It was also clear that all five hospitals had a clear mission, vision and values, regardless of whether they were from the private or public sector or what management model they were implementing. In order to achieve its objectives, each hospital includes in its conceptual matrix evidence of an MVV, which is consistent with the findings indicated in previous studies that hospitals should be open to the public about the MVV that constitutes the code of ethics, as it is a subject with ethical, legal and social responsibilities [33]. Between MVV, much of the content of the five hospitals is consistent and sometimes overlaps. All contents address quality of care, clinical areas, and technical and organizational management, valuing human dignity and focusing on an ethical paradigm of individuality, responsibility, and care. Healthcare delivery outcomes are shaped by considering the MVV defined by healthcare organizations as a model to guide them to practice and obtain excellence in performance.
Mission
The five hospitals’ mission statements mention quality and excellence, education and research, community engagement, access and equity, sustainability, belonging, and innovation. The missions of all five hospitals are related to life health and health care and serve a range of populations from individuals to communities to the world. As demonstrated in the results, three hospitals have inserted the pursuit of health quality and excellence into their missions. Research indicated that nearly all hospitals have adopted a management excellence approach and set goals within this framework to improve the performance of their health services organizations [34].
Meanwhile, the missions of the five hospitals show different levels of emphasis on clinical, research, and teaching, with MC focusing on all three, CC focusing on research and education, MGH and JHU on community health, and JHHs on standards of care. Four hospitals mentioned education and research in their missions. Although JHH does not mention research and education in its mission, its parent institution, Johns Hopkins Medicine (JHM), does mention research and education at length in its mission [35]. After the day of the first COVID-19 case, the primary source of global data was reported by Johns Hopkins University in the United States. The first global real-time coronavirus surveillance system was launched by the Johns Hopkins University Center for Systems Science and Engineering (JHU CSSE): Coronavirus Resource Center [36]. As of June 1, 2022, the dashboard has served a global audience for over 30 months, totaling over 226 billion feature layer requests and 36 billion page views [36]. Therefore, the academic health center, such as JHH, MGH, and UHN, can share common resources with the university, not only for the university's research but also in other fields (such as technology, law, engineering, etc.).
The role of university-affiliated hospitals has traditionally been defined by its “tripartite” mission: education, research, and clinical care [37]. These three missions have become ends in themselves rather than activities that support a common goal. Research cannot and should not become a mission in and of itself, nor should education or clinical care. All three mission areas must act together to advance a common goal: a healthy future for all. In 2021, the Association of American Medical Colleges (AAMC) authors proposed a new framework that builds on the three missions described above and expands on the fourth mission, community collaboration. The AAMC’s call to prioritize community collaboration and health equity as pillars of the academic medicine mission [38]. This new mission may bring new inspiration to the world's hospitals in the post-Covid-19 epidemic era.
All five hospitals are affiliated or partnered with medical schools in this study. Hospitals affiliated with universities usually combine teaching and education with saving lives, clinical, research, and talent training, allowing students to learn in practice and doctors to conduct clinical medicine and research work. In managing hospitals, hospitals affiliated with universities are usually larger, more resourceful, and have more substantial research capabilities. In addition, teaching hospitals are often considered to promote higher quality care, including treating rare diseases and complex patients, providing specialized services and advanced technologies, and conducting biomedical research [39].
It can be seen that the mission of evolving excellence in healthcare services, research, and education can embody the quality of healthcare services in the future of hospital management.
Vision
In our study, all five hospitals have a global vision, aiming for the health and well-being of all people with inclusive values, humanitarian-based health care, and health services. Moreover, all five hospitals highly emphasize collaboration and leadership with their colleague teams.
After comparing the visions of the five hospitals, we found that MGH and JHH are from the individual, the family, and the community to the global. In other words, their visions are covered from the microscopic to the macroscopic. MC, UNH, and CC mentioned changing the lives of their communities, and in parallel to clinical care, they also focus on the integration of medical education, health research, and health services.
As public hospitals, UHN and MGH showed their unique vision. Their vision does not have a clear goal, and they also fight for a healthier and fairer medical environment for the local community and all people. On the contrary, the three private hospitals, such as MC, the world's leading hospital, aspire to medical progress. CC's vision is more oriented toward its employees and creating a perfect workplace for them, while JHH's is more oriented towards cultivating talents. We found that private hospitals want different results than public hospitals. Public hospitals are considering more about the community, and private hospitals are focusing more on organizational development and health service performance. The vision of hospitals differs in its oriented focus. The reasons for this may be related to the nature of the hospital. It has been noted that while the high quality of healthcare is a priority for all hospitals, there are noticeable differences between private and public hospitals in terms of compassion, relevance, reliability, and executive response [40].
