Many cardiac units fall short at best management practices

Few cardiac units have adopted many of the management practices that have proven effective in manufacturing, according to a recent study. “We have good understanding of what it means to practice evidence-based medicine,” the lead author told Cardiovascular Business. But in terms of evidence-based management, “we are still in the dark ages.”

K. John McConnell, PhD, director of the Oregon Health & Science University’s Center for Health Systems Effectiveness in Portland, and colleagues adapted “lean” and other formalized management approaches used in manufacturing and technology sectors to improve quality to develop a survey for the cardiac inpatient setting. They reasoned that practicing best management strategies might improve the quality of care in cardiac units.

Their survey included 18 management practices grouped in four categories: standardizing care, performance measurements, targets and employee incentives. They recruited 597 nonfederal cardiac units in the U.S. in 2010 to participate in the survey and complete interviews, and they then scored each unit’s performance on the 18 practices on a one- to five-point scale. Five was best, one was worst.

To assess quality of care, they obtained 2010 data publicly available through Hospital Compare on units’ performance in six acute MI measures. They used the 2010 Medicare Provider Analysis and Review file and risk adjustment techniques to calculate 30-day mortality and readmissions.

Less than 2 percent of units achieved a score that reflected little or no adoption of the management practices, and 10.6 percent scored in a range that showed high adoption of the practices. Across all 18 practices, only 23.1 percent scored a four or five (indicating best practices) on more than nine measures.

McConnell et al found that management scores were associated with a significant improvement in 30-day risk-adjusted mortality but not readmissions.

McConnell said that interviews showed that many units had applied good management practices such as standardization, training and use of targets. “That is in part a reflection of where cardiology is relative to other specialties,” he said, pointing to implementation of evidence-based guidelines and buy-in in the cardiology community to adopt these standards.

But the researchers also identified wide differences in management practices across hospitals. “For a few hospitals, it is still the norm for the physician to drive the ship,” he said, by dictating procedures, choosing vendors and discouraging nurses from contributing to the dialog, for instance. “Mostly hospitals have moved away from that norm, but we still saw examples where that happened.”

The lack of an association between best management practices and 30-day readmissions may suggest that factors outside the hospital drive readmissions, he said.

Also, the 18 practices summarized in the study may provide a framework for cardiac units in need of defining a management strategy, or they may serve as a check list for hospitals’ existing management programs. The 18 practices are broadly applicable to other clinical settings as well, McConnell said.

But he acknowledged that implementing best practices remains a challenge. “How do you get from being a hospital that does two’s to five’s?” he said. “That is much murkier and a more difficult process.”    

The study was published online March 18 in JAMA Internal Medicine.