Top-performing Hospitals Research Articles

The burden of major complications on failure to rescue after surgery for acute type A aortic dissection: Analysis of more than 19,000 patients

BackgroundThe relationship between the number and type of postoperative complications and mortality in the setting for surgery for acute type A aortic dissection (ATAAD) remains underexplored despite its critical role in the failure-to-rescue (FTR) metric. MethodsThis retrospective study used data from the Society of Thoracic Surgeons Adult Cardiac Surgical Database on ATAAD surgeries performed between January 2018 and December 2022. Patients were categorized based on their number of major complications. The primary outcome was FTR. We used multilevel regression and classification and regression tree models. ResultsWe included 19,243 patients (33% females), with a median age of 61 years. Regarding complications, 47.7% of patients had 0, 20.2% had 1, 12.7% had 2, and 19.4% experienced 3 or more. The most frequently reported complications were prolonged mechanical ventilation (30.3%), unplanned reoperation (19.5%), and renal failure (17.2%). Cardiac arrest occurred in 7.1% of cases. FTR increased from 13% in patients with 1 complication to >30% in those with 4 or more complications. Cardiac arrest (adjusted odds ratio [aOR], 10.9) and renal failure (aOR, 5.3) had the highest odds for mortality, followed by limb ischemia (aOR, 2.7), stroke (aOR, 2.6), and gastrointestinal complications (aOR, 2.4). Hospitals in the top performance quartile consistently showed lower FTR rates across all levels of complication. ConclusionsThe study validates a dose–response association between postoperative complications and mortality in patients undergoing surgery for ATAAD. Top-performing hospitals consistently show lower FTR rates independent of the number of complications. Future research should focus on the timing of complications and interventions to reduce the burden of complications.

Core elements of excellent hospital leadership: lessons from the five top-performing hospitals in China.

Substantial evidence indicates that leadership plays a critical role in an organization's success. Our study aims to conduct case studies on leadership attributes among China's five top-performing hospitals, examining their common practices. A semi-structured interview was conducted with 8 leaders, 39 managers, 19 doctors, and 16 nurses from the five sample hospitals in China. We collected information from these hospitals on the role of senior leadership, organizational governance, and social responsibility, aligning with the leadership assessment guidelines in the Baldrige Excellence Framework. Qualitative data underwent interpretation through content analysis, thematic analysis, and comparative analysis. This study adhered to the consolidated criteria for reporting qualitative research guidelines for reporting qualitative research. Our study revealed that the leaders of the five top-performing hospitals in China consistently established "Patient Needs First" as the core element of the hospital culture. Striving to build world-renowned hospitals with Chinese characteristics, the interviewees all believed strongly in scientific vigor, professionalism, and cooperative culture. The leaders adhered to a staff-centered approach, placing special emphasis on talent recruitment and development, creating a compensation system, and fostering a supportive environment conducive to enhancing medical knowledge, skills, and professional ethics. In terms of organizational governance, they continuously enhanced the communication between various departments and levels of staff, improved the quality and safety of medical care, and focused on innovative medical and scientific research, thereby establishing evidence-based, standardized hospital management with a feedback loop. Meanwhile, regarding social responsibility, they prioritized improvements in the quality of healthcare by providing international and domestic medical assistance, community outreach, and other programs. To a large extent, the excellent leadership of China's top-performing hospitals can be attributed to their commitment to a "Two-Pillared Hospital Culture," which prioritizes putting patient needs first and adopting a staff-centered approach. Furthermore, the leaders of these hospitals emphasize hospital performance, operations management, and social responsibility.

