I was recently chastised by a colleague for being too negative in one of my pieces on hospital care. His is a remarkable story of what happens when things go well, and it has made me think a lot about why, in some places, things seem to work while in others, not so much.
He told me how a few months ago, soon after returning to Boston from a trip to China, he had started feeling short of breath. When his cardiologist convinced him to be evaluated, he found himself at the Beth Israel Deaconess Medical Center (BIDMC), arriving in the ER late one evening. He was triaged within minutes, had an EKG within 15 minutes, at which time comparisons were made to previous EKGs. After ruling out a heart attack, his ER physicians quickly ordered a CT Angiogram.
That test, completed within an hour of his initial arrival to the ER, revealed the reason for his shortness of breath: he had a large saddle pulmonary embolus. He was started immediately on IV heparin and sent quickly to the ICU, experiencing essentially no delay in care. He spent three days there and reports receiving care that was attentive, expert, and consistently of the highest quality. Even after discharge, he received two nursing visits at home to ensure he was doing OK. In discussing his experience, he repeatedly emphasized the fantastic communication and teamwork that he witnessed. Weeks after discharge, he continues to get better and feels the benefits of the excellent care he received.
This is the story we all hope for. And when I heard it, I have to say that I wasn’t surprised. There’s something about the BIDMC that’s unusual. Of the 4,500 hospitals that report their mortality rates to Medicare’s Hospital Compare website, only 22 (less than 0.5%) have better than predicted mortality rates for all three reported conditions: heart attack, congestive heart failure, and pneumonia. And, we know that the combined performance on these three conditions is remarkably good at predicting hospital-wide outcomes, including outcomes for pulmonary embolism.
If you are a patient and care deeply about good outcomes, BIDMC seems to be a good place for you.
So what’s so special about them? What do they do that’s different? I don’t know, specifically, all of their tactics, but I have some guesses about what seems to differentiate high performing institutions from the rest. And in a word, it’s leadership. BIDMC has had two CEOs over the past few years, and both of them have been unusually committed to achieving high quality care. That commitment translates into real activities that make a big difference. Let me divert us with a story of what this might actually mean.
A few years ago, I was working on a strategy for improving the quality and safety of VA healthcare. As part of this effort, I called up senior quality leaders of major healthcare organizations across the nation. One call is particularly memorable. Because I promised anonymity, I will not name names but this clinical leader was very clear about his responsibility: every month, he met with his CEO, who began the meetings with three simple questions: “How many patients did we hurt last month? How many patients did we fail to help? And did we do better than the month before?”
The CEO and the entire hospital took responsibility for every preventable injury and death that occurred and the culture of the place was focused on one thing: getting better. When I looked them up on Hospital Compare, they too had excellent outcomes and they regularly get “A” ratings for patient safety from the Leapfrog Group.
How do the BIDMCs and these other super-high performers pull it off? How do they build a culture of quality when so many organizations seem to struggle? High performance is complex, of course, and I won’t try to be overly simplistic. But a few things seem common among many high performing institutions. They seem to be focused on three things: timely, clinically relevant outcomes data; transparency within (and usually outside) the organization; and a constant focus on getting better.
You can see the kinds of data that BIDMC posts on its website – it’s not just the standard Hospital Compare stuff (which everyone has to do) but other data on a series of outcomes which are not required. When I hear Kevin Tabb, their current CEO talk about quality – it’s obvious that quality is not a platitude. He is genuinely focused on getting better.
So what’s the lesson from BIDMC, Mayo and other high performing institutions? There is no substitute for great leadership. Each of them seems to have been blessed with leaders who, despite all the wrong incentives in the healthcare system, prioritize patient care and drive their organizations to great performance. They are internally motivated and do all the things I describe above, despite the fact that our primary payment systems incentivize them to do more, not better. They are extraordinary leaders- with not only great vision but also the ability to execute that vision.
