Being a good team player may make all the difference when trying to save patients suffering from heart attacks. Top-tier hospitals with low acute myocardial infarction (AMI) mortality rates achieve those results not only though state-of-the-art care but also because they foster a work atmosphere in which people combine their talents and strive toward a common goal, according to a study published in the March 15 issue of theAnnals of Internal Medicine

“While protocols and processes are important for AMI outcomes, it really is critical to pay attention to the environment in which those are implemented,” said Leslie A. Curry, M.P.H., Ph.D., research scientist at the School of Public Health and lead author of the paper. 

Curry and her colleagues found that hospitals with the lowest AMI mortality rates exhibit a “positive culture” characterized by shared organizational values and goals; consistent involvement of senior management; broad staff presence and expertise in AMI care; effective communication and coordination among interdependent groups; and an approach to problem solving that emphasizes learning and growth. In low-performing hospitals, they found, staff often work in isolation, communicate poorly with members of the multidisciplinary health care team, point fingers when problems arise, and have no common vision regarding delivery of excellent health care. 

“The importance of a positive culture has not been highlighted in the medical literature or in medical education, and our study may be heralding a factor that is as powerful as any new treatment,” said co-author Harlan M. Krumholz, M.D., M.Sc., the Harold H. Hines Jr. Professor of Medicine. 

Surprisingly, the Yale investigators did not find any specific process or protocol, such as the use of rapid response teams or clinical guidelines, which differentiates high- from low-performing hospitals. “We may know what to do given current evidence, but how we provide care may also be very important,” Krumholz said. “An environment of coordination, communication, and collaboration may make a difference in making sure that mistakes are avoided and treatments achieve their promise.” 

Researchers focused on improving the quality of health care have long sought to identify the factors that distinguish top-performing hospitals with stellar heart attack survival records. Prior studies, however, have failed to identify a silver bullet. The Yale group took a decidedly different approach with a provocative methodology called positive deviance. This approach examines exceptional performance (so-called positive deviance) to understand how it leads to high outcomes relative to others. The Yale team explored myriad aspects of the hospital setting qualitatively rather than quantitatively—an approach that better reveals the importance of social interactions and organizational culture, which are difficult to measure using common research methods like surveys. “The nice thing is that we discovered a lot of approaches that do not require huge financial investments, which bodes well for improving quality without increasing costs,” said Elizabeth Bradley, M.B.A., Ph.D. ’96, professor of public health and a co-author of the paper. 

The Yale group is now validating their initial qualitative findings, culled from 11 hospitals that ranked in either the top or bottom 5 percent in risk-standardized mortality rates, by conducting a nationally representative survey of more than 500 U.S. hospitals to identify and confirm specific hospital behaviors that promote positive AMI outcomes. “Soon we’ll be able to give hospitals more concrete advice about actions they can take to provide quality AMI care,” said Curry.