Spherical Fuzzy Multicriteria Decision Making for Evaluating Healthcare Service Quality of Hospitals During the Global Pandemic

AbstractThis study identifies hospitals in Iran that have demonstrated exceptional performance in service quality during the COVID-19 pandemic based on the proposed integrated multicriteria decision-making (MCDM) process. Although the coronavirus has been eradicated in most countries, occasional outbreaks of COVID-19 variants have occurred, affecting many individuals, particularly in Iran. The pandemic caused an influx of hospital visits, with people seeking treatment for various illnesses. However, the abrupt onset of the pandemic and its global impact challenged hospitals’ ability to provide timely care, leading to a noticeable decline in service quality. Identifying the top-performing hospitals is crucial for benchmarking and enhancing healthcare quality. To assess hospital service quality, the study employed a customized SERVQUAL model, which helped identify key factors that served as criteria and subcriteria for the evaluation process. The priority weights of these factors were then obtained using the spherical fuzzy analytic hierarchy process. For each SERVQUAL criterion, the hospitals were evaluated using the spherical fuzzy weighted aggregated sum product assessment method, resulting in respective rankings of the hospitals. Finally, an integrated Borda−Copeland method was utilized to generate the aggregate evaluation ranking, a feature that serves as an important departure from the literature. The contribution of this work lies in developing an integrated approach that intends to serve as a benchmark not only for hospitals in different countries but also for those confronting similar challenges and offers guidance for seeking insights from top-performing hospitals in comparable situations.

Real-life benchmarking bladder cancer care: A population-based study.

Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators, with associated benchmarks created using available evidence and expert opinion to inform and measure future performance. Herein, we report real-life benchmark performance for the management of muscle-invasive bladder cancer (MIBC) relative to expert opinion guidance. This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009-2013. Electronic records of treatment from 1573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators, first as median values obtained across hospitals or providers, as well as a "pared-mean" approach to identify a benchmark population of "top performance," as defined as the best outcome accomplished for at least 10% of the population. Overall, performance in Ontario across all indicators fell short of expert opinion-determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark >6, percent of institutions meeting benchmark=20%), percent of patients with MIBC referred preoperatively to medical oncology (MO; benchmark>90%, percent of institutions meeting benchmark=2%) and radiation oncology (RO; benchmark>50%, percent of institutions meeting benchmark=0%), time to cystectomy within six weeks of transurethral resection of bladder tumor (TURBT) in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark=0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark>85%, percent of institutions meeting benchmark=0%), percent of patients with positive margins post-RC (benchmark <10%, percent of institutions meeting benchmark=46%), and 90-day mortality (benchmark<5%, percent of institutions meeting benchmark=37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly underestimated benchmarks that were possible by top-performing hospitals. Performance through most bladder cancer quality-of-care indicators fall short of benchmarks proposed by expert opinion. Different methodologies, such as a paredmean approach of top performers, may provide more realistic benchmarking.

PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY

You have accessJournal of UrologyCME1 Apr 2023PD29-02 BENCHMARKING BLADDER CANCER CARE: A REAL-LIFE POPULATION-BASED STUDY Nicolas Vanin-Moreno, Marlo Whitehead, and Robert Siemens Nicolas Vanin-MorenoNicolas Vanin-Moreno More articles by this author , Marlo WhiteheadMarlo Whitehead More articles by this author , and Robert SiemensRobert Siemens More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003315.02AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Radical cystectomy (RC) is a complex oncological surgical procedure and population studies of routine surgical care have suggested suboptimal results compared to high-volume centers of excellence. A previous Canadian bladder cancer quality-of-care consensus led to adoption of multiple key quality-of-care indicators with associated benchmarks created utilizing available evidence and expert opinion to inform and measure future performance. Herein we report real-life benchmark performance for the management of muscle invasive bladder cancer (MIBC) relative to expert opinion guidance. METHODS: This is a population-based, retrospective, cohort study that used the Ontario Cancer Registry (OCR) to identify all incident patients who underwent RC from 2009 and 2013. Electronic records of treatment from 1,573 patients were linked to OCR; pathology records were obtained for all cases and reviewed by a team of trained data abstractors. The primary objective was to describe benchmarks for identified indicators first as median values obtained across hospitals or providers as well as a “pared-mean” approach to identify a benchmark population of "top performance" as defined as the best outcome accomplished for at least 10 percent of the population. RESULTS: Overall, performance in Ontario across all indicators fell short of expert-opinion determined benchmarks. Annual surgical volume by each surgeon performing a RC (benchmark>6, percent of institutions meeting benchmark =20%), percent of patients with MIBC referred pre-operatively to Medical Oncology (MO; benchmark >90%, percent of institutions meeting benchmark =2%) and Radiation Oncology (RO; benchmark >50%, percent of institutions meeting benchmark =0%), time to cystectomy within 6 weeks of TURBT in patients without neoadjuvant chemotherapy (benchmark <6 weeks, percent of institutions meeting benchmark =0%), percent of patients with adequate lymph node dissection (defined as >14 nodes, benchmark >85%, percent of institutions meeting benchmark =0%), percent of patients with positive margins post RC (benchmark <10%, percent of institutions meeting benchmark =46%), and 90 day mortality (benchmark <5%, percent of institutions meeting benchmark =37%) fell considerably short. Simply evaluating benchmarks across the province as median performance significantly under-estimated benchmarks that were possible by top-performing hospitals. CONCLUSIONS: Performance through the majority of BC quality of care indicators fall short of benchmarks proposed by expert-opinion. Different methodologies such as a pared-mean approach of top performers may provide more realistic benchmarking. Source of Funding: This study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC). Parts of this material are based on data and information compiled and provided by CIHI. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e824 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Nicolas Vanin-Moreno More articles by this author Marlo Whitehead More articles by this author Robert Siemens More articles by this author Expand All Advertisement PDF downloadLoading ...

