The roles of senior management in quality improvement efforts: what are the key components?
Subject: Quality control (Methods)
Management (Methods)
Medical errors (Prevention)
Health care industry (Management)
Hospitals (Research)
Authors: Bradley, Elizabeth H.
Holmboe, Eric S.
Mattera, Jennifer A.
Roumanis, Sarah A.
Radford, Martha J.
Krumholz, Harlan M.
Pub Date: 01/01/2003
Publication: Name: Journal of Healthcare Management Publisher: American College of Healthcare Executives Audience: Trade Format: Magazine/Journal Subject: Business; Health care industry Copyright: COPYRIGHT 2003 American College of Healthcare Executives ISSN: 1096-9012
Issue: Date: Jan-Feb, 2003 Source Volume: 48 Source Issue: 1
Topic: Event Code: 200 Management dynamics; 310 Science & research Computer Subject: Quality control; Health care industry; Company business management
Product: Product Code: 9913300 Quality Control Management; 9911400 Management Development; 8060000 Hospitals NAICS Code: 622 Hospitals SIC Code: 8060 Hospitals
Accession Number: 97873510
Full Text: EXECUTIVE SUMMARY

With increasing attention directed at quality problems and medical errors in healthcare organizations, the ability of senior management to promote and sustain effective quality improvement efforts is paramount to their organizational success. We sought to define key roles and activities that comprise senior managers' involvement in improvement efforts directed at physicians' prescription of beta-blockers after acute myocardial infarction (AMI). We also developed a taxonomy to organize the diverse roles and activities of managers in quality improvement efforts and proposed key elements that might be most central to successful improvement efforts.

Results are based on a qualitative study of 8 hospitals across the country and included in-depth interviews with 45 clinical and administrative staff from these hospitals. The findings help identify a checklist that senior managers may use to assess their own and others' participation in quality improvement efforts in their institutions. By reinforcing their current involvement or by identifying potential gaps in their involvement in quality improvement efforts, practitioners may enhance their effectiveness in promoting and sustaining quality in clinical care.

**********

The role of senior management in promoting and sustaining quality improvement efforts has been recognized since the earliest efforts to embed continuous quality improvement in healthcare. Berwick and colleagues (1990) have identified the support of management as one of the ten principles underlying successful quality improvement efforts. Experts on more recent innovations to enhance quality in healthcare (Arntdt and Bigelow 1998, Chassin 1998) also highlight the importance of administrative support in driving successful efforts.

Similarly, industrial experts in quality (Deming 1982, 1986; Juran 1986, 1989; Crosby 1992) have highlighted the critical role of management in effecting an organizational shift from quality control to quality improvement. The literature, both in general industry and healthcare, suggests that the role of senior management is paramount to successful quality improvement efforts (Arndt and Bigelow 1998; Chassin 1998; Deming 1982, 1986; Juran 1986, 1989; Crosby 1992; Feigenbaum 1991; Ishikawa 1985; Berwick 1996; Bigelow and Arndt 1995; Carman et al. 1996; Weiner, Shortell, and Alexander 1997). Consistent with this premise, several studies have reported "inadequate leadership" (Hughes 1992; Sullivan and Frentzel 1992) or "unclear vision" (Ancona 1990; Gann and Restucci 1994) as primary reasons for failed quality improvement team efforts.

The explicit objectives of this analysis were to (1) define the key roles and activities that comprise senior management's involvement in quality improvement efforts, (2) develop a taxonomy to classify such roles and activities, and (3) propose key elements of management involvement that might be most central to successful quality improvement efforts. We chose to examine a clinical process--the use of beta-blockers after AMI--because of the widely recognized challenges of applying quality improvement to clinical, rather than administrative, processes (Berwick, Godfrey, and Roessner 1990; McLaughlin and Kaluzny 1999; Longest, Rakich, and Darr 2000). Furthermore, typically underutilized in AMI care (Crockett et al. 1998; Krumholz et al. 1998), beta-blocker prescription after AMI is a quality indicator for the Center for Medicare and Medicaid Services (CMS). Hence, hospitals and physicians have ample opportunity and motivation to enhance this area of clinical practice.

