July 1, 2004
Todd Kutyla, Jack Meyer, Sharon Silow-Carroll
Hospital Quality: Ingredients for Success A Case Study of Beth Israel Deaconess Medical Center, Jack A. Meyer, Ph.D., Sharon Silow-Carroll, M.B.A., M.S.W., Todd Kutyla, M.L.A., et al., The Commonwealth Fund, July 2004
This related report summarizes four case studies of hospital quality, HOSPITAL QUALITY: INGREDIENTS FOR SUCCESS—OVERVIEW AND LESSONS LEARNED
Beth Israel Deaconess Medical Center (BIDMC), located in the heart of Boston's academic medical area, is a 589-bed hospital noted for its high quality research, teaching, and patient care. While cost pressures stemming from a recent financial crisis and local competition drive the hospital's efforts to improve efficiency, these initiatives are augmented by and integrated with a drive toward improved quality of care.
A key factor that distinguishes BIDMC from other hospitals is a commitment to change and innovation among employees who survived and persevered through financial troubles and other stresses related to a past merger. This commitment to change is coupled with the knowledge and skills of a talented cadre of physicians, nurses, pharmacists, and other staff who cull and use evidence-based standards, pore over and analyze data on practice patterns and outcomes, and devise workable plans to improve quality indicators. BIDMC's success can also be attributed in part to state-of-the-art information and decision support systems that are home-grown to best meet the institution's culture and needs.
It appears that BIDMC's excellent performance and emphasis on quality improvement (QI) is due to a combination of organizational factors, internal processes, and practical tools. The key organizational factors include the following:
- The effective use of multidisciplinary teams to study quality problems, drill down deeply to identify root causes, and develop a solid plan to correct the problems;
- An advanced IT system that supports this key problem-solving function;
- A long history and strong culture of serving the community and emphasizing patient care;
- A strong commitment to and involvement in quality issues from the top, at both the CEO and Board levels;
- The adoption of the Institute of Medicines' (IOM's) six domains of quality (safety, timeliness, effectiveness, efficiency, equity, patient centeredness)as a central framework for pursuing quality, with specific reporting requirements related to these measures;
- Relationships with a premier medical school and research departments that attract highly motivated, top-notch physicians;
- Preference for internal development of best practices, and
- A high-level, physician-led Health Care Quality department dedicated to improving performance.
BIDMC's effective QI process is based on the following:
- Centralized data analysis combined with decentralized development and implementation of action plans;
- A multistep collaborative QI process that utilizes internal data and evidence-based practice guidelines, emphasizes volume to outcome relationships, and has a strong participatory nature;
- Use of multidisciplinary teams to identify solutions;
- A good understanding of what motivates staff;
- A heavy use of objective data comparing physicians to their institutional peers, as well as to the norm for the region;
- A focus on standardization to improve efficiency and safety.
Another key factor that distinguishes BIDMC from other hospitals is its state-of-the art information systems that are largely made in-house and can be customized and harnessed to drive performance measurement and improvement in ways that off-the-shelf information systems cannot. Quality and QI at BIDMC have been enhanced through investments in clinically driven information systems and decision support that include:
- A Provider Order Entry system based on evidence (medical journal literature) and experience at BIDMC;
- Dashboards and reports in certain units to enhance safety and patient flow.
Competition with surrounding institutions and premier hospitals nationwide drive BIDMC's focus on QI as well. Other external factors, such as pressure from the business community, insurers, and regulators, did not appear to play a significant role at the time of this evaluation, though this has been changing recently.
BIDMC has faced, and is trying to address, the following challenges related to nourishing a culture of QI:
- Financial turmoil, which forced the administration to focus on short term survival efforts;
- Attitudes that can impede QI, such as resistance to self-measurement, fear of admitting errors, and rejection of externally-imposed rules;
- Lack of financial incentives to improve efficiency or quality;
- Getting best practices adopted by rank-and-file physicians;
- Lack of teamwork training in physician education;
- Significant technical infrastructure requirements.
Identifying the key factors and successes, as well as the ongoing challenges, facing BIDMC in its efforts to promote quality and QI yields important lessons for other health care institutions.
This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.