Effect of Medicare Advantage on Hospital Readmission and Mortality Rankings.

Medicare links hospital performance on readmissions and mortality to payment solely on the basis of outcomes among fee-for-service (FFS) beneficiaries. Whether including Medicare Advantage (MA) beneficiaries, who account for nearly half of all Medicare beneficiaries, in the evaluation of hospital performance affects rankings is unknown. To determine if the inclusion of MA beneficiaries in readmission and mortality measures reclassifies hospital performance rankings compared with current measures. Cross-sectional. Population-based. Hospitals participating in the Hospital Readmissions Reduction Program or Hospital Value-Based Purchasing Program. Using the 100% Medicare files for FFS and MA claims, the authors calculated 30-day risk-adjusted readmissions and mortality for acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, and pneumonia on the basis of only FFS beneficiaries and then both FFS and MA beneficiaries. Hospitals were divided into quintiles of performance based on FFS beneficiaries only, and the proportion of hospitals that were reclassified to a different performance group with the inclusion of MA beneficiaries was calculated. Of the hospitals in the top-performing quintile for readmissions and mortality based on FFS beneficiaries, between 21.6% and 30.2% were reclassified to a lower-performing quintile with the inclusion of MA beneficiaries. Similar proportions of hospitals were reclassified from the bottom performance quintile to a higher one across all measures and conditions. Hospitals with a higher proportion of MA beneficiaries were more likely to improve in performance rankings. Hospital performance measurement and risk adjustment differed slightly from those used by Medicare. Approximately 1 in 4 top-performing hospitals is reclassified to a lower performance group when MA beneficiaries are included in the evaluation of hospital readmissions and mortality. These findings suggest that Medicare's current value-based programs provide an incomplete picture of hospital performance. Laura and John Arnold Foundation.

Harnessing our greatest asset: Solving margin issues by investing in frontline leaders

The rate of change in combination with the scope and magnitude and the need for increased efficacy in healthcare operations are on the rise, especially with the advent of a plethora of patient needs in the post-COVID-19 world. Senior leaders in the field are faced with various operational and financial challenges on account of the new and rapidly rising patient requirements in the healthcare sector, and, instead of optimising existing resources to meet current challenges, they are often persuaded to just add on new programmes, leaving the existing programmes to languish. Thus, to circumvent some of the major issues in healthcare operations, a more effective strategy has to be pursued than the usual one of simply buying and implementing a new productivity system with updated targets or performance benchmarks. The solution is to assess the efficacy and profitability of existing improvement programmes and resources in the advent of a new set of requirements: deploying burst versus incremental improvement; engaging middle managers to enable their solutions; and achieving organisation speed, spread and scalability across the organisation [Caldwell, C., Cook, K., (2020), ‘Achieving speed, spread, scalability, and sustainability in health systems’, American College of Healthcare Executives-Cluster Session, Clearwater, FL, 17–20th January]. This paper describes how Dignity Health East Valley was able to optimise the use of existing performance improvement resources and deploy an accelerated improvement structure to achieve rapid gains, followed by incremental improvement to both sustain and further the gains made. The approach included mentoring middle managers to become adaptive change agents and achieve 5 per cent improvement in margins in six months. The burst method described in this paper is based on the findings from the research undertaken by top-performing hospitals that identified five essential characteristics that healthcare’s frontline leaders are expected to possess and which are a clear mark of their leadership skills and competence [Caldwell, C., Cook, K., (2020), ‘Achieving speed, spread, scalability, and sustainability in health systems’, American College of Healthcare Executives-Cluster Session, Clearwater, FL, 17–20th January]. The paper presents the background to this research as well as the structure that builds these top-performer capabilities in the front-line team in order for them to lead change and drive its implementation. The positive results that emerged from the leadership training provided to frontline leaders are substantial, including improved margin, higher patient experience and higher employee engagement.

