title: Organizational culture change in U.S. hospitals: a mixed methods longitudinal intervention study.
abstract: BACKGROUND
  Improving outcomes for patients with acute myocardial infarction (AMI) is a priority for hospital leadership, clinicians, and policymakers. Evidence suggests links between hospital organizational culture and hospital performance; however, few studies have attempted to shift organizational culture in order to improve performance, fewer have focused on patient outcomes, and none have addressed mortality for patients with AMI. We sought to address this gap through a novel longitudinal intervention study, Leadership Saves Lives (LSL).
  
  
  METHODS
  This manuscript describes the methodology of LSL, a 2-year intervention study using a concurrent mixed methods design, guided by open systems theory and the Assess, Innovate, Develop, Engage, Devolve (AIDED) model of diffusion, implemented in 10 U.S. hospitals and their peer hospital networks. The intervention has three primary components: 1) annual convenings of the ten intervention hospitals; 2) semiannual workshops with guiding coalitions at each hospital; and 3) continuous remote support across all intervention hospitals through a web-based platform. Primary outcomes include 1) shifts in key dimensions of hospital organizational culture associated with lower mortality rates for patients with AMI; 2) use of targeted evidence-based practices associated with lower mortality rates for patients with AMI; and 3) in-hospital AMI mortality. Quantitative data include annual surveys of guiding coalition members in the intervention hospitals and peer network hospitals. Qualitative data include in-person, in-depth interviews with all guiding coalition members and selective observations of key interactions in care for patients with AMI, collected at three time points. Data integration will identify patterns and major themes in change processes across all intervention hospitals over time.
  
  
  CONCLUSIONS
  LSL is novel in its use of a longitudinal mixed methods approach in a diverse sample of hospitals, its focus on objective outcome measures of mortality, and its examination of changes not only in the intervention hospitals but also in their peer hospital networks over time. This paper adds to the methodological literature for the study of complex interventions to promote hospital organizational culture change.
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. leslie.curry@yale.edu.|Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. leslie.curry@yale.edu.
authors.forename: Leslie A
authors.initials: LA
authors.lastname: Curry
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. erika.linnander@yale.edu.
authors.forename: Erika L
authors.initials: EL
authors.lastname: Linnander
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. amanda.brewster@yale.edu.
authors.forename: Amanda L
authors.initials: AL
authors.lastname: Brewster
authors.affiliation: New York Presbyterian Hospital, New York, NY, USA. hting@nyp.org.
authors.forename: Henry
authors.initials: H
authors.lastname: Ting
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. harlan.krumholz@yale.edu.|Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. harlan.krumholz@yale.edu.|Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA. harlan.krumholz@yale.edu.|Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. harlan.krumholz@yale.edu.
authors.forename: Harlan M
authors.initials: HM
authors.lastname: Krumholz
authors.affiliation: Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA. elizabeth.bradley@yale.edu.|Robert Wood Johnson Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA. elizabeth.bradley@yale.edu.
authors.forename: Elizabeth H
authors.initials: EH
authors.lastname: Bradley
mesh_terms: D004059:Diffusion of Innovation; D006739:Hospital Administration; D006761:Hospitals / Q000592:standards; D006801:Humans; D008137:Longitudinal Studies; D009203:Myocardial Infarction / Q000628:therapy; D015279:Organizational Culture; D009936:Organizational Innovation; D058996:Quality Improvement / Q000458:organization & administration; D013598:Systems Theory; D014481:United States