Tech

How Many Patients Did We Hurt Last Month? Learning (But Not Too Much) From The Best Hospitals

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.

Livongo’s Post Ad Banner 728*90

23
Leave a Reply

14 Comment threads
9 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
13 Comment authors
JoeMargaret FlemingBobby GladdMD as HELLlegacyflyer Recent comment authors
newest oldest most voted
Joe
Guest
Joe

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.

Margaret Fleming
Guest

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.

MD as HELL
Guest
MD as HELL

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.… Read more »

Bobby Gladd
Guest

“Quality of care is best determined by the physician.”
__

IF the physician is competent.

MD as HELL
Guest
MD as HELL

As I conceded by referencing some loser doctors

legacyflyer
Guest
legacyflyer

So Beth Israel Deaconess Medical Center did a good job of taking care of a PE. Good for them. They are: – 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… Read more »

Dr. Rick Lippin
Guest
Dr. Rick Lippin

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
Southampton,Pa

Ashish Jha
Guest

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.

Davis Liu, MD
Guest

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,… Read more »

Davis Liu, MD
Guest

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… Read more »

Rob
Guest

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… Read more »

Ashish Jha
Guest

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… Read more »

Vik Khanna
Guest

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… Read more »

Ashish Jha
Guest

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.

Davis Liu, MD
Guest

Interestingly, we do know what patients want. It was part of the Employee Benefits Research Institute Survey 2005 – see Figure 1. http://www.ebri.org/pdf/EBRI_Notes_11-2005.pdf 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. https://thehealthcareblog.com/blog/2011/04/15/does-america-want-apple-or-android-for-health-care/ 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… Read more »

Vik Khanna
Guest

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… Read more »

Al Lewis
Guest
Al Lewis

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… Read more »

Ashish Jha
Guest

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”

Ashish Jha
Guest

John — I always enjoy your outside the box thinking.

John Irvine
Guest

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 ..

mm13
Guest

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.

Ashish Jha
Guest

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.