Performance evaluation of general public hospitals in territories of the Former Yugoslavia: An ecological study using the Pabon Lasso model.

Measuring hospital performance is an area of great importance due to limited resources. Additionally, hospital activities are vital during emergencies providing care under pressure of external factors. This study aimed at analysing performances of general public hospitals from territories of the Former Yugoslavia. This ecological study includes 99 hospitals from 6 territories based on annual reports of institutions in charge of territorial health data. The Pabon Lasso method was used, considering hospitals in the third quadrant of the plot as top-performing in the territory. A particular focus was on performance changes during the pandemic caused by SARS-COV-2 coronavirus. There is considerable heterogeneity in the length of stay, bed occupancy and turnover rate between territories. The proportion of top-performing hospitals varied between 20% and 43%, providing between 16% and 69% of inpatients episodes within the territory. However, countries did not differ in how their hospitals were distributed across the four quadrants of the Pabon Lasso plot. Comparison of Croatian and Kosovar data from 2019 to 2020 suggested a significant decrease in turnover and occupancy rates, but most hospitals retained their plot quartiles from the previous year. This supports the finding that there were no significant changes in hospital performance based on the Pabon Lasso method. The analysis showed significant room for performance improvement and highlighted the ability of the Croatian and Kosovar hospitals and their health systems to maintain efficiency during emergencies.

Best Practices for Education and Training of Resuscitation Teams for In-Hospital Cardiac Arrest.

Survival outcomes following in-hospital cardiac arrest vary significantly across hospitals. Research suggests clinician education and training may play a role. We sought to identify best practices related to the education and training of resuscitation teams. We conducted a descriptive qualitative analysis of semistructured interview data obtained from in-depth site visits conducted from 2016 to 2017 at 9 diverse hospitals within the American Heart Association "Get With The Guidelines" registry, selected based on in-hospital cardiac arrest survival performance (5 top-, 1 middle-, 3 low-performing). We assessed coded data related to education and training including systems learning, informal feedback and debrief, and formal learning through advanced cardiopulmonary life support and mock codes. Thematic analysis was used to identify best practices. In total, 129 interviews were conducted with a variety of hospital staff including nurses, chaplains, security guards, respiratory therapists, physicians, pharmacists, and administrators, yielding 78 hours and 29 minutes of interview time. Four themes related to training and education were identified: engagement, clear communication, consistency, and responsive leadership. Top-performing hospitals encouraged employee engagement with creative marketing of new programs and prioritizing hands-on learning over passive didactics. Clear communication was accomplished with debriefing, structured institutional review, and continual, frequent education for departments. Consistency was a cornerstone to culture change and was achieved with uniform policies for simulation practice as well as reinforced, routine practice (weekly, monthly, quarterly). Finally, top-performing hospitals had responsive leadership teams across multiple disciplines (nursing, respiratory therapy, pharmacy and medicine), who listened and adapted programs to fit the needs of their staff. Among top-performing hospitals excelling in in-hospital cardiac arrest survival, we identified core elements for education and training of resuscitation teams. Developing tools to expand these areas for hospitals may improve in-hospital cardiac arrest outcomes.

Measuring Quality of Public Hospitals in Croatia Using a Multi-Criteria Approach.

