Systemic changes require cooperation between those who deliver care and administrators committed to the public disclosure of outcomes.
Academic medical centers, the crown jewels of the medical system, have a tripartite mission. First, of course, as hospitals, they are intimately involved in clinical care. At Beth Israel Deaconess Medical Center (BIDMC), for example, we take care of about 40,000 inpatients, about 50,000 emergency room patients, and about half a million ambulatory patients a year. BIDMC provides the full range of medical services, from primary care through advanced imaging and diagnostics to liver transplants, bone marrow transplants, and other tertiary and quaternary services.
Research and education, the other two parts of the academic medical center’s mission, supplement and reinforce advances in and delivery of clinical care. At BIDMC, research accounts for more than $200 million of our $1.2 billion dollar budget, and clinical care and research are integrated. Say, for example, a specialist in gastroenterology who is treating a patient with irritable bowel syndrome notices something about the patient’s condition that prompts her to hypothesize something about the cause of the disease. Based on that observation, she might construct a series of laboratory experiments, perhaps using mice as models, and, over time, she might learn things from these and other experiments that can be applied in the clinical setting. Over the years, this shuttling back and forth between “the laboratory bench and the bedside” informs both clinical care and research.
The third part of the mission is education, teaching the next generation of doctors, from undergraduate medical students (in our case from Harvard Medical School) to residents and fellows from around the world engaged in graduate medical education and advanced training. Nurses, dietitians, laboratory technicians, and many other health care workers are also part of the educational program.
Academic doctors teach not only because they love to teach, but also because teaching keeps them up to date on the latest advances in medicine. Let’s say a bright young medical student is following the treatment of a patient by a doctor who says, “This is the way we always care for someone with this problem.” If the student asks why, the answer cannot be because it’s been done that way for 20 years. Students expect, and demand, more complete, in-depth answers. This kind of give and take with students requires that doctors remain sharp and current in their fields.
Patients, whether in Boston, Seattle, Chicago, or any other city or region with a major academic medical center, are the beneficiaries of this marvelous agglomeration of clinical care, research, and teaching. They are seen by very bright people who are totally committed to taking care of them, using the most up-to-date diagnostics and therapies. Even patients who live in communities that do not have academic medical centers benefit, because advances in research and clinical care diffuse throughout the world, and there are doctors everywhere who have been trained in one of these centers.
Notwithstanding the marvelous features of academic medicine, the actual delivery of care and practice of medicine in academic hospitals is still a cottage industry that basically involves a one-to-one relationship between the patient and the provider of the moment. A good deal of what goes on in academic medicine in the clinic is private.
The question is not how care providers make decisions. The issue is how the environment in which they work can be studied and reconfigured to eliminate systemic problems that lead to harmful outcomes and how doctors can be brought into that process. The truth is that even these very well intentioned, bright, experienced, often superb subspecialists, who justifiably inspire confidence, work in a cottage industry that has not had the benefit of the system-improvement practices that are common in other industries. They haven’t been educated to take into account how—or how much—the hospital or facility in which they work affects their performance and patient care.
As the Institute of Medicine has documented, a very large number of people are killed or harmed in hospitals in this country (IOM, 2000). In fact, health care does not meet the quality standards we expect from any other industry. Indeed, it does not meet the quality standards (e.g., Six Sigma) of the industries from which health-care goods and services are purchased. This is true even though everyone involved in the delivery of care is well intentioned and thoughtful. Using theories and practices of process improvement to ensure that quality standards are met is simply not part of their training. And frankly, the administrators of academic hospitals have not been thinking in a systems way either.
According to insurance companies in Massachusetts, their annual increase in medical costs is 10 to 12 percent, as it has been for several years and is expected to be for years to come (e.g., Krasner, 2006). A key driver for the increase is demographics. Baby boomers, now in their 50s and 60s, the age of hospitalization, are being seen in hospitals for the first time (except for women who had their babies in hospitals). At the same time, thanks to medical advances, like stents, which were invented and proven in academic medical centers, baby boomers’ parents, who in previous generations would have already died, are still alive. A person who might have died of a heart attack 15 or 20 years ago may now live long enough to get cancer and might remain under long-term treatment for this disease, now often a chronic condition, once again because of advances developed at academic medical centers. Thus insurance companies are coping with a growing number of people entering the tertiary care system with more expensive and difficult diagnoses and treatments.
The cost increase of 10 to 12 percent a year compares to a 3 percent annual growth in GNP. This means that, as Congress, state legislators, and taxpayers (who pay for Medicare and Medicaid), as well as employers and employees (who pay for insurance in the private sector), experience a 3 percent increase in available income, the cost of health care goes up three or four times faster.
I believe that academic medical centers, which have been at the forefront of so many medical advances, should also take the lead in addressing the cost issue. As anyone who has experience with process improvement in other industries knows, quality improvement and cost improvement go hand in hand. If you improve production processes or service processes, the delivery of those processes or services becomes generally more efficient. So how do we transfer process improvements to health care?
I am not talking about global changes in the way we organize and provide health care all along the continuum. I am talking just about changes in a given hospital, particularly in an academic medical center.