METHODS Study Design and Sample

We conducted a qualitative study employing in-depth, open-ended interviewing of clinical and administrative staff during hospital site visits from March through June of 2000 (Bradley et al. 2001). Using purposeful sampling consistent with standard qualitative sampling methodology (Strauss and Corbin 1990; Crabtree and Miller 1999), study hospitals were selected to represent a range of sizes, geographic regions, and beta-blocker improvement rates over a three-year period. Changes in beta-blocker use rates at discharge were determined using data from the National Registry of Myocardial Infarction (NRMI) (French 2000) and calculated as the beta-blocker use rates during the follow-up period (April 1998 to September 1999) minus the beta-blocker use rates during a baseline period (October 1996 to March 1998) at each hospital.

After arraying all eligible hospitals by deciles according to their changes in beta-blocker use rates, we selected hospitals that represented a range of improvement rates in beta-blocker use. Thus, three hospitals were randomly selected from the lowest two deciles (representing declines in beta-blocker use rates ranging from -22 to -6 percentage points), the middle two deciles (representing increases in beta-blocker use rates ranging from 5 to 7 percentage points), and the highest two deciles (representing increases in beta-blocker use rates ranging from 19 to 35 percentage points). In two cases, randomly selected hospitals did not meet selection criteria (i.e., they did not differ in size or geographical region from others already selected) and thus were replaced with other randomly selected hospitals from the same deciles.

Additional hospitals were selected and visited until the point of theoretical saturation (Strauss and Corbin 1990; Crabtree and Miller 1999)--that is, until no new concepts were identified by the additional interviews. This occurred after the eighth hospital site visit and 45 interviews. The research team was blinded to hospital beta-blocker use rates until the completion of the data collection and coding. The characteristics and beta-blocker use rates in the study hospitals are presented in Table 1.

Data Collection

The investigators conducted in-depth interviews (McCracken 1998; Glaser and Strauss 1967) in person with physician, nursing, quality management, and administrative staff identified by the director of quality assurance or quality management as key staff involved with improving the care of patients with AMI. Four to seven individuals were interviewed at each hospital, for a total of 45 respondents. Respondents included 14 medical staff, 15 nursing staff, 11 staff from quality management or quality assurance departments, and 5 senior managers. Interviewers employed a standard interview guide with probes. The interviews opened with a grand-tour question (McCracken 1998) as is standard in in-depth, open-ended interviewing: "Would you tell us about the quality improvement activities your hospital has undertaken in the last three years?" Probes were used to gain additional detail or clarity about experiences the respondents described. Interviews were 1 to 1.5 hours in length and were typically conducted by at least two members of the research team, as recommended by in-depth interviewing experts (McCracken 1998). All interviews were audiotaped and transcribed by independent professional transcriptionists.

Data Analysis

Interview data were coded and analyzed using the constant comparative method for analysis (Strauss and Corbin 1990; Glaser and Strauss 1967; Miles and Huberman 1994; Devers 1999). The code structure was reviewed three times for logic and breadth during its development by the full research team. Coded data were entered in NUD-IST 4 (Sage Publications Software) to assist in reporting recurrent themes, links among the themes, and supporting quotations. Further analysis was conducted to identify distinctions in management roles in quality improvement efforts between higher-performing and lower-performing hospitals using standard hypothesis-generating methods for comparing distinct groups based on qualitative data (Ragin 1987). For this analysis, higher-performing hospitals (a total of three) were characterized as those in which at least 65 percent of all AMI patients in the follow-up period were prescribed beta-blockers at discharge and in which beta-blocker use rates had improved at least 10 percent over the study period. Lower-performing hospitals (a total of five) were characterized as all others--those sampled from the middle and lowest deciles of performance.

RESULTS

Respondents' descriptions of the nature and level of management involvement and support for quality improvement efforts differed substantially among the study hospitals, yet several common roles and activities characterize these differences (see Table 2).

Personal Engagement of Senior Management

Several respondents described personal engagement of senior managers as paramount to the success of quality improvement efforts. Personal engagement was characterized by three dimensions: (1) advocacy for quality improvement efforts within the hospital and at the board level, (2) participation in quality improvement teams, and (3) dissemination of quality improvement data.

In some hospitals, senior managers advocated for quality improvement efforts with influential committees in the hospital and with the board.

Other aspects of personal engagement by senior managers were the degree to which they participated in quality improvement teams and were involved in disseminating clinical performance data.

In some hospitals, personal engagement of senior managers was quite limited. In these hospitals, respondents described the CEO as "distant" and the administrative involvement as only occurring at the middle-management level or lower In one hospital, clinical staff described the hospital's quality improvement efforts as "grass roots" and without any senior management involvement or knowledge.