Quality of public hospital services presents one of the most important aspects of public health in general. A significant number of health services are delivered due to public hospitals. Under the World Bank program “Improving Quality and Efficiency of Health Services: Program for Results”, the competent bodies in Croatia aimed to identify the top 40% best-performing public acute hospitals in Croatia, based on a clinical audit in the preceding 12 months. This paper presents how this goal was achieved, using a multi-criteria decision-making (MCDM) approach. A MCDM approach was selected due to the multidimensionality and complexity of healthcare performance and service quality. We aimed to develop a methodology for ranking top-performing hospitals at the national level. We chose the composite indicator methodology, combined with the analytic hierarchy process (AHP) as a tool for determining weights for aggregation of individual indicators. The study looked at three clinical entities: acute myocardial infarction, cerebrovascular insult, and antimicrobial prophylaxis in colorectal surgery. Indicators for each entity were evidence-based, following the national guidelines, but limited by availability of data. The clinical audit and databases of competent administrative bodies were used as sources of data. The problem investigated in this paper has a significant impact at the strategic (national) level. Even though the AHP has already been applied in the public health domain, to the best of our knowledge, this is the first application of the AHP in combination with composite indicators for hospital ranking at a national level. The AHP enabled participation of experts from the audited hospitals in the assessment of indicator weights. Results show that composite indicators can be successfully implemented for acute hospital evaluation using the AHP methodology: (1) the AHP supported a flexible structuring of the problem; (2) the resulting complexity of pairwise comparisons was appropriate for the experts (consistency ratios were under 0.1); (3) using the AHP approach enabled a successful aggregation of different opinions into group priorities; (4) the developed methodology was robust and enabled identifying the top 40% ranking best-performing public acute hospitals in Croatia combining 20 criteria within three entities, based on input from 36 clinical experts. The proposed methodology can be useful to other researchers for assessment of healthcare quality at the strategic level.

Association of acute resuscitation and post-resuscitation survival with overall risk-standardized survival to discharge for in-hospital cardiac arrest

Abstract Background Although survival for in-hospital cardiac arrest (IHCA) varies markedly across sites, it remains unknown whether high survival at top-performing hospitals is due to high rates of acute resuscitation survival (i.e., achievement of return of spontaneous circulation [ROSC]), post-resuscitation survival (i.e., survival to discharge among patients who achieved ROSC), or both. Methods Using 2015–2018 Get With The Guidelines (GWTG)-Resuscitation data, we identified 290 hospitals (86,426 patients) with IHCA. For each hospital, we calculated overall risk-standardized survival (RSSR) to discharge for IHCA using a previously validated hierarchical regression model and categorized hospitals into quartiles based on that metric. Risk-adjusted rates of acute resuscitation survival (defined as return of spontaneous circulation for &amp;gt;20 minutes [ROSC]) and post-resuscitation survival (defined as the proportion of patients achieving ROSC who survived to hospital discharge) were also computed for each hospital. We examined the correlation between a hospital's overall RSSR with its risk-adjusted rate of acute resuscitation and post-resuscitation survival. Results Among study hospitals, the median RSSR was 25.1% (inter-quartile range [IQR]: 21.9%–27.7%). The median risk-adjusted rate of acute resuscitation survival was 72.4% (IQR: 67.9%–76.9%) and post-resuscitation survival was 34.0% (IQR: 31.5%–37.7%). Hospital rates of RSSR were less strongly correlated with risk-adjusted rates of acute resuscitation survival (rho=0.50, P&amp;lt;0.001) than post-resuscitation survival (rho=0.90, P&amp;lt;0.001). Compared with hospitals in the lowest quartile of RSSR, hospitals in the highest quartile had substantially higher rates of acute resuscitation survival (Q4: 75.4% vs. Q1: 66.8%; P&amp;lt;0.001) and post-resuscitation survival (Q4: 40.3% vs. Q1: 28.7%; P&amp;lt;0.001). Notably, there was no correlation between hospital risk-adjusted rates of acute resuscitation survival and post-resuscitation survival (rho=0.09, P=0.11). Conclusion Hospital that excel in overall IHCA survival in general excel in either acute resuscitation or post-resuscitation care. As most hospital-based quality improvement initiatives largely focus on acute resuscitation survival, our findings suggest that efforts to strengthen post-resuscitation care may offer additional opportunities to improve IHCA survival. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): NHLBI

Characteristics of Top-Performing Hospitals Caring for High-Need Medicare Beneficiaries.

