title: Physicians' identification of factors associated with quality in high- and low-performing hospitals.
abstract: BACKGROUND
  Increasing the transparency of quality outcomes will demand that organizations strive to improve their performance, which in turn will require that physicians become engaged in the improvement process. Frontline physicians from hospitals with low and high performance on quality indicators were interviewed about contributors and obstacles to quality in their organizations.
  
  
  METHODS
  Hospital Quality Alliance data were used to identify hospitals with consistent performance during the preceding two years from the top (high performing) and bottom deciles (low performing) on internal medicine outcome measures (pneumonia and congestive heart failure). Semistructured interviews were conducted in early 2008 with 17 physicians (internists) from three academic medical centers and two small community hospitals.
  
  
  RESULTS
  Five themes emerged from the interviews: leadership characteristics, information technology, personalized and organizational outcome data, investment in education for quality, and physician organization structure. Although physicians' views about influences on quality were similar across low- and high-performing hospitals, low performers tended to have transient leadership, low levels of access by frontline physicians to leaders, little investment in information technology, and fewer clear mechanisms to ensure clinical accountability.
  
  
  CONCLUSIONS
  Frontline physicians' views provide insights into determinants of quality that are consistent with the literature. Physician engagement with quality appears to be more a property of organizations than physicians and emerges from organizational leadership. A number of policies, informed by frontline physicians' views, could be pursued to achieve better quality, especially in organizations whose outcomes suggest poor performance.
authors.affiliation: Division of General Internal Medicine, Brigham and Women's Hospital, Boston, USA. phockey@partners.org
authors.forename: Peter M
authors.initials: PM
authors.lastname: Hockey
authors.forename: David W
authors.initials: DW
authors.lastname: Bates
mesh_terms: D006761:Hospitals / Q000592:standards*; D006801:Humans; D007407:Interviews as Topic; D010820:Physicians; D019984:Quality Indicators, Health Care