Relationship with Clinical Staff

In nearly all hospitals, the relationship between senior management and clinical staff was described as influential in the success or failure of quality improvement efforts. Relationships between the senior managers and the medical staff differed widely, from cooperative and respectful to polarized and strained. Although most comments pertained to physician staff, some respondents described managers' relationships with nursing staff as important to the success of quality improvement efforts. The relationship with medical staff was characterized by two dimensions: (1) senior managers' understanding and responsiveness to physician needs and (2) senior managers' ability and willingness to negotiate with medical staff.

In some hospitals, the perception that managers understood, and often supported, the goals of medical staff was noted by physician and nonphysician respondents. In contrast, several respondents in other hospitals noted difficulties when medical staff perceived senior managers' goals to be divergent with their own clinical goals.

Respondents also focused on the ability of senior managers to negotiate effectively with physicians. Effective managers knew what they might be able to offer physicians in return for their participation and cooperation with quality improvement efforts.

Promotion of a Quality Improvement Culture

The promotion of an organizational culture of quality improvement was a third area in which respondents described managers' roles in improvement efforts. We observed three dimensions of organizational culture germane to quality improvement efforts and influenced by senior managers: (1) goal setting and the degree to which quality improvement was integrated into overall organizational goals, (2) norms regarding collaboration across departments and disciplines, and (3) innovation and risk taking within the organization.

Hospitals differed in the level of integration of their quality improvement efforts in AMI care with the overall organizational goals. In several hospitals, staff reported that improvements in quality of cardiac care were part of the organization's strategic plan and that quality progress was reported to the board or senior administrative team regularly. In these hospitals, senior managers highlighted quality as central to their survival in the marketplace and to their organizational mission. In other hospitals, although staff reported implementing several quality improvement efforts, they viewed these efforts as separate from the larger organizational goals. They voiced frustration at the lack of overall goals directed at AMI care.

Marked differences in norms regarding collaboration across departments or disciplines were observed. Some respondents described consensus and cooperation among diverse clinical and ancillary staff.

In other hospitals, staff described ongoing turf battles and interdepartmental conflicts related to quality improvement efforts. As examples, respondents said:

Finally, in terms of innovation and risk taking, some respondents described their hospital as always seeking a new or improved method for caring for patients. At these hospitals, administrative and clinical staff were perceived to be flexible and interested in novel approaches to care.

In other hospitals, staff reported their organizations as risk averse.

In one hospital, respondents noted that senior managers often avoided risks to maintain current departmental structures or embedded relationships with senior medical staff, who themselves were loathe to change practice.

Support of Quality Improvement With Organizational Structures

Nearly all respondents described the importance of organizational structures, typically created with senior management involvement, to guide and empower quality improvement efforts. Two dimensions characterized the diversity of such organizational structures: (1) whether multidisciplinary teams existed that were focused on AMI care and (2) whether quality improvement teams were linked to centralized decision-making bodies in the hospital.

Most hospitals had quality improvement teams that focused on AMI care, although some hospitals did not. Further, the degree to which quality improvement teams were linked to higher-level decision-making bodies varied among hospitals. In some hospitals, quality committees reported directly to senior administrative and clinical staff or influential committees. Illustrating this organizational structure, one respondent stated:

The manager further described that the quality management teams felt that they informed decision making at higher levels and that they were empowered to make substantial changes. In contrast, quality improvement efforts in other hospitals were decentralized, and teams' decisions were not always upheld at higher levels of the organization. For instance, respondents described issues that stymied quality improvement initiatives.

Procurement of Organizational Resources

Respondents in all hospitals discussed the issue of resource and budget constraints. Senior managers were viewed as playing key roles in procuring and allocating needed resources for quality improvement efforts. The common dimensions of this role were (1) staffing adequacy and (2) information technology (IT) capability.

In terms of staffing, respondents noted the critical role of management in approving budgets to procure necessary staff. Similarly, IT resources (including systems to capture, analyze, and summarize performance data) were viewed as essential for quality improvement efforts. Managers were charged with deriding on the resources allocated to centralized data collection, analysis, and reporting functions. Illustrating the lack of necessary staff resources, respondents stated:

Hospitals that performed particularly well reflected a mix of ownership types. Additionally, some of the higher performers were teaching hospitals, while others were not. The number of beds varied substantially among the higher-performing hospitals; however, the three highest-ranking hospitals in terms of improved beta-blocker use during the study period were also those with the greatest AMI discharge volumes.

