JAMA Internal Medicine: Medical Practice Topic Collection

Management Practices and the Quality of Care in Cardiac Units Management Practices in Cardiac Units

McConnell K, Lindrooth RC, Wholey DR, et al. — Mon, 22 Apr 2013 00:00:00 GMT

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.

To Meet Health Care's Triple Aim, Lean Management Must Be Applied Across the Value Stream Comment on “Management Practices and the Quality of Care in Cardiac Units” Application of Lean Management

Armstrong S, Fox E, Chapman W. — Mon, 22 Apr 2013 00:00:00 GMT

Many health care organizations seeking solutions to the broad and complex range of problems facing US health care are exploring management practices, such as the “Lean” system, that have improved performance in manufacturing and technology sectors. McConnell and colleagues report that adapting such practices to one type of health care setting—hospital interventional cardiac units—resulted in improved process-of-care measures and lowered 30-day mortality from acute myocardial infarctions.

Interventions to Decrease Hospital Readmissions Keys for Cost-effectiveness Interventions to Decrease Hospital Readmissions

Burke RE, Coleman EA. — Mon, 22 Apr 2013 00:00:00 GMT

Hospitals began paying financial penalties for high-risk–adjusted 30-day readmission rates for certain diagnoses in October 2012. Physician leaders seeking to reduce readmission rates will find that proven interventions often require substantial up-front financial and organizational investment. To reduce readmissions while minimizing the investment, leaders need to develop new and creative strategies guided by the evidence. This article describes 5 proposed strategies or “best practices” derived from critical evaluation of prior interventions and experience in the field. These practices include matching the intensity of the intervention to the patient's risk of readmission, avoiding commonly used but unproven interventions, using interventions with a durable effect, creating an effective team before selecting an intervention, and focusing on previously unrecognized high-risk patient groups.

Burnout Exists: Cut the Fuel and Use the Fire Hose

Girbes AJ, Zijlstra JG. — Mon, 22 Apr 2013 00:00:00 GMT

Shanafelt et al again underscore the embarrassing incidence of burnout symptoms among physicians. However, in the discussion, 2 important issues should be addressed. Attributing burnout score differences between the general population and physicians to job characteristics can only be done after correction for baseline differences in proneness for burnout. Maybe students choosing medicine are somewhat more neurotic or less resilient. These students, and this is the second issue, start a professional life in an emotionally, physically, and financially exhausted condition. During training they have to survive in a highly competitive atmosphere, with still extreme working hours, and will end with large debts. In the meantime they have to find a relation and start a family. And then they are ready for a profession with a discolored aura.

Declining Proportion of Physician-Owned Practices Possibly Related to Increasing Burnout

Joshi S, Nehaul R, Broome MA. — Mon, 22 Apr 2013 00:00:00 GMT

In their article “Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population,” Shanafelt et al do an excellent job identifying increased rates of burnout among physicians, especially those in primary care. Their findings deserve immediate action to address the underlying causes.

Physician Burnout: An Urgent Call for Early Intervention

Mirrakhimov AE, Rimoin LP, Kwatra SG. — Mon, 22 Apr 2013 00:00:00 GMT

We read the study by Shanafelt et al with great interest. The authors surveyed 7268 US physicians for professional burnout in comparison with nonmedical US workers. They showed that physicians have a higher prevalence and a significantly greater risk for professional burnout compared with the general population. We are thankful to the authors for studying this extremely important topic. The major question that remains is why this happens, and more importantly, what we can do to prevent physician burnout?

Physician Burnout: An Urgent Call for Early Intervention—Reply

Shanafelt TD, Dyrbye LN, West CP. — Mon, 22 Apr 2013 00:00:00 GMT

In reply

Clinical and Ethical Aspects of Placebos in Clinical Practice—Reply

Avins AL. — Mon, 22 Apr 2013 00:00:00 GMT

In reply

Acupuncture's Elephant in the Room

Barrett S, London WM. — Mon, 22 Apr 2013 00:00:00 GMT

The optimistic article by Vickers et al did not consider an important point. Research studies may not reflect what takes place in most acupuncturist offices. Most acupuncturists are graduates of “oriental medical schools,” where they learn about 5-element theory, “energy” flow through meridians, and other fanciful traditional Chinese medicine (TCM) concepts that do not correspond with scientific knowledge of anatomy, physiology, or pathology. Practitioners of TCM typically rely on inappropriate diagnostic procedures (pulse and tongue diagnosis) and prescribe herbal mixtures that have not been sufficiently studied. Diagnoses based on TCM such as “Qi stagnation,” “blood stagnation,” “kidney Qi deficiency,” and “yin deficiency” may not jeopardize patients who are treated in an academic setting, where they have received a medical diagnosed before entering the study. But what about people with conditions that TCM-trained acupuncturists are not qualified or inclined to diagnose? Real-world evaluations of acupuncture should also consider the cost of unnecessary treatment.