But here’s the risk: too many policymakers believe that all we need to do is figure out what BIDMC or Mayo or Kaiser does and just get everyone else to do it. Such an approach, while seemingly perfectly good on paper, fails to account for the human element. The strategies that they have used have been executed by individuals unusually focused on improving care. Barring substantial improvements in cloning technology, we can’t expect that each hospital will have a great leader.
We don’t expect that every technology company will have a Steve Jobs. In every industry, there are a few visionary leaders, but the rest of the organizations? They are run by mortals – and mortals respond to incentives. And here lies the problem: the incentives in the system are not motivating the typical CEO to improve care. Whatever strategy we employ around timely data, transparency, etc. won’t work until the leadership is properly motivated and focused on quality. And while that happens in pockets, it’s not happening across the entire healthcare system. And this is where we will pick up in my next blog: how to get the rest of the organizations to make quality a real priority.
Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence where this post originally appeared. He is also the Senior Editor-in-Chief for Healthcare: The Journal of Delivery Science and Innovation.
Here’s the think about incentives:
(1) Incentives work
(2) Incentives are based on measurable outcomes
(3) There is usually more than 1 way to influence the measurable outcome
(4) Human creativity has no bounds when it comes to finding non-productive ways to influence measurable outcomes, particularly when faced with an incentive.
See the field of education for many many examples.
Having the correct incentives is a necessary beginning. They are often not sufficient to obtain the desired outcome.
Again, thank you for spotlighting knots in the system, and the role of incentives, which is often overlooked. I appreciate your courage and your efforts to find out how it’s done right, and where.
Every hospital must deal with the “central committee”. The burdensome regs from the Joint Commission and CMS affect hospitals differently depending on the fear or lack of it in their nursing staff. Fearful leadership in nursing leads to fearful nurses caring for patients.
Hospitals that have a policy for everything are paralyzing the nurse. Great care is delevered at the bedside, not from the CEO suite. Often the CEO has no clue how care is being provided. The CEO trusts the nursing VP to get the nursing care right.
The medical staff of many hospitals has been neutered and silenced. Certainly the medical staff does not hve the clout in once had to determine the care given by nurses. The rise of hospitalists is the rise of drones serving the queen. The regular staff has abrogated inpatient care to the hospitalist. No continuity of care exists between the hospital and the primary doc. The medical home of the patient is isolated from the hospital.
Quality of care is best determined by the physician. And I can tell you a lot of care is crappy because it is policy-driven and the nurse mainly must acquire information for the EMR rather than providing care. There are loser doctors as well, but not by policy. Nurses know when they are making the system happy rather than doing the best thing.
Stay away from doctors and you will be happier. Go if you must, but do not swollow the preventive care crap. And try not to pay for stuff you do not need.
“Quality of care is best determined by the physician.”
IF the physician is competent.
As I conceded by referencing some loser doctors
So Beth Israel Deaconess Medical Center did a good job of taking care of a PE. Good for them.
– One of the premier Medical institutions in the country – by reputation. (The way this status is determined is probably statistically and scientifically invalid)
– Because of their reputation, they are able to attract some of the top talent in the US.
– The cost of care is probably at least 2 standard deviations above that in most other parts of the country.
Don’t break your arms patting yourself on the back!
It is a little like giving a coach a football team made up of NFL players and matching me up against a Division III college team. And if the coach with the NFL players wins the game, it must surely be due to his brilliance!
Instead, tell me a story about a hospital in E. Podunk, with a cost structure in line with the community that is doing a great job. That is where the real credit belongs!
Brace yourself for the closure of up to 1/3rd of US hospitals in the next 5-10 years. There are just too many, redundant and maldistributed geographically
Only the efficient and safe will survive.
Dr. Rick Lippin
Davis — as always, I appreciate your comments. What I worry about is that while leadership is centrally important, we can’t wait for every hospital to have a great leader. We need the system to work in a way that the average hospital with the average leader can still deliver great care…and we just don’t have that.
