亡率也存在很大差异；但是，对于可能影响这种差异的医院因素知之甚少。
确定可能与 AMI 护理绩效相关的因素，其衡量标准为风险标准化死亡率。
使用现场访问和深入访谈的定性研究。
美国 11 家医院，这些医院在最近两年内（2005 年至 2006 年和 2006 年至 2007 年）的医疗保险和医疗补助服务中心（Centers for Medicare & Medicaid Services）风险标准化死亡率排名均在前 5%或后 5%，这些医院在关键特征上具有多样性。
11 家医院的 158 名医院工作人员，他们都参与了 AMI 的治疗。
2009 年在 11 家医院的医院工作人员进行现场访问和深入访谈。一个多学科团队使用恒定比较法进行分析。
在组织价值观和目标、高级管理层参与、广泛的员工存在和 AMI 护理专业知识、各团队之间的沟通和协调以及问题解决和学习等领域，绩效表现高和低的医院之间存在很大差异。参与者描述了 AMI 护理的各种方案或流程（例如快速反应团队、临床指南、使用医院医生和药物协调）；但是，这些方案并没有系统地区分绩效表现高和低的医院。
定性设计为提出假设提供了信息，并且无法评估统计关联。
绩效表现高的医院的特点是一种支持努力改善整个医院 AMI 护理的组织文化。尽管循证方案和流程很重要，但对于在 AMI 患者的护理中实现医院的高绩效而言，这些可能还不够。
美国卫生保健研究与质量局、联合健康基金会和英联邦基金会。