Several features of management involvement and support described in Table 2 were apparent in the higher-performing hospitals (hospitals 7, 8, and 4 in Table 1) and were not apparent among the other hospitals. Specifically, differences were apparent in the areas of advocacy for quality improvement, relationships with clinical staff, norms regarding interdepartmental and multidisciplinary collaboration, and procurement of organizational resources.

First, in the higher-performing hospitals, the senior managers (the CEO or COO or both) were actively engaged in quality improvement efforts. This engagement included advocating for quality improvement efforts within the hospital and with the board, participating in quality improvement groups, and providing visibility for quality improvement data. In the lower-performing hospitals, managers disseminated quality improvement data from other sources but did not participate on teams and were not viewed as advocating widely for quality improvement in AMI care.

Second, in the higher-performing hospitals, senior management had positive working relationships with individual physicians and the medical staff as a whole. In one hospital, a physician respondent said, "He (referring to the CEO) understands physicians." In two of the higher-performing hospitals, the CEO was a physician. In all three, the CEO or COO was perceived as responsive to physician needs and able to negotiate effectively with physicians. In lower-performing hospitals, staff reported that senior management had poor relationships with the medical staff and did not understand or support the issues the clinicians cared about. In these hospitals, staff perceived management to be often more concerned with fiscal viability than with clinical improvement.

Third, while the organizational culture was described in lower-performing hospitals as "back-biting" and "finger-pointing," the organizational culture in the higher-performing hospitals was described as consensus driven--having shared goals and interdepartmental collaboration to improve quality. Respondents in these hospitals noted the lack of blame and policing of individuals for poor performance. Finally, in all hospitals, respondents described the quality improvement efforts as requiring enormous commitment of resources. Yet, in the high-performing hospitals, staff also reported being able to typically obtain needed resources to make and monitor improvements. In the lower-performing hospitals, respondents consistently stated that they lacked the resources (both people and information technology) to collect and disseminate needed data or to create new systems to improve care.

DISCUSSION

This study revealed five common roles and activities that captured the variation in management involvement in quality improvement efforts: (1) personal engagement of senior managers, (2) management's relationship with clinical staff, (3) promotion of an organizational culture of quality improvement, (4) support of quality improvement with organizational structures, and (5) procurement of organizational resources for quality improvement efforts. The multiple roles and activities that characterize management involvement suggest that hospitals cannot be easily characterized as either having or not having management support for quality improvement. Rather, management support is a multifaceted concept that encompasses a variety of aspects of administrative activities, roles, and interventions.

Our study found that some activities were more apparent than others in the higher- versus the lower-performing hospitals. Statistical differences could not be assessed because of qualitative study design and limited sample size. However, in the higher-performing hospitals we studied, senior managers were personally engaged in quality improvement efforts through active advocacy of such efforts within the hospital and with the board, had good working relationships with the medical staff, supported norms of interdepartmental and multidisciplinary collaboration, and ensured the availability of resources needed to conduct quality improvement efforts. These features were not apparent in the lower-performing hospitals. AMI volume was also greater in the three higher-performing hospitals.

The patterns in management roles found in higher- versus lower-performing hospitals generate credible hypotheses. For instance, the hypothesis that managers' personal engagement in quality improvement can promote success is consistent with writings by Deming (1982) and Crosby (1992) as well as recent findings in the dissemination of continuous process innovations in healthcare (Savitz 2000; Weiner, Shortell, and Alexander 1997). Further, management's role in promoting an organizational culture of improvement and organizational structures to support that culture, even before quality improvement techniques are fully realized, is consistent with the concepts of commitment and preparedness described by Savitz (2000) and Brailer (1998) and with the importance of group dynamics and culture in managing change described by Shortell and colleagues (1998) and Gist and colleagues (1987). However, larger-scale quantitative studies of these features and related performance outcomes are necessary to confirm or reject the hypotheses we proposed based on this initial study.

As a practical implication of our findings, this study highlights a limited set of roles and activities that managers might consider as they assess how supportive they are of quality improvement in their own hospitals. The dimensions of each role and activity might be included in a checklist for planning or evaluating one's own efforts in quality improvement, highlighting areas of administrative responsibility and influence. The five roles and activities illustrate potentially important, broad areas of administrative influence; their dimensions suggest more specific planning activities for managers.