Dr. Jha – completely agree with you. We can’t wait. Turns out though, we don’t have a system of creating leaders and ensuring they are consistently excellent. To create a system that the average hospital with the average leader can provide great care requires a “playbook” or operational tactics what one should do (i.e. checklist, etc). We have that from IHI and many others.
It is ensuring consistency, adoption, and execution of the playbook that requires leaders who can lead their organizations / hospitals. The issue in health care is that we don’t have scale. We have academic medical centers, hospital systems, but little at the national scale.
When we marvel at the consistency of aviation safety we never reflect on how the relatively small number of airlines in of itself might be an important reason for their safety. Within these airlines, they have organizational structure and leadership that can scale. Imagine if there were thousands of airlines like we have thousands of hospitals, how might they perform then?
Given our reality how our health care system is structured, a few ideas emerge. Health care organizations affiliate their expertise. As an example, the leadership and operational expertise at Cleveland Clinic to other hospitals. http://www.modernhealthcare.com/article/20130316/MAGAZINE/303169975
Train physician leaders in medical school and residency. Expect leadership skills to be an important part of medical training. Expect this generation of doctors to leave their academic medical centers and what they learn and spread best practices. If we don’t, there will continue to be a gap between what we know and what we can do. As She Lay Dying: How I Fought To Stop Medical Errors From Killing My Mom – Health Affairs December 2012 – http://content.healthaffairs.org/content/31/12/2817.full.html
Finally, we as doctors need to embrace leadership. Like any other skill, as noted by Gladwell and Gawande, 10,000 hours of deliberate practice matter. Leadership like any other skill for an internist or surgeon can be learned and mastered. Turns out, however, in our training somehow leadership development (if it exists) is considered beneath us. Is there CME to acquiring leadership skills the same way we acquire the latest in clinical medicine? Where are the forums in medical schools and residencies to foster this skill? For those outside of academic medicine?
Because of the success of American medicine, the complexity of care and what we can do has exceeded how we addressed problems and issues in the past. It will be teams that succeed. http://davisliumd.blogspot.com/2012/04/why-understanding-teaming-is-critical.html.
If our role is to do no harm, then leadership is competency we should expect more doctors to have.
This is a great piece. Too often policymakers and other do not place a value on leadership. Certainly in medical school and training, we should develop future doctors to have this skill. Yet within our field of medicine, how many of us want to be leaders and step up? It’s in our medical culture not to step into leadership roles. In the best article I’ve come across, “Challenges for Physicians in Formal Leadership Roles: Silos in the Mind” by Thomas N. Gilmore, he notes:
Because [doctor] training inculcates values of autonomy, learning from experience, and professional distance, physicians see a team (managerial) approach as ‘other’ and distance themselves from those colleagues who take up formal leadership roles.
The consequences are ambivalence and splits, both among leaders and within individuals who accept such leadership roles. A maladaptive strategy is often silos in the mind, in which the different bodies of knowledge (clinical and business) are kept too separate, with the latter denigrated. Yet, many of the current challenges require closer linking of substantive medical knowledge with sophisticated organizational and managerial knowledge to invent and implement new systems…
But having been at a physician led medical group, I’m optimistic like Dr. Jha that the right leaders will change medical care for the better.
Davis Liu, MD
The Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving Money (2012)
Let me throw a little water on this love-fest. I actually know both of these CEO’s (one from years of blogging and the other from his pre-BIDMC days in the EMR world). While they are caring and compassionate (I’ve been accused of that), they would both insist that they are simply doing what is expected of them. It’s not that necessarily that they are more capable than other CEO’s, or that they care more; it’s that they have a higher idea of what’s expected of them. It’s not magic or genius, it’s high expectations that create high performers.
Additionally, the Steve Jobs analogy is not a good one, as Jobs used creativity to invent something people didn’t know they wanted, then patenting the technology so he could beat his competition. Who is BIDMC competing against? Why couldn’t the systems used there (and more importantly, the high-standards) be exported? Isn’t this the equivalent of me telling my wife that the guy who treats his wife so well is an exceptionally caring person who is clearly in the top 0.5%? She should not expect that of me. It sounds an awful lot like an excuse to have low expectations.
