Why Do Academic Medical Centers Do Poorly on Quality Report Cards?

In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut.  Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’”

The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21stcentury.

The most pressing challenge for American medicine has been summarized in the triple aim:  how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.

Can we expect academic medical centers to lead the country in meeting the challenge?  If history is any guide, the answer may be no.  In a 2001 article titled “Improving the Quality of Health Care:  Who Will Lead?” the authors write:

“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education.  They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years:  tobacco control, health care cost containment, and universal access.”

Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research.  While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.

This gap between what the country needs and what medical schools traditionally emphasize was demonstrated when researchers studied more than 60,000 medical school graduates from 1999 to 2001.  As Pauline W. Chen, MD wrote in the New York Times:

“Putting the issues of primary care shortage, underserved communities and workforce diversity under the banner of ‘social mission,’ the researchers found that many of the schools that were traditionally ranked highly were also among those least focused and least successful in addressing the most pressing issues facing the country right now.”

A recent report from the Lucien Institute at the National Patient Safety Foundation describes the kind of culture required to achieve the goals of the triple aim.

“Achieving safety in the work environment requires much more than implementing new rules and procedures. It requires developing and sustaining cultures of safety that engender trust and embrace reporting, transparency, and disciplined practices.  It also requires an atmosphere of respect among the health care disciplines and a fundamental ability of all practitioners to work together in teams.”

The Association of American Medical Colleges survey on medical school culture reveals a culture that does little to encourage trust and transparency. From 2004 to 2008, 12.7% to 16.7% of students reported being publicly belittled or humiliated.  The best program for implementing a culture of safety I have seen did not originate in an academic medical center; it was developed and implemented at the Sentara Healthcare System in Virginia.

Academic medical center hospitals often save the lives of patients with complicated conditions who benefit from cutting edge treatments supported by basic science research.  However, it is revealing that the community Holy Cross Hospital in Silver Spring, Maryland made the Joint Commission’s list of  “top performers” and the famed Johns Hopkins did not do as well on the quality scoring report card.

The Holy Cross vice president of quality and care management cites three factors for the hospital’s excellent quality results: intensive review of patients’ charts, the electronic medical record system, and the leadership focus on quality.

When it comes to choosing a hospital, patients should take into account quality report cards as well as reputation.


7 replies »

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  2. I worked in risk and safety (before they really developed into two different disciplines) in a major academic center. I found it very difficult to direct attention and resources to safety and loss prevention, when most allocation of resources related to supporting the folks who got the most grant money and publicity. When there were safety initiatives, they tended to follow the tracks that would support research and publication, not necessarily what we needed. I completely agree that an academic center will have unique access to cutting edge care, but in most that comes at the cost of reducing support for the dull, everyday work of safety.

  3. Kent–

    You say it all in this sentence:

    “The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21st century.”

    Yes. Thank you.

  4. gotta love people who want to compare apples to pineapples. Tertiary care is truly a thankless place to work, you get the complicated cases who have the higher morbidity and mortality rates, and now that you have a faceless, nameless bureaucracy running the show that some people commenting here think is the second coming of Christ, well, is he going to be treating these people so these academic centers score better?

    Wow, the disingenuous commentary is becoming legendary in shoving this legislation down our unrepresented throats. Again, I hope what goes around comes around!

  5. sm2012–

    I agree that “outcomes reserach “i s an infant sicence. And “performance measures” can be very misleading.

    That said, brand-name hospitals (usually academic medical centers) charge far more than other providers, and the quality evidence that we have suggests that they quality of care that they offer doesn’t even come close to equalling the price differential.

    They can charge private insurers more because they have more market clout. Patietns believe that the most expensive providers must be better, and so want them in their insurers’ networks.

    Moreover, in most academic medical centers, research equals glory–clinical care is considered far less important. Doctors are not rewarded for excelling at clinical care.

    Finally, residents working 12-hour shifts in AMCs often endanger patients.

    That said, I agree that small community hospitals do not necessarily provide better care.

    Too many small hospitals in the suburbs are in way over their heads–doing
    organ transplants when they don’t do enough to develop expert teams

    What we need are more “centers of excellence” that put clinical care ahead of
    research. Traditionally, Mayo in Rochester, Minnesota has done this, as has MD. Anderson (the cancer center in Houston). I’m a little worried that the new CEO at Anderson is now trying to turn it into a research institution. Will be writing about this. (Does anyone have any information?)

    Obviously we also need institutions that focus on research But clinical care and research are two differnt missions.


  6. I have been an academic surgeon for many years and for the last several, a consultant brought in to hospitals to work on exactly the issues this post references. Working with the big academic institutions is particularly interesting and challenging because of the increased complexity of factors involved (residency, work hour issues, research mandates, obligation for unfunded care, etc). Here’s what I learned…

    There is no question about the focus on individual performance and also on research /publication/ clinical work at the big academic centers. But..and this is a big but…the idea that Local Community Hospital X delivers better care than Big Academic Center Y based on USNews/Jcaho/HealthGrades/Rating System Z really is often more of a statement about the poor quality of the metrics and assesment systems than it is about the quality of care provided.

    My favorite comment when I’d go into a new hospital and have to convince a physician about the changes needed is when the physician who worked at the worse ranked academic hospital AND the better ranked community center would criticize the ratings systems – ‘I work at both hospitals and there is no question that the (academic hospital) is better than the (community one). That tells me your rating system is shit’.

    It wasn’t just doctors whining. They were anecdotally correct, the data just didn’t show it. Any time I hear information where anecdotal experience and formalized data don’t line up, I wonder where the mismatch is. In this case, the issues are around process and outcomes measures. We have become so obsessed with outcomes and quality measures that are hard to wrap our hands around, we have come up with a whole series of proxies to do our work (readmission rates, wait times, morbidity rates for outcomes like renal failure after hip surgery, rates of hand washing, etc). Of course it’s important to look at outcomes and to gear the processes that help to lead to these better outcomes, but it is a major mistake to think that these outcome measures alone provide a real sense of whether or not the care is better.

    I trained at Hopkins and I know the local community hospital being referenced. I understand the importance of the processes that some of the better rated institutions use, and I know the limits and problems at the big academic centers. There is no question that some of the processes from organizations that focus on quality should be incorporated into the academic centers, but it is a mistake to think that these measures alone reflect the value of one hospital vs another.