Our findings also might promote better classification and measurement of managerial involvement in quality improvement efforts for future empirical studies evaluating the influence of such involvement. With some exception (Boerstler et al. 1996), the literature has noted the importance of senior management support in successful quality improvement efforts. However, the difficulty in measuring what management support comprises limits our understanding of this essential element of quality improvement. Better classification of this concept can facilitate more accurate evaluation of management interventions to improve quality in clinical practice. Such information can then provide the necessary science to promote evidence-based training and practice of healthcare managers in the skills of quality improvement.

Several issues should be considered in interpreting our findings. Although we believe the roles and activities we identified are applicable to other clinical process improvement efforts, our study focused on a single clinical process--beta-blocker use after AMI. Additionally, we focused on senior managers' roles and activities without full assessment of their interactions with other potentially confounding influences. With the exception of AMI volume, none of the organizational factors we collected (i.e., geographic state, bed count, ownership type, teaching status, or urban versus rural location) appeared to differ between the higher-versus lower-performance improving hospitals. However, additional organizational and cultural factors not assessed in this study may be important to consider. Finally, although the hospitals we studied were diverse in size, location, and beta-blocker use, our findings came from a select number of sites and may not fully reflect experiences in other hospitals. Although the qualitative methodology allows for a more in-depth understanding of management roles, our results remain exploratory.

Our findings can be used to support several important aspects of management development in this field. First, the findings suggest fundamental roles that senior managers play in clinical quality improvement and thus highlight curricular aspects that may be important for their academic preparation. Second, the taxonomy provides current managers with a checklist of roles against which they can evaluate their own performance as catalysts for and participants in quality improvement efforts in their hospitals. Finally, the study can enhance the quality of future research by more clearly articulating the management roles and activities that may be essential to the success of such initiatives.

Acknowledgments

This research was supported by the Agency for Healthcare Research and Quality, R01 HS10407. Dr. Bradley is also supported in part by the Donoghue Medical Research Foundation (02-102) and by a grant from the Claude D. Pepper Older Americans Independence Center at Yale University (#P30AG21342).

The authors are grateful to Peter Herbert, M.D., Katherine Littrell, William Kissick, M.D., Donna Diers, R.N., and Stephen Mick, Ph.D. for their comments on the manuscript. We also thank Emily Cherlin, Kinda King, Jen Fiorillo, and Kristin Mattocks for their research assistance in this project.

References

Ancona, D. G. 1990. "Outward Bound: Strategies for Team Survival in an Organization." Academy of Management Journal 33: 334-65.

Arndt, M., and B. Bigelow. 1998. "Reengineering: Deja vu All Over Again." Health Care Management Review 23: 58-66.

Berwick D., A. Godfrey, and J. Roessner. 1990. Curing Health Care: New Strategies for Quality Improvement in Health Care. San Francisco: Jossey-Bass Publishers.

Berwick, D. M. 1996. "A Primer on Leading the Improvement of Systems." British Medical Journal 312: 618-22.

Bigelow, B., and M. Arndt. 1995. "Total Quality Management: Field of Dreams?" Health Care Management Review 20: 15-25.

Boerstler, H., R. W. Foster, E. J. O-Connor, J. L. O-Brien, S. M. Shortell, J. M. Carman, and E. E Hughes. 1996. "Implementation of Total Quality Management: Conventional Wisdom versus Reality." Hospital & Health Services Administration 41: 143-59.

Bradley, E. H., E. S. Holmboe, J. Mattera, S. A. Roumanis, M. J. Radford, and H. M. Krumholz. 2001. "A Qualitative Study of Increasing Beta-Blocker Use After Myocardial Infarction: Why Do Some Hospitals Succeed?" Journal of American Medical Association 285: 2604-611.

Brailer, D. J. 1998. "Clinical Performance Improvement: Measuring Costs and Benefits." Journal of Medical Practice Management 14: 31-34.

Carman, J. M., S. M. Shortell, R. W. Foster, E. E X. Hughes, H. Boerstler, J. L. O'Brian, and E. J. O'Connor. 1996. "Keys for Successful Implementation of Total Quality Management in Hospitals." Health Care Management Review 21: 48-60.

Chassin, M. R. 1998. "Is Health Care Ready for Six Sigma?" Milbank Quarterly 76: 565-91.

Crabtree B. F., and W. L. Miller. 1999. Doing Qualitative Research, 2nd ed. Thousand Oaks, CA: Sage Publications.

Crockett, S. E., L. A. Green, D. Davis, A. E. Merriam, W. E. Golden, and T. J. Ryan. 1998. Beta-Blocker Prophylaxis After Acute Myocardial Infarction. Chicago: American Medical Association.

Crosby, P. 1992. Quality Is Free. New York: McGraw-Hill.