A small proportion of high-need (HN) Medicare beneficiaries account for a large share of medical expenditures in the United States. Identifying hospitals with the best outcomes for HN patients is central to identifying and spreading evidence-based practices to improve care for this population. The objective of this study was to identify and characterize top-performing hospitals for HN patients. Administrative claims data from 2013-2014 were used to identify HN beneficiaries and their treating hospital; hospitals were ranked based on their HN beneficiaries' outcomes in 2015. Hospitalization, mortality, and days spent in community were assessed, and all outcomes were risk standardized for age, sex, dual eligibility, and hospital referral region. American Hospital Association and aggregated inpatient claims data characterized hospitals. Logistic regression models estimated the odds of ranking in the top 20% on all outcomes. Of 2253 hospitals with at least 500 HN patients in the United States, 92 (4.1%) ranked in the top 20% across all outcomes. No hospital characteristics were associated with being top performing across all outcomes, but urban hospitals were significantly less likely to perform well on hospitalization and private, for-profit hospitals performed better on mortality. Small hospitals, Accountable Care Organization providers, and those providing palliative care services were more likely to rank highly on days spent in the community. Top-performing hospitals served fewer minority, dual eligible, and HN patients, suggesting that case mix may explain some of the differences in performance, and that additional work is needed to examine programs and practices at outstanding hospitals.

Abstract 311: Trajectory of Risk-Standardized Survival Rates for In-Hospital Cardiac Arrest

Introduction: Risk-standardized survival rate (RSSR) for in-hospital cardiac arrest (IHCA) has emerged as an important metric to measure and incentivize resuscitation quality at a hospital-level. We examined whether hospital performance on the RSSR metric was generally stable year-over-year. Methods: We used data from 81,795 adult patients with an IHCA from 163 hospitals with continuous participation in Get With The Guidelines-Resuscitation from 2012 to 2017. A two-level hierarchical regression model was used to compute RSSRs for 2 time intervals (baseline: 2012-13; follow-up: 2014-17). Hospitals were classified as top-, middle- and bottom-performing if they ranked in the top 25%, middle 50%, and bottom 25% on the RSSR metric during 2012-2013. We examined the trajectory of top, middle, and bottom-performing hospitals’ RSSR during 2014-2017 (follow-up). Results: During 2012-2013, 41 hospitals were identified as top-performing (median RSSR 31.9%), 81 as middle-performing (median RSSR 24.9%) and 41 as bottom-performing (median RSSR 18.5%). During 2014-2017, more than 3/4 th (75.6%) of top-performing hospitals remained in the top 50% and 53.7% remained in the top 25% (Table). In contrast, most (81.5%) bottom-performing hospitals ranked in the bottom 50%, and 56.1% remained in the bottom 25% during 2014-2017. Performance of middle-performing hospitals on the RSSR metric was variable. Importantly, rankings improved by at least 1 quartile ( &gt; 25 percentile points) at 26.8% and by at least 2 quartiles ( &gt; 50 percentile points) at 12.2% bottom-performing hospitals (Table). Likewise, rankings at 31.7% and 19.5% of top-performing hospitals worsened by at least 25 and 50 percentile points during 2014-2017, respectively. Conclusion: Hospital performance on RSSR during a baseline period was generally consistent with their performance during follow up. However, percentile rankings changed markedly over time at a small proportion of top- and bottom-performing hospitals.

Nurse Empowerment a Key Factor in Cardiac Arrest Survival of Hospitalized Patients.

According to this study: Important differences exist in the organizational structure and function of rapid response teams (RRTs) at top-performing versus non–top-performing hospitals for in-hospital cardiac arrest survival. Top-performing hospitals tend to have dedicated RRT staff who collaborate with bedside nurses in the surveillance of at-risk patients, both during a rapid response activation and afterward.

