Domains, Key Themes, and Quotes in Hospitals With High Performance in 30-Day Risk-Standardized Mortality Rate for Patients With Acute Myocardial Infarction

Domain and Theme	Quotes
Organizational values and goals
Shared values to provide exceptional, high-quality care	[We are] constantly resetting that bar, retooling every single thing. . . . [I]f you aim for As, you get As, and if you accept Zs, that’s what you get. We don’t accept anything less than the very best. (Nurse manager, hospital 4)
Alignment of quality and financial goals of the organization	I think they made the case very strongly to the hospital partners that this was, you know, very good for the public health. It was good for the hospital from a position of being known nationwide and then financially it was very good. That always helps, especially with the CFO [chief financial officer], and we’re spending resources and making investments. (Administrator, hospital 2)
Senior management involvement
Provision of adequate financial and nonfinancial resources	Administration was overwhelmingly supportive of the needs of the staff and the departments to say, “What do you need to get this done?” And that truly . . . they set the guidelines and the standard to say, “This is not acceptable and this is where we need to go.” In my opinion, I think that was huge. (Cardiologist, hospital 7)
Use of quality data in management decisions	I pay attention to all that data that comes out in real time and view it as my job to, to intervene but also not just the person intervene but manage it from the top down but to create a culture where, where in fact that is embedded. (Vice President, Quality, hospital 4)
Holding staff accountable for decisions	If there’s something that’s out of line, we’re not bashful about sending a quality letter to that individual and asking them to explain the variance. . . . When people do the right thing, we send out a letter from our Medical Director. . . . [Y]ou have to have the accountability on one side and then the recognition on the other. (Medical Director, Emergency Services, hospital 7)
Broad staff presence and expertise
Sustained physician champions	We have a pretty structured process-improvement mechanism. We have a culture of sort of getting along, sharing, and sort of raising the bar. We have some pretty exacting people that do this. We have a huge process champion in [X]. It helps to have the chief of the department be an interventional cardiologist. It’s what his research interest is; it’s what he does clinically, and sort of the people that have, under him over the years, sort of looked up at the structure he’s created, and we’ve built upon that with a lot of successes. (Cardiologist, hospital 5)
Empowered nurses	I started writing my [nursing] consult notes in the physician progress notes. . . . [O]ver the years it’s just become the standard. . . . That was a way of my breaking into the culture saying, “This is my note; I want you to read it. It’s not in the nurse’s section. I have some ideas . . . and I’m open to talking about it.” (Nurse manager, hospital 5)
Involved pharmacists	The pharmacy department . . . has put a system in place where each order needs to be verified by a pharmacist, so a pharmacist needs to review each prescription order, look at the drug, the dose, and the route. And then if everything sort of checks, the dose and drug gets verified. So, that’s one system that has been put into place to help, hopefully to prevent medical errors. (Pharmacist, hospital 3)
High-quality standards for staff	[Staff here have] a very, very strong work ethic. . . . [I]f you didn’t intend to work in a similar fashion, this [isn’t] a good place for you. . . . [T]hey are very careful in their selection from the very beginning. Success breeds success. . . . [Y]ou have to fit into the culture. (Chief Executive Officer, hospital 2)
Communication and coordination among staff
Valuing diverse roles and skills	Everyone brings something to the table; the nurse has great patient assessment skills; the radiologic technologist is great with my equipment and tweaks that so that works; the cardiovascular technologist is great with the hemodynamics and some of the recording stuff; and they’ve all been cross-trained to prepare the drugs, administer the drugs, monitor the patients, sit in any one of the roles in the room. (Cardiologist, hospital 5)
Recognizing interdependencies	I walk into this cath lab and I can’t tell who’s a nurse and who’s a tech because they all work together as a team. So I thought that was like . . . that’s a really good compliment because you would be able to see the differences if they didn’t work as a team, if each one worked in a different pocket. But she was so new and just seeing how everybody worked together with the patient it was like I can’t tell who’s who here. Everybody works as a team. (Cardiac program manager, hospital 6)
Smooth information flow	There’s a nursing leadership group and all this information is shared. And you know they’re pretty open to doing what’s best for the patient. (Nursing manager, hospital 7)
Problem solving and learning
Use of adverse events as opportunities to learn	There are 4 stages in dealing with adverse events: The data are wrong; the data are correct but it’s not a problem; the data are correct and it’s a problem, but it’s not my problem; the data are correct and I own the responsibility to fix the problem. . . . [T]his organization [is at] the level of “the data are correct and I own the responsibility to fix the problem.” I think that’s really the key. (Chief Executive Officer, hospital 2)
Use of data for nonpunitive learning	We’ll do an e-mail to everybody and say, “These are the things we did well at, and these are the things that we missed the mark on.” And then we’ll go through, because we’ve documented to see which person we need to contact, and then either . . . it’s usually the unit-based educator will contact those people and say, “Look, you did great here. Just what we’re noticing, and we want to make sure that you know this, that you have to document restraints every two hours by hospital policy. It’s not punitive at all. It’s just, we want to make sure you know this. (Nurse manager, hospital 5)
Innovation and creativity in trial and error	I think one of the reasons that it’s been successful is it makes clinical sense to the people given the care and it’s not a fancy 6-sigma. It’s just like how they care for patients every day. You know? You look. You do something. Did it work or not? You tweak the system and that’s why we’ve been very successful. (Director of Quality, hospital 4)
Learning from outside sources	We send our staff from the east coast to the west coast to see what the latest technology is. . . . [W]e can either improve upon that or say that that’s not the right thing for us. . . . [W]e’re always out to try new things. (Manager, catheterization laboratory, hospital 2)