Deming, W. E. 1982. "Improvement in Quality and Productivity Through Action by Management." National Productivity Review 1: 12-22.

--. 1986. Out of Crises. Cambridge, MA: Massachusetts Institute of Technology Press.

Devers, K. J. 1999. "How Will We Know `Good' Qualitative Research When We See It? Beginning the Dialogue in Health Services Research." Health Services Research 34: 1153-88.

Feigenbaum, A. 1991. Total Quality Control, 3rd ed., revised. New York: McGraw-Hill.

French, W. J. 2000. "Trends in Acute Myocardial Infarction Management: Use of the National Registry of Myocardial Infarction in Quality Improvement." American Journal of Cardiology 85: 5B-12B.

Gann, M. J., and D. I. Restucci. 1994. "Total Quality Management in Health Care: A View of Current and Potential Research." Medical Care Review 51 (4): 465-500.

Gist, M. E., E. A. Locke, and M. S. Taylor. 1987. "Organizational Behavior: Group Structure, Process, and Effectiveness." Journal of Management 13: 237-57.

Glaser B. G., and A. L. Strauss. 1967. The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago: Aldine.

Hughes, J. M. 1992. "Total Quality Management in a 300-Bed Community Hospital: The Quality Improvement Process Translated into Patient Care." Quality Review Bulletin 18: 293-300.

Ishikawa, K. 1985. What is Total Quality Control? Englewood Cliffs, NJ: Prentice-Hall.

Juran, J. M. 1986. "The Quality Trilogy." Quality Progress 19: 19-24.

--. 1989. Juran on Leadership for Quality. New York: The Free Press.

Krumholz, H. M, M. J. Radford, Y. Wang, I. Chen, A. Heiat, and T. A. Marciniak. 1998. "National Use and Effectiveness of Beta-Blockers for the Treatment of Elderly Patients After Acute Myocardial Infarction. National Cooperative Cardiovascular Project." Journal of American Medical Association 280: 623-29.

Longest, Jr., B. B., J. S. Rakich, and K. Dart. 2000. "Quality and Competitive Position." In Managing Health Services Organizations and Systems, 4th ed. Baltimore, MD: Health Professions Press.

McCracken G. 1998. The Long Interview. Newbury Park, CA: Sage Publications.

McLaughlin, C. P., and A. D. Kaluzny. 1999. "Defining Quality Improvement: Past, Present, and Future." In Continuous Quality Improvement in Health Care, edited by C. P. McLaughlin and A. D. Kaluzny. Gaithersburg, MD: Aspen.

Miles, M. B., and A. M. Huberman. 1994. Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Thousand Oaks, CA: Sage Publications.

Ragin, C. C. 1987. Comparative Method: Moving Beyond Qualitative and Quantitative Strategies. Berkeley, CA: University of California Press.

Savitz, L. A. 2000. "Assessing the Implementation of Clinical Process Innovations: A Cross-case Comparison." Journal of Healthcare Management 45 (6): 366-80.

Shortell, S. M., C. L. Bennet, and G. R. Byck. 1998. "Assessing the Impact of Continuous Quality Improvement on Clinical Practice: What Will It Take to Accelerate Progress?" Milbank Quarterly 76: 593624.

Strauss A. L, and J. Corbin. 1990. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage Publications.

Sullivan, N., and K. U. Frentzel. 1992. "A Patient Transport Quality Improvement Team." Quality Review Bulletin 18: 215-21.

Weiner, B., S. M. Shortell, and J. Alexander. 1997. "Promoting Clinical Involvement in Hospital Quality Improvement Efforts: The Effects of Top Management, Board, and Physician Leadership." Health Services Research 32: 491-510.

PRACTITIONER APPLICATION

Gayle Capozzalo, FACHE, executive vice president, Strategy and System Development, Yale New Haven Health System, New Haven, Connecticut

When quality improvement efforts in healthcare began in the 1980s, the importance of senior management involvement in the success of quality improvement efforts was not clearly understood. Many hospitals started "bottom-up" quality improvement efforts, while others focused on the "top-down" approach. Anecdotal quality improvement success was achieved using both approaches.

Since the late 1990s, however, senior managers have understood that their involvement in quality improvement efforts is essential to success. This study of Bradley and colleagues brings this awareness to the attention of the academic and clinical communities and identifies the roles and activities of managers that lead to successful quality improvement achievement. Although the study is directed specifically at the care of patients with acute myocardial infarction, the key senior management activities identified in the article--personal engagement in quality improvement, the relationship with clinical staff, willingness to promote a culture of quality improvement, creation of organizational support structures, and provision of resources--are applicable to all improvement efforts within the hospital.