Accountability and Change
Everyone should understand that hospitals are dangerous places where mortality and morbidity occur, and academic medical centers have a responsibility to hold themselves accountable for quality and safety. I believe the best way of doing that is by publishing our data. My hypothesis is that holding ourselves accountable to the public will make our well intentioned doctors and nurses work even harder and “smarter” to improve processes and make hospital stays safer and less expensive.
I noticed that some people on our staff were doing creative and interesting things related to improving quality and safety, and I decided to test the idea that publishing our clinical data would be good for our organization. I thought the transparency of clinical results would produce a kind of creative tension that, in itself, would help drive process improvement. So, a few months ago I started a blog (www.runningahospital.blogspot.com) about what is going on in our hospital.
Here is an example about ventilator-associated pneumonia (VAP), a problem relevant to anyone who has been or will be in an intensive care unit (ICU) or who will have a loved one in an ICU. A patient on a ventilator who contracts pneumonia has a 30 percent chance of dying, a pretty high rate of mortality. The good thing is that we know how to prevent many of these cases by taking five well documented steps, including elevating the bed to 30 degrees, plus washing out the patient’s mouth every four hours to decrease the chances that bacteria growing there will enter the lungs and cause pneumonia.
Keep in mind that an ICU, even though it is staffed by one nurse for every patient, is a very demanding and busy place and that the staff has a lot to do. To successfully prevent VAP, the five steps plus oral hygiene must, therefore, be part of the culture, part of the routine, required workflow.
FIGURE 1 - Graph showing improvement in performance of five-step VAP bundle.
FIGURE 2 - Graph showing improvement in ICU oral care.
This blog posting shows the results of changes in our ICU protocol (Figures 1 and 2). No partial credit was given—unless all five steps in the “bundle” and the oral hygiene were done, the score was zero. The graph shows that in the months since the ICUs began working on reducing cases of VAP, performance of the five-step bundle, and the oral care, have risen to 100 percent.
Note that the change was not a response to an order from CMS (the Medicare agency), which keeps track of infections and other events and posts results a few years after the fact. Neither the insurance companies nor patients nor even the hospital administrator insisted that these things be done. In fact, it was academic physicians, who read journals and other publications from around the world, who instigated the changes. After several of them had read the recent literature about preventing VAP, they decided they should change the way ICUs cared for patients.
But—and here’s the key—they then had to organize the 200 people who work in ICUs. Respiratory therapists, nurses, and doctors all had to be trained to change the “industrial” process, with no increase in staff and with basically no increase in resources. The doctors went to work and made it happen.
Many of the changes were not very complex. It became apparent, for example, that people do not have a good sense of angles. A nurse or doctor might think the head of the bed has been raised to a 30-degree angle when it has only been raised to 20 degrees. To address this problem, protractors were put on the beds—the big ones used by construction companies that are easy to see.
I watched the results of the changes and started posting them before they reached the 90 percent rate. At that point, the head of this group sent an e-mail to his colleagues that read something like this: “As you may have heard, Mr. Levy has a blog on which he is now posting our success rates with ventilator-associated pneumonia prevention. Perhaps we should take this as an additional impetus to do even better, because people out there are watching.” This message seemed to support my hypothesis that public disclosure of clinical results could motivate efforts to improve processes.
Estimates of the results of our changes in ICU care are that 300 cases of VAP were prevented last year, and 90 lives were saved. At a cost of $40,000 per case, we believe we avoided about $12 million in health care expenses. This is a clear example of how quality improvement and cost savings can go hand in hand.
Motivations for Change
People in an academic setting are motivated by a combination of factors—competition, data, intellectual curiosity, and deep concern for the welfare of patients. They are decidedly not motivated by demands from on high, particularly from an administrator, who is not necessarily an MD or even an engineer. However, when the administrator or CEO of a hospital posts good results, they feel proud of their efforts and motivated to move on to the next topic and the next opportunity for clinical improvement. To the extent that results have not yet reached the hoped-for target, publication acts as an incentive to do better.
Systemic change occurs as a result of an unusual type of cooperation between the technical experts who deliver care and an administration dedicated to transparency of outcomes. Creative tension creates a climate in which the only way to relieve it is to actually reach the goal, no matter how audacious the target. The only alternative would be to lower the target, an unacceptable result for personal, professional, and institutional reasons.
I would be remiss, however, if I did not point out a symptom of the problems in academic medical centers. When I began posting clinical results on my blog, I received many less than positive reactions from other academic medical centers in Boston. Many were disdainful and convinced that publication of results was “not good for academic medicine.”
I hope to break down that attitude and persuade people of the value of public disclosure. From the traffic on my blog (more than 10,000 viewings per week, including visits from medical centers all around the world), it now appears that people are watching. I believe that social and political forces will combine to make public disclosure the norm in the future.
IOM (Institute of Medicine). 2000. To Err Is Human: Building a Safer Health System. Washington, D.C.: National Academies Press.
Krasner, J. 2006. Medical insurance hikes loom in Massachusetts. Boston Globe, September 10, 2006. Available online at http://www.boston.com/news/local/articles/2006/09/10/medical_insurance_hikes_loom_in_mass/.