Management Practices and the Quality of Care in Cardiac Units.

JAMA Internal Medicine (Impact Factor: 13.25). 03/2013; DOI: 10.1001/jamainternmed.2013.3577
Source: PubMed

ABSTRACT IMPORTANCE To improve the quality of health care, many researchers have suggested that health care institutions adopt management approaches that have been successful in the manufacturing and technology sectors. However, relatively little information exists about how these practices are disseminated in hospitals and whether they are associated with better performance. OBJECTIVES To describe the variation in management practices among a large sample of hospital cardiac care units; assess association of these practices with processes of care, readmissions, and mortality for patients with acute myocardial infarction (AMI); and suggest specific directions for the testing and dissemination of health care management approaches. DESIGN We adapted an approach used to measure management and organizational practices in manufacturing to collect management data on cardiac units. We scored performance in 18 practices using the following 4 dimensions: standardizing care, tracking of key performance indicators, setting targets, and incentivizing employees. We used multivariate analyses to assess the relationship of management practices with process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for acute myocardial infarction (AMI). SETTING Cardiac units in US hospitals. PARTICIPANTS Five hundred ninety-seven cardiac units, representing 51.5% of hospitals with interventional cardiac catheterization laboratories and at least 25 annual AMI discharges. MAIN OUTCOME MEASURES Process-of-care measures, 30-day risk-adjusted mortality, and 30-day readmissions for AMI. RESULTS We found a wide distribution in management practices, with fewer than 20% of hospitals scoring a 4 or a 5 (best practice) on more than 9 measures. In multivariate analyses, management practices were significantly correlated with mortality (P = .01) and 6 of 6 process measures (P < .05). No statistically significant association was found between management and 30-day readmissions. CONCLUSIONS AND RELEVANCE The use of management practices adopted from manufacturing sectors is associated with higher process-of-care measures and lower 30-day AMI mortality. Given the wide differences in management practices across hospitals, dissemination of these practices may be beneficial in achieving high-quality outcomes.

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    ABSTRACT: Background Management practices, including, for example, “Lean” methodologies originally developed at Toyota, may represent one mechanism for improving healthcare performance. Methods We surveyed 597 nurse managers at cardiac units to score management on the basis of poor, average, or high performance on 18 practices across 4 dimensions (Lean operations, performance measurement, targets, and employee incentives). We assessed the relationship of management scores to hospital characteristics (size, non-profit status) and market level variables. Results Our findings provide concrete examples of the high degree of management proficiency of some hospitals, as well as wide variation in management practices. Although the exact ways in which these tools have been implemented vary across hospitals, we identified multiple examples of units that use standardization in their care, track performance on a frequent basis and display data in a visual manner, and set aggressive goals and communicate them clearly to their staff. Regression models indicate that higher management scores are associated with hospitals in more competitive markets, teaching hospitals, and hospitals with a higher net income from patient services (p<0.05). Conclusions High quality management practices have been successfully adopted by some hospitals in the US, but the ways in which these practices have been implemented may vary, reflecting the specific context or environment of the hospital. The adoption of modern management practices may be driven in part by market pressure. Implications An improved understanding of key management practices may assist researchers and policy-makers in identifying mutable hospital characteristics that can drive efficiency, safety, and quality.
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May 23, 2014