My belief is that people don’t clamor for truly good care because they don’t realize how bad their care is. They don’t realize how bad their care is because they don’t know how good it could be. We need to use examples like this to raise the bar for everyone, not to single them out as exceptions to the rule.
Rob — I agree with almost everything you say. These two BIDMC CEOs (I don’t want to turn this into a story about them) would agree that they are not magicians or more capable. I’ve just been impressed that they both think that improving patient outcomes is a key part of their job — and they walk the walk.
The point about Steve Jobs was simply that we don’t expect every technology company to have one. We shouldn’t expect every hospital to have a CEO who has a higher idea of what is expected of them.
Finally — agree wholly with the idea that people just don’t realize how bad their care is. Thanks for the comments.
Why don’t we think about quality from a completely different vision, to use Ashish’s term? The patient’s (or consumer’s) perspective. In most of the quality articles I read (maybe I don’t read enough) I almost never see mention of what patients want to know and what quality means to them. Does anyone know that? Because I sure don’t. And, might that thinking it lead us to very different conclusions about what quality means than the ruminations of hospital CEOs who are, quite naturally, interested first and foremost in the viability and growth of their institutions? There is a reason that they stalk the hallways muttering “optimize payer mix, maximize reimbursement under their breath” and quality (real or imagined) is just a lever for those goals.
I think we make a serious error if we labor under the misconception that just because most people pay a relatively small portion of inpatient care costs that they don’t care about what happens in hospitals and how it’s reported out to them. If their share of this spending grows, there will certainly be rumblings about people having too little information to make informed choices; or, perhaps those choices will be made for them by both health plans and employers that engage in the narrow network trend and contract with providers based on opaque criteria that might or might not include quality indicators of merit.
Granted, there are some kinds of care that are not shoppable, such as an MI, massive trauma, or the pulmonary embolism in the essay. But, many kinds of care are shoppable (for example, in my neighborhood, knee replacements for pre-Medicare boomers seem to be the procedure du jour). Maybe the quality indicators that matter to consumer will vary along those lines and others. But, it seems to me that we dither endlessly on this topic without anyone really articulating what matters to end users. If we asked consumers to assemble a Consumer Reports-style hospital report card, what would they want to see on it, and why can’t we do that? Resisters of this idea are likely channeling the auto companies of yore who similarly said that the quality and safety of their increasingly complex products just was not reducible to facile, consumer-friendly reporting. Guess who won that debate.
As for Steve Jobs…the health care industry has no Steve Jobs, never has, and probably never will. The incentives are too perverse, the system is almost entirely reactive, and it’s too dependent on making people dependent because that is its financial yellowbrick road. http://khannaonhealthblog.com/2011/08/31/where-is-the-health-industrys-apple/
Vik — the really interesting question, which you put your finger on, is why don’t we know what the end user wants? Is it because too many healthcare organizations don’t think of the patient as their real customers? They know what the payer wants.
Interestingly, we do know what patients want. It was part of the Employee Benefits Research Institute Survey 2005 – see Figure 1.
As for the comment about where is the health industry’s Apple? I would suggest it is a philosophical perspective of whether health care should be delivered as an integrated or fragmented system. It will be the public that ultimately decides which philosophy is favored.
As for Steve Jobs, like many people, I was inspired by his vision and perspective. http://www.kevinmd.com/blog/2011/10/steve-jobs-mentored-physician-changed-health-care.html
Though we need visionaries in health care, what made Jobs also incredibly successful his second time around was the creation of teams with A+ players. We don’t need a Steve Jobs in every hospital. What we do need is COO like Tim Cook – the operations and execution of the vision..
