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      Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies

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          Identifying characteristics associated with struggling healthcare organisations may help inform improvement. Thus, we systematically reviewed the literature to: (1) Identify organisational factors associated with struggling healthcare organisations and (2) Summarise these factors into actionable domains.


          Systematic review of qualitative studies that evaluated organisational characteristics of healthcare organisations that were struggling as defined by below-average patient outcomes (eg, mortality) or quality of care metrics (eg, Patient Safety Indicators). Searches were conducted in MEDLINE (via Ovid), EMBASE, Cochrane Library, CINAHL, and Web of Science from database inception through February 8 2018. Qualitative data were analysed using framework-based synthesis and summarised into key domains. Study quality was evaluated using the Critical Appraisal Skills Program tool.


          Thirty studies (33 articles) from multiple countries and settings (eg, acute care, outpatient) with a diverse range of interviewees (eg, nurses, leadership, staff) were included in the final analysis. Five domains characterised struggling healthcare organisations: poor organisational culture (limited ownership, not collaborative, hierarchical, with disconnected leadership), inadequate infrastructure (limited quality improvement, staffing, information technology or resources), lack of a cohesive mission (mission conflicts with other missions, is externally motivated, poorly defined or promotes mediocrity), system shocks (ie, events such as leadership turnover, new electronic health record system or organisational scandals that detract from daily operations), and dysfunctional external relations with other hospitals, stakeholders, or governing bodies.


          Struggling healthcare organisations share characteristics that may affect their ability to provide optimal care. Understanding and identifying these characteristics may provide a first step to helping low performers address organisational challenges to improvement.

          Systematic review registration

          PROSPERO: CRD42017067367.

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          Most cited references 61

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          Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus.

          Despite control efforts, the burden of health-care-associated infections in Europe is high and leads to around 37,000 deaths each year. We did a systematic review to identify crucial elements for the organisation of effective infection-prevention programmes in hospitals and key components for implementation of monitoring. 92 studies published from 1996 to 2012 were assessed and ten key components identified: organisation of infection control at the hospital level; bed occupancy, staffing, workload, and employment of pool or agency nurses; availability of and ease of access to materials and equipment and optimum ergonomics; appropriate use of guidelines; education and training; auditing; surveillance and feedback; multimodal and multidisciplinary prevention programmes that include behavioural change; engagement of champions; and positive organisational culture. These components comprise manageable and widely applicable ways to reduce health-care-associated infections and improve patients' safety.
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            Implementation of the patient-centered medical home in the Veterans Health Administration: associations with patient satisfaction, quality of care, staff burnout, and hospital and emergency department use.

            In 2010, the Veterans Health Administration (VHA) began implementing the patient-centered medical home (PCMH) model. The Patient Aligned Care Team (PACT) initiative aims to improve health outcomes through team-based care, improved access, and care management. To track progress and evaluate outcomes at all VHA primary care clinics, we developed and validated a method to assess PCMH implementation.
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              What distinguishes top-performing hospitals in acute myocardial infarction mortality rates? A qualitative study.

              Mortality rates for patients with acute myocardial infarction (AMI) vary substantially across hospitals, even when adjusted for patient severity; however, little is known about hospital factors that may influence this variation. To identify factors that may be related to better performance in AMI care, as measured by risk-standardized mortality rates. Qualitative study that used site visits and in-depth interviews. Eleven U.S. hospitals that ranked in either the top or the bottom 5% in risk-standardized mortality rates for 2 recent years of data from the Centers for Medicare & Medicaid Services (2005 to 2006 and 2006 to 2007), with diversity among hospitals in key characteristics. 158 members of hospital staff, all of whom were involved with AMI care at the 11 hospitals. Site visits and in-depth interviews conducted with hospital staff during 2009. A multidisciplinary team performed analyses by using the constant comparative method. Hospitals in the high-performing and low-performing groups differed substantially in the domains of organizational values and goals, senior management involvement, broad staff presence and expertise in AMI care, communication and coordination among groups, and problem solving and learning. Participants described diverse protocols or processes for AMI care (such as rapid response teams, clinical guidelines, use of hospitalists, and medication reconciliation); however, these did not systematically differentiate high-performing from low-performing hospitals. The qualitative design informed the generation of hypotheses, and statistical associations could not be assessed. High-performing hospitals were characterized by an organizational culture that supported efforts to improve AMI care across the hospital. Evidence-based protocols and processes, although important, may not be sufficient for achieving high hospital performance in care for patients with AMI. Agency for Healthcare Research and Quality, United Health Foundation, and the Commonwealth Fund.

                Author and article information

                BMJ Qual Saf
                BMJ Qual Saf
                BMJ Quality & Safety
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                January 2019
                25 July 2018
                : 28
                : 1
                : 74-84
                [1 ] departmentDepartment of Internal Medicine , University of Michigan Medical School , Ann Arbor, Michigan, USA
                [2 ] departmentCenter for Clinical Management Research , Veterans Affairs Ann Arbor Healthcare System , Ann Arbor, Michigan, USA
                [3 ] departmentPatient Safety Enhancement Program , Ann Arbor Veterans Affairs Medical Center/University of Michigan , Ann Arbor, Michigan, USA
                [4 ] departmentDepartmentof Pediatrics and Communicable Diseases , University of Michigan Medical School , Ann Arbor, Michigan, USA
                [5 ] departmentTaubman Health Sciences Library , University of Michigan , Ann Arbor, Michigan, USA
                Author notes
                [Correspondence to ] Dr Valerie M Vaughn, Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; valmv@
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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