1. Research on the relationship between organisational culture and outcomes A study of 11 US hospitals used risk adjusted 30 day mortality for AMI as an outcome measure and explored reasons for variation between high and low performers: Top 5% performers Bottom 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Mortality rates were as much as double in poor performers compared with top performers, but differences in care processes and protocols could not account for this…

2. Distinguishing cultural features in high performing hospitals DomainTheme Organisational values and goals. Shared values to provide exceptional care. Alignment of quality and financial goals. Senior management involvement. Adequate financial and non-financial resources. Use of quality data in management decisions Holding staff accountable for decisions. Broad staff presence and expertise. Sustained medical champions. Empowered nurses and pharmacists. High quality standards for all staff. Communication and coordination among staff. Valuing diverse roles and skills. Recognising interdependencies. Smooth information flow. Problem solving and learning. Use of adverse events as opportunities to learn. Use of data for non-punitive learning. Innovation and creativity in trial and error. Learning from outside sources

3. Organisational values and goals Top 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Bottom 5% performers We constantly re-set the bar. If you aim for A’s you get A’s. Common vision and values are the driving force behind everything. Clinical and admin staff recognise that aligning multiple goals is essential. Achieving high quality clinical outcomes is consistent with achieving positive financial outcomes The hospital likes to get disease specific accreditation and advertise it. They formed a committee and tried to tick the boxes on what they are supposed to do. The administration is concerned about the bottom line.

4. Senior management involvement Top 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Bottom 5% performers If there’s something out of line, we’re not bashful about asking individuals to explain the variance. You have to have accountability on one side and recognition of high performance on the other Using data openly and consistently to foster staff accountability. Senior management rely on quality data in strategic planning and resource allocation. Accountability is uneven and feedback does not always result in corrective action. Data is used intermittently or ineffectually to guide decisions Managers do not encourage ownership of performance problems Involvement of senior managers is sporadic

5. Staff presence and expertise in AMI care Top 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Bottom 5% performers We have a pretty structured process improvement mechanism. Staff have a very strong work ethic – you have to fit into the culture. There is a passion from clinical leaders to have the best outcomes in the world. Nurses sare empowered to challenge the status quo. It’s discouraging not having doctor-nurse conversations. There a difficulties in attracting and retaining skilled and experienced staff. Physician involvement in improvement efforts are weak or non-existent. Nurses are not treated as valued team members and are expected to carry out doctor instructions

6. Communication and coordination Top 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Bottom 5% performers Everyone in this hospital from the house-keeper to the CEO plays a role. A shared commitment to ensure effective communication across disciplines and departments Staff recognise interdependency and have a shared commitment to seamless transitions of care The hospital is feeling under pressure, so everybody is not into this teamwork attitude. Poor structural support for communications in terms of meetings and IT Lack of respect for diverse roles Everyone wants to know they have their own nests feathered.

7. Problem solving and learning. Top 5% performers Curry, L et al.(2011) What distinguishes top-performing hospitals in AMI mortality rates? Ann Intern Med. 154:384-390. American College of Physicians Bottom 5% performers We identify improvement steps and we continue to measure to see if it is working Adverse events are used as opportunities for to analyse root causes, learn from experience and improve care A non-punitive approach to problem solving. [In quality improvement meetings you hear] what can I do about that stupid department – they can’t get anything done! Problem solving is less constructive and formal tools are not used. Staff seek outside expertise to solve problems and learn new approaches. Little encouragement for innovation by frontline staff Use of data is variable