Assessment of Rapid Response Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest

Rapid response teams (RRTs) are foundational to hospital response to deteriorating conditions of patients. However, little is known about differences in RRT organization and function across top-performing and non-top-performing hospitals for in-hospital cardiac arrest (IHCA) care. To evaluate differences in design and implementation of RRTs at top-performing and non-top-performing sites for survival of IHCA, which is known to be associated with hospital performance on IHCA incidence. A qualitative analysis was performed of data from semistructured interviews of 158 hospital staff members (nurses, physicians, administrators, and staff) during site visits to 9 hospitals participating in the Get With The Guidelines-Resuscitation program and consistently ranked in the top, middle, and bottom quartiles for IHCA survival during 2012-2014. Site visits were conducted from April 19, 2016, to July 27, 2017. Data analysis was completed in January 2019. Semistructured in-depth interviews were performed and thematic analysis was conducted on strategies for IHCA prevention, including RRT roles and responsibilities. Of the 158 participants, 72 were nurses (45.6%), 27 physicians (17.1%), 27 clinical staff (17.1%), and 32 administrators (20.3%). Between 12 and 30 people at each hospital participated in interviews. Differences in RRTs at top-performing and non-top-performing sites were found in the following 4 domains: team design and composition, RRT engagement in surveillance of at-risk patients, empowerment of bedside nurses to activate the RRT, and collaboration with bedside nurses during and after a rapid response. At top-performing hospitals, RRTs were typically staffed with dedicated team members without competing clinical responsibilities, who provided expertise to bedside nurses in managing patients who were at risk for deterioration, and collaborated with nurses during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgment and experience without fear of reprisal from physicians or hospital staff. In contrast, RRT members at non-top-performing hospitals had competing clinical responsibilities and were generally less engaged with bedside nurses. Nurses at non-top-performing hospitals reported concerns about potential consequences from activating the RRT. This qualitative study's findings suggest that top-performing hospitals feature RRTs with dedicated staff without competing clinical responsibilities, that work collaboratively with bedside nurses, and that can be activated without fear of reprisal. These findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

Surveying the Literature

Surveying the Literature

How Do Resuscitation Teams at Top-Performing Hospitals for In-Hospital Cardiac Arrest Succeed? A Qualitative Study.

In-hospital cardiac arrest (IHCA) is common, and outcomes vary substantially across US hospitals, but reasons for these differences are largely unknown. We set out to better understand how top-performing hospitals organize their resuscitation teams to achieve high survival rates for IHCA. We calculated risk-standardized IHCA survival to discharge rates across American Heart Association Get With The Guidelines-Resuscitation registry hospitals between 2012 and 2014. We identified geographically and academically diverse hospitals in the top, middle, and bottom quartiles of survival for IHCA and performed a qualitative study that included site visits with in-depth interviews of clinical and administrative staff at 9 hospitals. With the use of thematic analysis, data were analyzed to identify salient themes of perceived performance by informants. Across 9 hospitals, we interviewed 158 individuals from multiple disciplines including physicians (17.1%), nurses (45.6%), other clinical staff (17.1%), and administration (20.3%). We identified 4 broad themes related to resuscitation teams: (1) team design, (2) team composition and roles, (3) communication and leadership during IHCA, and (4) training and education. Resuscitation teams at top-performing hospitals demonstrated the following features: dedicated or designated resuscitation teams; participation of diverse disciplines as team members during IHCA; clear roles and responsibilities of team members; better communication and leadership during IHCA; and in-depth mock codes. Resuscitation teams at hospitals with high IHCA survival differ from non-top-performing hospitals. Our findings suggest core elements of successful resuscitation teams that are associated with better outcomes and form the basis for future work to improve IHCA.

