March 15, 2011 -- When you're having a heart attack, it's usually too late to choose which hospital will save your life. But as it turns out, the team spirit of the hospital staff can have a profound effect on your well-being when it comes to heart-related emergencies.
"The truth is that there are large variations in outcomes, and the hospital where you receive your heart attack care has a profound impact on whether you live or die," said Dr. Ashish Jha, associate professor of health policy and management at Harvard School of Public Health.
In fact, death rates for heart attack patients greatly vary throughout the country's hospitals -- as much as twofold between the highest- and lowest-performing hospitals.
Now, new research out of Yale University offers fresh hints as to how a hospital's organizational structure and interpersonal relationships among its staff relate to your chances of surviving a hospitalization for a heart emergency.
Yale researchers previously conducted a study in 2009, published in Circulation, which found that patients' outcomes and survival rates are greatly dependent, at least in part, on the hospital that provides their care.
This time around, researchers wanted to conduct a qualitative study that would analyze the top- and bottom-rated hospitals through site visits and in-depth personal interviews. The 11 hospitals remained anonymous in the study results.
How Hospital Staff Relations Can Affect Your Life
In a one-year period, researchers visited 11 hospitals that ended up in either the top or bottom 5 percent of heart attack patient death rates. They also interviewed 158 staff members to determine factors associated with better heart attack care.
"We really wanted to look at how the staff interacts together, and how they work as a team," said Leslie Curry, lead author of the study and a research scientist at the Yale School of Public Health.
While all the hospitals involved in the study had general protocols and procedures to reduce death among patients with heart attacks, there were significant differences between the top and bottom, Curry said.
The highly rated hospitals shared organizational values and goals and a vision of excellence that filtered through the entire staff, researchers said. There was also expertise in heart attack care and better interpersonal communication between doctors and their teams.
Among the top performers, Curry said, the doctors tended to look to other team members for their strength and allowed them to rise to the challenge and be innovative. There was no blaming, which allowed people to feel safe to speak up, make mistakes and learn from them.
"The top performing hospitals really believed they would become the best and really pushed on that," Curry continued.
In contrast, researchers found that the staff among the lower performing hospitals was more constrained. Curry said there were several stories of a finger-pointing culture, where people were anxious about assigning responsibility.
Generally, the staff didn't feel encouraged to be creative or innovative, and there was a focus on individual, rather than team, performance. The low-rated hospitals also had a much higher turnover rate at the executive level, which researchers said made it more difficult to encourage passion and striving to do the best among the staff.
Empower Yourself: Searching for the Best in Heart Health
Dr. Anthony Shih, executive vice president for programs at the Commonwealth Fund, said consumers no longer have to rely on word-of-mouth or reputation to choose a doctor and hospital. There are now several sources of objective data, including the Medical Hospital Compare Site, for consumers.
The site documents hospital quality by measuring the adherence to recommended clinical care guidelines, mortality rates and patient experience.
"However, despite the availability of data, many patients do not have the ability to choose a hospital during an emergency, such as a heart attack," Shih said. "Therefore, it is important that we focus on improving performance for all hospitals, rather than on identifying the best and worst."
Since consumers cannot see an organizations' culture, the study underscores the importance of patients paying attention to the information to which they do have access.
"Hospitals' mortality rates are now public information, and consumers should begin to use that information in identifying good hospitals in their community," Jha said.
John Griffith, professor in the department of health management and policy at University of Michigan School of Public Health, also suggested looking up real data on patient outcomes and satisfaction found at Why Not the Best.
"The organization structure is essential," Griffith said. "Healthcare is a people business and a team business. The team's training, motivation, and attitudes are all affected by the organization, and they in turn affect patient results."
While previous studies have documented high performance hospitals' pursuit of basic organizational structure and continuous improvement of operation, Griffith said Curry's study is the first to show that weaker performers fail to implement these strategies.
"Incentives for improved performance must be enhanced," Griffith said. "Too many hospitals are allowed to continue with weak organizations and poor results when they could do much better."
What's a Hospital to Do?
Study authors recommend that all hospital staff, especially doctors and executives, pay attention to work relationships and be sure that all levels of staff feel empowered to be involved and have a voice. Be nimble, value diversity, don't blame, foster creativity and be on the cutting edge, researchers said.
"I think the main take-away here is that it's important to pay attention to the relational aspects of work," Curry said. "It was not just what the hospitals were doing but how they were doing it. This a gentle caution to be mindful not just of the gadgets, but of the environment where they're being used."
Dr. Harlan Krumholz, associate professor of medicine in the section of cardiology at Yale University School of Medicine and co-author of the study, said the study is an important key to unlocking the secrets of top performance in the care of patients with heart attacks.
"Outstanding performance seems to require an emphasis on how the care is provided -- not just what care is provided," he said.
"As we think about how to improve care for the population as a whole, it is important that we continue to try to understand the key drivers of performance improvement," Shih said. "Armed with this knowledge, along with the right incentives for the hospitals, we can spread these successful practices and strategies from the best performers to the worst performers to improve the public's health."