Managed care payers and the Center for Medicare and Medicaid Services are beginning to tie provider payment to effective patient safety and clinical quality improvement initiatives and achievements. As a result, hospitals will need to provide consumers and payers with information regarding clinical quality and patient safety outcomes, forcing greater focus on improvement efforts. This national call for action to improve clinical quality and patient safety throughout the healthcare industry requires senior managers to create an organizational culture of quality improvement.

This article offered three dimensions of organizational culture germane to quality improvement efforts that were influenced by senior managers: (1) goal setting and the degree to which quality improvement was integrated into the overall organizational goals, (2) norms regarding collaboration across departments and disciplines, and (3) innovation and risk taking within an organization. Senior managers should take time to evaluate their performance as catalysts of quality improvement at their hospitals and to take stock of their organizational culture in the suggested dimensions. In addition, the education of future healthcare administrative and clinical leaders should incorporate the insights enumerated in this article.

For more information on this article, please contact Dr. Bradley at Elizabeth.bradley@yale.edu.

Elizabeth H. Bradley, Ph.D., associate professor, Department of Epidemiology, and Public Health, Yale University School of Medicine, New Haven, Connecticut; Eric S. Holmboe, M.D., associate professor, Department of Medicine, Yale University School of Medicine; Jennifer A. Mattera, assistant director, Yale-New Haven Hospital, Center for Outcomes Research and Evaluation; Sarah A. Roumanis, R.N., project coordinator, Yale-New Haven Hospital, Center for Outcomes Research and Evaluation; Martha J. Radford, M.D., system director, Clinical Quality, Yale-New Haven Health System, and associate professor of medicine, Section of Cardiovascular Medicine, Yale University School of Medicine; and Harlan M. Krumholz, M.D., professor of medicine and epidemiology and public health, Departments of Medicine and Epidemiology and Public Health, Yale University School of Medicine
"The one thing [the president]
   believed in very strongly was that
   TQM had to start at the president level
   and filter down. It must [also] start at
   the board level. The board, the vice
   president, the directors need to walk
   it, talk it. The team members--the
   doctors--will never catch on if it's not
   walked and talked and breathed at that
   level." (administrative director)


"We have [a new CEO]. He is
   exceedingly committed to quality.
   He wants report cards. He wants
   data out in front of everybody." (care
   coordinator)

      "We have what we call "wailing
   walls" where we show performance
   data. Each department has one. If
   you walk there, you'll see one on the
   wall. Every department has indicators
   that their team picked in service and
   outcome and costs." (administrative
   director)


"I went through a very difficult
   time with a vice president who was
   in charge of the heart center. To me,
   he was an obstruction. He was not a
   doctor. He didn't understand what we
   were talking about. Yet, he had the
   power to make decisions." (chief of
   cardiology)


"Our GEO says, `Look, heart
   is your baby. You handle it.' The
   money aspect of the heart is not my
   baby ... so I will have ... the VP or
   CEO ... handle the money aspect ...
   and we can work together." (chief of
   cardiology)


"It is very important that the goals
   of leadership in terms of performance
   improvement are brought down to the
   staff." (nursing manager)

      "We have our own personal goals
   that we're working on, but we have no
   input into the organizational goals for
   those [with AMI]." (care coordinator)


"You may see [the quality
   management department] approaching
   AMI a little differently than what
   cardiology is doing. But eventually, it
   all rolls in. And there's no tuff. If I go
   to my boss and complain about what
   Dr. so and so is doing or what nurse
   practitioner so and so is doing, guess
   who's gone? We have to work together."
   (senior manager)


"I screamed and yelled and
   hollered and said, `We're changing this.'
   The comeback was, `Well, nurses just
   have to get used to looking for the
   green and yellow.' [I said] take as many
   errors out of the system as you can. We
   finally worked it through, but it proved
   to be a battle, a very frustrating battle."
   (director of emergency medicine)

      "We still get a lot of defensive
   behaviors, and it is cumbersome to
   get a QI team together. I think once
   we make that better, and we get all
   the departments working together on
   a problem instead of pointing fingers,
   we'll do better [with QI efforts]."
   (nursing manager)


