The story of one of the most famous quality measures -- percentage of patients with acute myocardial infarction who receive a prescription for beta-blockers within seven days of hospital discharge -- is an example of how people fit together. Beta-blockers are a class of drugs that block the effects of adrenaline and slow down the heart rate. In 1982, results from a randomized controlled trial found that administering beta-blockers after heart attacks cut patients’ death rate by an astounding 40 percent. The results were so conclusive for all types of patients that within two years, they had been written into medical textbooks and featured in both medical journals and mainstream news media. By the end of the decade, the medical profession at large had come to understand the importance of a veritable “silver bullet” for heart attack care.
And yet, by the mid-1990s, only 34 percent of patients received beta-blockers after heart attacks. The policy response was an expansive campaign by some of the largest institutions in medicine. The American College of Cardiology and the American Heart Association incorporated beta-blocker treatment in guidelines for heart attack care. Buoyed by the IOM report, The Institute for Healthcare Improvement launched the 10,000 Lives Campaign and its successor, 5 Million Lives, both of which stressed beta-blocker treatment after heart attacks as priorities. Beta-blockers become an indicator for HMOs in national quality report cards, and hospital accreditation was tied to its public reporting. The campaigns stressed the importance of system care coordinators, carefully scheduled reminders, and team-based interventions, along with accountability through public reporting and data-driven feedback to doctors. In the early 2000s, the Joint Commission offered greater payments for those providers who administered beta-blocker treatment with high reliability.
Something worked. By 2007, virtually all heart attack patients in the United States were receiving beta-blocker treatment; in all, it had taken 25 years for the one of the most significant medical advances of our time to become a no-brainer.
The experience with beta-blocker treatment has been touted by health policy experts as a triumph of policy and public health. Subsequent research, however, has shed light on the extent of that impact. A cross-sectional review of 234 medical centers by Yale researchers sought to understand the characteristics separating high-performing and low-performing hospitals that beta-blocker treatment. Ultimately, even after accounting for all the geographic and demographic variations across hospitals and their patient populations, the most important aspects of achieving quality were organizational support for the intervention (by physicians, hospital administration, and nurse practitioners) and leadership by physicians themselves.
“I have to believe beta blockers are the way to go,” the chief cardiologist of one hospital said in a separate interview with the researchers. “Then you teach. You first learn, and then you teach. And you teach not only doctors, but you also teach your residents, you teach your nurses, you teach your care coordinators. Everybody has to be on the bandwagon of beta-blockers.”
Here is what hardly mattered: the type of approach. The researchers looked at the seven most common techniques used by hospitals – standing orders, clinical pathways, educational efforts, multidisciplinary teams, care coordinators, reminder forms, and computer support systems – and found that no intervention separated the good and bad hospitals (only standing orders were found to be borderline significant). After everything, what mattered most was not the intervention itself, but the organizational context into which it was implemented.
Earlier this year, the same researchers returned to the issue of heart attack care in a qualitative study published in the Annals of Internal Medicine. This time, they presented snippets from interviews with administrators and physicians whose hospitals ranked among the best and worst in efforts to improve mortality rates for severe heart attack patients. The conversations were illuminating.
A medical director in Hospital 9 described the leadership’s outlook: “The hospital likes to get disease-specific certification and to advertise it … they formed the committee and tried to check off all the boxes on the list of what they’re supposed to do,” he said, adding: “The administration is concerned about the bottom line.” Despite executing a range of approaches, no set of practices emerged as a solution for quality improvement. “There was no ‘Ah ha!’ We spent years trying to find the silver bullet that would fix everything,” the frustrated Director of Quality Management said. “There is no one issue [in which] we were doing something glaringly wrong.” Incidentally, Hospital 9 was one of the worst in the nation in its efforts to improve quality.
Among the highest-performing hospitals, the differences were clear. Medical leaders and their staff spoke almost reverently about something much more abstract – organizational values and a shared vision of clinical excellence, described as the “glue” and the “driving force behind everything.” Most importantly, they had found a way to make those values resonate not simply with the leadership, but throughout the entire organization.
“Everyone in this hospital from the housekeeper to the CEO plays a role. The housekeeping needs to know why it’s important for them to go out and do their job. No one has an insignificant role in it,” said the medical director of one hospital. “So everyone needs to be educated. Everyone.”
Clinically, the silver bullet for heart attack treatment was a once-in-a-lifetime pharmaceutical innovation. But if there was a silver bullet for achieving high-quality health care delivery, it involved something policy mandates, large-scale public awareness campaigns, and board certification could not do: make people really care.