Functional alignment, not structural integration, of medical schools and teaching hospitals is associated with high performance in academic health centers.

BACKGROUND: Debates continue regarding optimal structures for governance and administration between medical schools and their teaching hospitals. METHODS: Structural integration (SI) for 85 academic health centers was characterized as high (single leader or fiduciary) or low (multiple leaders or fiduciaries). Functional alignment (FA) was estimated from questionnaire responses by teaching hospitals' chief executive officers, and an index was calculated quantifying organizational collaboration across several functional areas. SI and FA were examined for their association with global performance measures in teaching, research, clinical care, finance, and efficiency. RESULTS: AHCs with high SI had significantly higher FA, though overlap between high-SI and low-SI institutions was considerable. SI was not significantly associated with any performance measure. In contrast, FA was significantly associated with higher performance in teaching, research, and finance but not clinical care and efficiency. CONCLUSIONS: FA between medical schools and their primary teaching hospitals more strongly predicts academic health centers' performance than does SI. As demands for greater collaboration increase under health reform, emphasis should be placed on increasing FA rather than SI.

Harmful medication errors involving unfractionated and low-molecular-weight heparin in three patient safety reporting programs.

BACKGROUND: External reporting of medical errors a adverse events enables learning from the errors of others in the pursuit of systems-level improvements that can prevent future errors. It is logical to presume that medication errors involving the use of anticoagulants, among the most frequently cited product classes involved in harmful medication errors, would be captured in a variety of patient safety reporting programs. METHODS: Data on reported errors involving the anticoagulant heparin were reviewed, compared, and aggregated from the databases of three large patient safety reporting programs-MEDMARX, the Pennsylvania Patient Safety Authority's Patient Safety Reporting System, and the University Health System Consortium, together representing more than 1,000 reporting organizations for 2005 RESULTS: Approximately 300,000 medication errors and near misses were reported to the programs, and 10,359-a mean of 3.6% (range, 3.1%-5.5%)-involved heparin products. The proportion of heparin-related reports that involved patient harm ranged from 1.4% to 4.9%. The phase of the medication use process cited most frequently in harmful events was the administration phase (56% of errors leading to harm), followed by the prescribing phase (19% of errors leading to harm). DISCUSSION: This study represents the first attempt by these three large reporting systems to combine data on a single clinical process. The consistent patterns evident in the reports, such as the percentage of all medication errors that involved heparin, suggests that reporting programs, at least for common events such as medication errors, may reach a point of diminishing returns in which aggregating more reports of a certain type yields no additional insight once a large volume of similar events is captured and analyzed.

Is there a relationship between high-quality performance in major teaching hospitals and residents' knowledge of quality and patient safety?

PURPOSE: The relationship of the quality of teaching hospitals' clinical performance to resident education in quality and patient safety is unclear. The authors studied residents' knowledge of these areas in major teaching hospitals with higher- and lower-quality performance rankings. They assessed the presence of formal and informal quality curricula to determine whether programmatic differences exist. METHOD: The authors used qualitative research methodology with purposeful sampling. They gathered data from individual structured interviews with residents and key educational and quality leaders in six medical schools and teaching hospitals, which represented a range of quality performance rankings, geographic regions, and public or private status. RESULTS: No relationship emerged between a hospital's quality status, residents' curriculum, and the residents' understanding of quality. Residents' definitions of quality and safety and their knowledge of the practice-based learning and systems-based practice competencies were indistinguishable between hospitals. Residents in all programs had extensive patient safety knowledge acquired through an informal curriculum in the hospital setting. A formal curriculum existed in only two programs, both of them ambulatory settings. CONCLUSIONS: Residents' learning about quality and patient safety is extensive, largely through a positive informal curriculum in the teaching hospital and, less frequently, via a formal curriculum. No relationship was found between the quality performance of the teaching hospital and the residents' curriculum or understanding of quality or safety. Residents seem to learn through an informal curriculum provided by hospital initiatives and resources, and thus these data suggest the importance of major teaching hospitals in quality education.

Ambulatory quality improvement in academic medical centers: a changing landscape.

Efforts to improve the quality of ambulatory care have received tremendous attention as bold new initiatives aimed at influencing the environment of care through financial incentives, public transparency, and information technology rapidly spread. Academic medical centers, which represent a long tradition of excellence and innovation in medical care, might be expected to lead the charge in these new arenas, but motivation for change may be mitigated by the unique complexity and multiple goals of these institutions. A survey conducted in the fall of 2006 examined the early impact of these major new influences on faculty practice plans. Respondents reported that many institutions have begun to develop key components of a quality infrastructure, but much work remains before a robust model emerges at most sites. Some academic medical centers have also embraced pay-for-performance and public reporting efforts, but many are not equipped or eager to engage in these new initiatives.