"We have done lots of things
   wrong ... and we are constantly
   learning. And it's a learning
   mentality ...; if something doesn't
   work, there's no penalty at the director
   level. [Senior administrators will] say,
   `OK ... Let's try something different.'
   So, you are not squelched to go
   outside the box and try something
   different." (director of quality
   management)


"I think the biggest [problem] is
   that we are scared to death.... Our
   culture has become [one that says],
   `Don't make a decision because that's
   safer than making one [that is] going
   to be wrong'." (director of quality
   management)


"We have quality teams in the
   department of medicine and all key
   areas report to our hospital-wide
   quality meeting, which is called
   our Performance Improvement
   Coordinating Group. They are
   scheduled to report on a regular
   basis." (quality improvement manager)


"The data project did not go
   through any official process. When I
   started collecting [data], I didn't have
   any formal reporting structure. It (the
   process) has not been part of the main
   quality department, which I think is a
   problem." (cardiovascular clinical nurse
   specialist)

      "This [CEO] was given ...
   authority to make decisions, being
   placed over the quality council, and ...
   the ball dropped. A department
   went out on a limb to make a
   recommendation [for improving
   AMI care], and the administration did
   not embrace that decision made at
   the lower level." (director of quality
   management)


"Over the last year, we've been
   so short-staffed that our goal was
   just to get the necessary things done."
   (cardiovascular clinical nurse specialist)

      "The hardest thing for me is
   not having the kind of data I want.
   We have several data systems; we've
   spent a lot of money on them; we've
   spent a lot of time on them. We need
   more." (director of physician quality
   management)


TABLE 1
Study Hospitals

                      Change in Beta-   Beta-Blocker    Use Rate
                       Blocker Use *     Follow-Up      Baseline
ID/State Performance    (% Points)      (% of Patients  with AMI)

7. CA    Higher             +30              73           43
8. OH    Higher             +22              69           47
4. FL    Higher             +12              68           56
3. CA    Medium              +7              46           39
1. NY    Medium              +6              67           61
6. AR    Medium              +6              35           29
5. MO    Lower              -16              47           63
2. MN    Lower              -30              45           66

                                                          Annual
          Staffed   Ownership     Teaching    Geographic   AMI
ID/State   Beds        Type       Status **    Location   volume

7. CA       271    for-profit    nonteaching  urban        236
8. OH       428    nonprofit     teaching     urban        405
4. FL       629    nonprofit     teaching     urban        300
3. CA       263    governmental  nonteaching  urban        164
1. NY       231    for-profit    nonteaching  urban         49
6. AR       275    nonprofit     nonteaching  rural        182
5. MO       708    nonprofit     nonteaching  urban        132
2. MN       110    governmental  nonteaching  rural         41

*  Beta-blocker use at discharge

** Has residency training approval by accreditation
of Council for Graduate Medical Education

TABLE 2
Management Involvement in and Support of Quality Improvement

Role/Activity       Dimension                      Range

Personal        Advocacy            Garners support for quality
Engagement                          improvement efforts within hospital
                                    and board versus does not support
                                    such efforts publicly or at higher
                                    levels

                Participation       Active membership and attendance
                on teams            versus nonparticipation

                Dissemination of    Reports performance data to broader
                performance data    audience in hospital and board
                                    versus does not get involved

Relationship    Perceived           Has regular contact with and
with Clinical   understanding       understands physicians; perceived
Staff           and                 as caring about clinical, not just
                responsiveness      financial, outcomes
                to physician
                needs

                Negotiation         Can find common ground and
                skills              bargain versus gives ultimatums or
                                    avoids clinical staff

Promotion of    Goal setting        Goals are consistent with QI and
a Quality                           are shared versus limited role of
Improvement                         QI and nonagreement in overall
(QI)                                organizational goals
Organizational
Culture         Norms regarding     Consensus-driven and cooperative
                interdepartmental/  versus blaming and fault-finding
                multi-
                disciplinary
                collaboration

                Innovation and      Seeks novel approaches and
                risk taking         processes versus likes the old
                                    ways and is slow to change

Support         Existence of        Teams to address AMI care present
of QI with      QI teams            or absent
Organizational
Structures      Linkages of QI      QI teams report to executive
                teams to central    committee or other senior group
                decision-making     versus act in isolation without
                structures          dear reporting

Procurement of  Staffing            Clinical, quality management, and
Organizational                      data-collection staff
Resources
                IT capability       Data-collection, analysis, and
                                    reporting capability
Gale Copyright: Copyright 2003 Gale, Cengage Learning. All rights reserved.