“Vision without action is a daydream. Action with without vision is a nightmare.” – Japanese Proverb
Davis Liu, MD
The Thrifty Patient – Vital Insider Tips to Staying Healthy and Saving Money (2012)
Perhaps the labeling of health plans as intermediaries was misnomer. It’s the patient that is an intermediary between the hospital and what it really wants…money, whether that’s in the form of reimbursement or research grants.
To carry my car example forward a bit, consider this. A couple of weeks ago, I thought my brakes needed adjustment. My mechanic test drove the car, inspected the brakes, and concluded that the problem required the dealer’s attention b/c it was likely a set of sensors he could not access. He was affable, clear, even apologetic that he couldn’t help me, and charged me nothing.
The dealer identified and fixed the problem, which was in the sensors. They were rude, obtuse, gave me a weasel explanation for why it was not a warranty fix (i.e., my “insurance” did not apply), and tried to charge me much than I thought was appropriate. I got the fee cut in half. Both organizations sent me automated customer satisfaction surveys. The questions were different but here is how my answers broke down:
Outcome satisfaction: Mechanic-C, Dealer-A
Customer experience: Mechanic-A, Dealer-F
Perceived value: Mechanic-B, Dealer-D
Likelihood of return business: Mechanic-A, Dealer-D
Why can’t I do this for my family’s physicians? The network they belong to? Our health plan? Because the health care industry really does not want to be graded.
I do actually know one of the principals here (previous BIDMC CEO), just for full disclosure and I’m glad to see that he is getting the recognition he deserves.
Having said that, there is a lesson I recall from my days at Bain & Co, where we used to think the answer was to have the smartest consultants but realized that such a model was not scalable because not every consultant could be the smartest. I recall Bill Bain, in a rare moment of introspection, saying: “What we need to do is develop a delivery model where even average consultants can get the right answer.”
Likewise, rather than urge everyone to become the hospital industry’s Steve Jobs, we need process redesign that makes it much easier to avoid errors. And in fact those redesigns are out there. Leah Binder wrote in a blog recently that bar-coded sponges are now available that can reduce to zero the likelihood that one will be left inside a patient — meaning that a “never event” whose cost including liablity could approach 6 figures could be solved by adding $5 to the cost of each operation. Bar-coded sponges are one example where bringing the average up reduces the need for everyone to be better than average, which of course is mathematically impossible.
And yet only about 15% of hospitals use these sponges. So much can be achieved by making it impossible to avoid mistakes rather than hoping that your surgical nurses will count sponges right every time, which all the training in the world won’t ensure.
Thanks for your comments Al.
I agree completely with the line (please don’t mind the friendly amendment)
“what we need to do is develop a model where even an average hospital with an average CEO can deliver the right care”
John — I always enjoy your outside the box thinking.
Barring substantial improvements in cloning technology, we can’t expect that each hospital will have a great leader.
Well, I’m not sure cloning hospital leaders is all that far fletched, given some of the stories I’ve heard about the cloning labs in Asia. Imagine: a Don Berwick clone for EVERY hospital? How cool would that be!!!!!
Things could get a little weird at the IHI meetings though ..
A corollary to the need for incentives is the need for structure. More and more literature is coming out talking about the importance of systems and processes that, when built into a system, encourage or hinder certain ways of working. The idea is that you take leadership (motivation and an ability to translate that to results) and correct incentives, to create structures that allow the members of an organization to make it easier to do the right actions.
Agree wholly. Structure, context are both incredibly important. A great leader is not just someone with terrific vision — but the ability to translate that vision into an organizational structure that makes it easy to execute on that vision. Thank you for your comment.
Words of wisdom:
“Too many policymakers believe that all we need to do is figure out what BIDMC or Mayo or Kaiser does and just get everyone else to do it. Such an approach, while seemingly perfectly good on paper, fails to account for the human element. The strategies that they have used have been executed by individuals unusually focused on improving care. Barring substantial improvements in cloning technology, we can’t expect that each hospital will have a great leader. “