We found that MGH included health equity in its vision, while the other four hospitals did not clearly state this in their vision. The World Health Organization defines health inequity as a systematic difference in the health status of different populations, which has been a worldwide concern for many years. Health inequality is a multisectoral problem that significantly impacts people and communities (health, society, economy, etc.) [39–41]. Previous studies have shown that medical professionals are biased against specific populations, which hinders their ability to provide adequate care [42]. Therefore, to avoid the prejudice of these medical professionals, MGH may seriously affect the medical quality results (for example, compliance with medical recommendations, cancer screening recommendations, and drug treatment plans). In the MGH vision, the maintenance of community health equity is particularly emphasized to reduce health inequity [43]
Finally, CC and MGH mentioned the training of talents and the employees' working environment. Unfortunately, many managers and owners rarely consider employee education. They do not think it is part of their responsibility. If they do, they have no time to do it. The same situation exists in hospitals. A previous study indicated that doctors might believe their energy, education, and training should focus on patient care and research. Although doctors play a vital role in staff development, staff education should be the responsibility of hospital managers [40]. However, the training of employees and doctors will be rewarded in many aspects, such as leadership, effective communication, team development, and conflict resolution training, all of which can significantly improve performance [44]. Through adequate education and training, the hospital can be guided to declare its vision and realize its goals based on a clear mission, vision, and values. It can provide patients with high-quality health services, winning the recognition of patients and their families.
Values
Different from the values of MGH, JHH, UNH, and CC, only Mayo Hospital takes the needs of patients as a core value. MGH, JHH, UNH, and CC all emphasized the importance of hospital management in realizing the hospital's mission, vision, and value and explained the importance of hospital management from different perspectives. The values of the above four hospitals all reflect quality and excellence, safety, integrity, and teamwork. For example, in the documents of Cleveland Hospital, we can see that the quality and safety of care, the compassion and integrity of patients, and the teamwork and innovation in the hospital are respectively included in the value description. The values of MGH, UNH, and JHH have similar descriptions.
Mayo Hospital has stated its value to put only the patient's needs first, reflecting the current trend: "patient-centeredness. Patient-centered care is globally recognized as high-quality and high-value healthcare that emphasizes extensive patient and family involvement in health-related decision-making and healthcare services that meet patients' needs, preferences, and values [45]. The mission of 'inspiring hope and promoting health’ and the vision ‘transform medicine to connect and heal’ of MC has been more reflective of the patient-centered theme of hospital culture at MC. When patient-centered, medical and nursing staff can view from the patient's perspective, enhance effective communication, and thus protect patients' rights and improve the quality of medical services [46].
In summary, we found that these five hospitals' MVVs were closely related to the overall management of the hospitals, which broadly included hospital safety, integrity, and teamwork. Value is for mission and vision achievement. While all the core values were related to performance excellence, there were varying degrees of difficulty in implementation among the core values. However, not all core values are equally easy to achieve. It means that some core values are more accessible to practice than others and can be used as benchmarks for hospitals with low overall performance excellence. For example, the Baldrige National Quality Award has all of the core values presented in it that are related to performance excellence. Projects with "entry-level" core values, such as patient-centered excellence, social responsibility, and community health, are easier to achieve than innovation management or agile management [47]. As far as hospital values are concerned, the top five hospitals have shared values. At the same time, it is imperative to emphasize safety, integrity, workforce management, and patient-centered values, which can help hospitals establish benchmarks and formulate strategies.
Strengths and Limitations
This study has two advantages. First, we selected the top five hospitals with the highest reputation in the world, analyzed what the five hospitals have in common in MVV, and examined the common elements of these high-quality hospitals in MVV so that hospital managers can learn their common characteristics. Second, we discovered the heterogeneity of five hospitals in MVV and found the individual high-quality elements of each hospital in its MVV, so that hospital managers can think deeply and apply this new knowledge to the advantage of their own hospital's MVV.
Some limitations in our study should be noted. First, we used secondary sources currently publicly available on the Internet. These data are individually disclosed to the public of each hospital, such as terminologies, formats, and other information that may not necessarily have a consistent description. Second, given the accuracy of information comprehension, we finally included five hospitals in North America to obtain the most publicly available information about the MVV in English. Finally, although we collected various publicly available documents and website materials to analyze and compare MVV across hospitals and eventually found that MVV in hospitals of excellence had standard features, we recommend further research using site visits in the future to receive more in-depth insights into the content of MVV.