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.’” (http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html )

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 21^st century.

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 state

“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.”  

(http://content.healthaffairs.org/content/20/5/164.abstract)

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.” (http://thehealthcareblog.com/blog/2010/03/20/a-culture-of-fear-and-intimidation-reforming-medical-education/)

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. (http://www.washingtonpost.com/national/health-science/holy-cross-2-other-area-hospitals-make-top-performer-list/2012/09/20/5cf2bba2-0334-11e2-9b24-ff730c7f6312_story.html )

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