Organizational factors associated with high performance in quality and safety in academic medical centers.

PURPOSE: Leaders of academic medical centers (AMCs) are challenged to ensure consistent high performance in quality and safety across all clinical services. The authors sought to identify organizational factors associated with AMCs that stood out from their peers in a composite scoring system for quality and safety derived from patient-level data. METHOD: A scoring method using measures of safety, mortality, clinical effectiveness, and equity of care was applied to discharge abstract data from 79 AMCs for 2003-2004. Six institutions (three top and three average performers) were selected for site visits; the performance status of the six institutions was withheld from the site visit team. Through interviews and document review, the team sought to identify factors that were associated with the performance status of the institution. RESULTS: The scoring system discriminated performance among the 79 AMCs in a clinically meaningful way. For example, the transition of a typical 500-bed hospital from average to top levels of performance could result in 150 fewer deaths per year. Abstraction of key findings from the interview notes revealed distinctive themes in the top versus average performers. Common qualities shared by top performers included a shared sense of purpose, a hands-on leadership style, accountability systems for quality and safety, a focus on results, and a culture of collaboration. CONCLUSIONS: Distinctive leadership behaviors and organizational practices are associated with measurable differences in patient-level measures of quality and safety.

The relationship between evidence-based practices and survival in patients requiring prolonged mechanical ventilation in academic medical centers.

Studies suggest variable adoption of evidence-based practice guidelines. The authors hypothesized that compliance with guidelines for patients requiring mechanical ventilation would vary among academic medical centers and that this variation might be associated with survival. A total of 1463 intensive care unit cases receiving continuous mechanical ventilation for >96 hours were reviewed. The variation in mortality based on compliance with 6 evidence-based practices was determined, and the effect of each intervention was estimated using a logistic regression model. Compliance varied widely across the participating centers. A strong association with survival was seen for 2 of the 6 practices: sedation management and glycemic control (odds ratios for death of 0.30 and 0.46, respectively, each P < .01). Spontaneous breathing trials, deep venous thrombosis prophylaxis, semi-recumbent positioning, and stress ulcer prophylaxis were not associated with survival in the model. More consistent adoption of these practices represents an opportunity for academic medical centers and was associated with enhanced survival.

Outpatient quality improvement in academic faculty practice plans: does it exist?

The purpose of this study was to (a) investigate the extent to which academic faculty practice plans (FPPs) are currently involved in ambulatory care quality improvement (QI), (b) describe the structure of QI initiatives at outpatient FPPs, and (c) delineate facilitators and barriers to development of FPP outpatient QI initiatives. Members of the Steering Committee of the Group Practice Council of the University HealthSystem Consortium (UHC), representing the leadership of 88 FPPs, were asked to respond to a 38-item Web-based questionnaire during February and March 2003. The survey elicited information on the organizational characteristics of FPPs, their current degree of engagement in outpatient QI activities, and factors driving interest and barriers impeding efforts to conduct outpatient QI initiatives. Descriptive statistics for all variables of interest were performed. Responses were received from 33 participants believed to represent at least 28 of the total 88 FPP members of the UHC. Nearly all respondents indicated that some types of outpatient QI initiatives were currently taking place in their FPP. However, only 12% of respondents met 4 or more of the 6 criteria deemed to be essential to having a robust outpatient QI program. Among key QI indicators, one third of respondents reported that their FPP had a separate and distinct outpatient quality committee, and some one fifth had a budget for outpatient QI or financial incentives for outpatient clinics to engage in QI (or both). The majority of respondents stated that at least some departments in their FPP were collecting quality data. Most respondents reported that patient safety and external demand for outpatient QI were the "more important" factors driving QI efforts, whereas lack of human resources and other resources were the "more significant" barriers hindering QI initiatives. The results of the study suggest that, although FPPs showed a strong interest in outpatient QI initiatives, FPPs' efforts are still in an infancy phase and lag far behind inpatient performance measurement activities. Without appropriate resources, it appears unlikely that FPPs will be able to move the agenda forward to develop a quality culture and robust program of self-assessment and improvement in the outpatient setting.