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BMJ Qual Saf. 2018 Mar;27(3):207-217. doi: 10.1136/bmjqs-2017-006989. Epub 2017 Nov 3.

Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study.

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Yale School of Public Health and Yale Global Health Leadership Institute, New Haven, Connecticut, USA.
Columbia University Mailman School of Public Health, New York, USA.
Tufts University School of Medicine, Boston, Massachusetts, USA.
Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
Vassar College, Poughkeepsie, New York, USA.



Hospital organisational culture affects patient outcomes including mortality rates for patients with acute myocardial infarction; however, little is known about whether and how culture can be positively influenced.


This is a 2-year, mixed-methods interventional study in 10 US hospitals to foster improvements in five domains of organisational culture: (1) learning environment, (2) senior management support, (3) psychological safety, (4) commitment to the organisation and (5) time for improvement. Outcomes were change in culture, uptake of five strategies associated with lower risk-standardised mortality rates (RSMR) and RSMR. Measures included a validated survey at baseline and at 12 and 24 months (n=223; average response rate 88%); in-depth interviews (n=393 interviews with 197 staff); and RSMR data from the Centers for Medicare and Medicaid Services.


We observed significant changes (p<0.05) in culture between baseline and 24 months in the full sample, particularly in learning environment (p<0.001) and senior management support (p<0.001). Qualitative data indicated substantial shifts in these domains as well as psychological safety. Six of the 10 hospitals achieved substantial improvements in culture, and four made less progress. The use of evidence-based strategies also increased significantly (per hospital average of 2.4 strategies at baseline to 3.9 strategies at 24 months; p<0.05). The six hospitals that demonstrated substantial shifts in culture also experienced significantly greater reductions in RSMR than the four hospitals that did not shift culture (reduced RSMR by 1.07 percentage points vs 0.23 percentage points; p=0.03) between 2011-2014 and 2012-2015.


Investing in strategies to foster an organisational culture that supports high performance may help hospitals in their efforts to improve clinical outcomes.


leadership; qualitative research; quality improvement

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