Abstract 223: Rapid Response Teams at Top-performing Hospitals for In-hospital Cardiac Arrest: A Qualitative Study

Background: Prior studies have shown that hospitals with exceptional survival for in-hospital cardiac arrest (IHCA) also excel at preventing IHCA—a key function of rapid response team (RRT). However, little is known about how RRTs differ across sites. We used qualitative methods to evaluate organizational and contextual factors of RRTs that may be linked to hospital performance on IHCA survival. Methods: We selected 9 academically and geographically diverse hospitals in the AHA Get With The Guidelines Resuscitation registry based on risk standardized IHCA survival during 2012-2014 (top quartile: 5 hospitals; middle quartiles: 1 hospital; bottom quartile: 3 hospitals). During site visits, we conducted semi-structured interviews with key stakeholders regarding resuscitation care at their site. We conducted a directed content analysis focused on RRT roles and activities related to preventing IHCA. Results: A total of 158 interviews were conducted that included physicians (17.1%), nurses (45.6%), other clinical (17.1%), and administrative staff (20.3%). Differences in RRTs at top and bottom performing sites were noted in the following domains: team design and composition, engagement of RRT in surveillance of at-risk patients, empowerment of bedside nurses to activate RRT, and collaboration of RRT members with bedside nurses during and after a rapid response. Differences within each domain and representative quotes are included in the Table. Top performing hospitals tended to have RRTs staffed with members without other clinical responsibilities, often served as a resource for bedside nurses in preventing patient decline, and collaborated with them during and after a rapid response. Bedside nurses were empowered to activate RRTs based on their judgement and experience. In contrast, RRTs at bottom performing hospitals were staffed with members with competing clinical responsibilities, and were generally less engaged with bedside nurses. Moreover, nurses were concerned about potential consequences (e.g. fear of reprisal from physicians) in calling a rapid response. Conclusions: The design and implementation of RRTs differ markedly between top and bottom performing hospitals with regard to IHCA survival. Our findings provide unique insights into RRTs at hospitals with better IHCA outcomes.

Ten CEO Imperatives for Healthcare Transformation: Lessons From Top-Performing Academic Medical Centers.

The transition from a delivery model based on volume to a model based on value is underpinning an unprecedented rate of change in healthcare. Our research identifies academic medical centers that have successfully moved their organizations from a volume-based care delivery model to a model that is based on value, achieving top decile performance in the transition. We asked senior leaders about their key imperatives in achieving system-wide healthcare transformations.Major teaching hospitals were sampled using data envelopment analysis to identify hospitals that produced the best value-based purchasing process of care, Hospital Consumer Assessment of Healthcare Providers and Systems scores, and mortality scores with the most efficient utilization of human and financial organizational resources. On-site interviews were conducted with the CEOs of the top-performing hospitals. Content analysis of the transcribed interviews revealed 10 clear imperatives that our sample of CEOs said were essential.

Abstract 11679: Post-resuscitation Care and Survival After In-hospital Cardiac Arrest

Background: More than 40% of in-hospital cardiac arrest (IHCA) deaths occur in patients during the post-resuscitation period following return of spontaneous circulation (ROSC). However, the degree to which post-resuscitation survival varies across hospitals and whether this variation is explained by hospital characteristics is unknown. Methods: We identified 80,201 patients within Get with the Guidelines-Resuscitation who achieved ROSC following IHCA. Using a multivariable hierarchical regression model, we calculated risk adjusted rates of post-resuscitation survival for each hospital and quantified hospital variation in post-resuscitation survival using median odds ratio (OR). We also assessed the association of hospital characteristics with post-resuscitation survival. Results: The mean age was 65.5 years, 57% were men, and 23% were black. Nearly 1 in 4 (23.0%) patients had an initial shockable rhythm. Overall, 33.5% of patients with ROSC survived to discharge, but the rate of post-resuscitation survival varied across hospitals (median hospital rate: 33.3%; interquartile range: 29.9%-36.7%; total range: 18.9%-55.1%). The median OR was 1.35 (95% CI: 1.30, 1.39, Figure), which suggests that post-resuscitation survival for 2 patients with similar covariates at 2 randomly selected hospitals varied by 35%. Except U.S. census region (P&lt;0.001), no hospital characteristic was associated with hospital rates of post-resuscitation survival including, academic status, total bed number, hospital ownership, use of intensivists; number and proportion of intensive care unit [ICU] beds, neurological services, and coronary angiography capability. Conclusions: Rates of post-resuscitation survival vary among U.S. hospitals. However, this variation is not explained by hospital structural characteristics, thus highlighting a pressing need to identify post-resuscitation best practices at top-performing hospitals in post-cardiac arrest care.