This case study first appeared in the report Hospital Quality Improvement: Strategies and Lessons From U.S. Hospitals by Sharon Silow-Carroll, M.B.A., M.S.W, Tanya Alteras, M.P.P., and Jack A. Meyer, Ph.D., Health Management Associates.
Setting
Beth Israel Medical Center is a very large, full-service tertiary teaching hospital located in New York City. Its main division, the focus of this case study, was founded on Manhattan's Lower East Side in the late 1800s to serve vulnerable populations in the community. It now serves a wider patient population, and the main division has about 1,080 staffed beds. Beth Israel is part of the Continuum Health Partners system, a not-for-profit integrated health services network including five hospitals (seven hospital facilities) in the New York metropolitan area.
We selected Beth Israel Medical Center because our analysis of Medicare data over 2002–2004 (the "study period") identified it as among 100 hospitals showing greatest improvement in a quality index based on risk-adjusted mortality, morbidity, and complication rates. Though it began with a high ranking compared with other hospitals, it showed continued, steady improvement through the study period to reach a very high ranking compared with other hospitals in 2004. Also, the selection of Beth Israel provided diversity among our case study sites by including a very large, not-for-profit urban teaching hospital.
Impetus for Quality Focus
Reportable Events
In the years just preceding the study period, a few negative events including two that made national news dealt a severe blow to Beth Israel's reputation with the public and state authorities, as well as to staff morale. The shock of these incidents and the negative publicity that ensued served as a wake-up call. They forced the hospital to take a close look at quality of care, and to make major changes in its medical leadership, priorities, policies, and procedures, described below. The changes instituted just prior to and during the 2002–2004 study period elevated the priority given to quality and quality improvement. The hospital established new committees with quality-related expectations and accountability, and this and other changes appear to have contributed to significant improvements in quality indicators.
Actions to Improve Quality: Organizational and Structural Changes
Creation of Board-Level Commission on Quality Care
While the Board of Trustees for Beth Israel had always been very active, its involvement in quality issues expanded and matured just prior to and during the study period. Through the Committee on Quality Care, formed around 2001, the board of the Continuum system demanded from each member hospital certain performance-related data, with comparisons to their past performances, to each other, and to benchmarks. In monthly meetings, which included hospital leadership, the chairmen of clinical services from the hospitals presented to the trustees where their hospital stood on key measures, where it should be, and what it was doing to get there.
In addition, Beth Israel has its own hospital QI Committee, for which the CEO, chief medical officer, vice president for QI, director of QI, directors of support departments, key physicians, and two trustees meet each month to examine trends in quality measures and set priorities.
Elevated Role of QI Department
Just prior to the study period, the QI department underwent a major restructuring. It shifted from being what one employee called a "back room receiver of reports" to a proactive department that identified problem areas and facilitated, coordinated, and monitored quality improvement initiatives throughout the hospital. Responsibility for state reporting (described below) shifted from the Risk Management to the QI department, providing data and tools to help QI staff investigate and solve problems. "Risk management collected numbers; QI saw the data as opportunities," according to a QI employee. The QI department was given resources to increase its staff to include nine QI coordinators, each assigned to specific clinical departments to monitor performance and suggest and facilitate QI efforts.
Also, the hospital established a new vice president (VP) position to oversee the QI and related departments. This VP reports to the chief medical officer (CMO), and from the start has interacted with the CMO on quality issues nearly every day. According to the VP, "[The CMO] is intimately involved in QI projects and every root cause analysis performed."
Changes in Physician Leadership, New Chief of Quality Position, New Protocols
Acknowledging a need to practice differently, hospital leadership took action. Two physician chairmen were replaced, and a new complaint system was established. Experts were gathered to start working on clinical guidelines using evidence-based medicine.
At the beginning of the study period (2002), the Department of Medicine developed a new position: the division chief of quality. The physician selected for this position became a real champion for quality improvement, working with physician staff and residents and developing protocols to address deficiencies in processes and outcomes. As the hospital's current CEO put it, "It helps to pay people to focus on quality." The following year, a Critical Care Coordination Committee was developed to examine standards (e.g., Institute for Healthcare Improvement data) and develop new protocols in problem areas.
Also around 2002, Beth Israel began to adopt the JCAHO Core Measures associated with heart failure, AMI (heart attacks), and pneumonia. This both reflected and contributed to a culture shift, as data were fed back to the chief of quality, who then developed care maps and questioned physicians when some measures were not up to standards.
Multidisciplinary Leadership Teams and Quality Plans
Around 1999–2001, Beth Israel implemented a redesign of patient care. After examining the skill mix of staff, the administration enhanced training of nurses' aides and gave them more responsibility; they also redefined the roles of transporters and housekeepers so that these staff would better support the nurses. At the same time, the hospital implemented Leadership Teams, multidisciplinary groups that include clinical staff, support staff if appropriate, and a QI coordinator. These teams meet once per month to focus on improving patient care and have greatly helped to involve everyone in QI.
Further, at the beginning of each year, each hospital department develops a quality plan containing specific goals. The QI coordinator assigned to the department may suggest goals related to areas that the data indicate are in need of improvement. To address a specific problem, the department creates a QI committee (on the nursing units they are called leadership teams) composed of appropriate individuals who deal with the issue as well as the QI coordinator. Together, this group studies the problem, conducts root cause analysis (when necessary) to understand the basic factors behind the problem, examines potential solutions (often looking at best practices), recommends a course of action, and implements the new policy or procedure. The department chairman is responsible for achieving results.
Best Practices Group
The first year of the study period (2002), a Best Practices Group composed of CEOs, CMOs, vice presidents for quality, and QI directors of the four hospitals in the Continuum health system was established to facilitate the sharing of innovations and best practices. For example, one hospital discovered that the use of impregnated catheters could reduce infection; they then shared this information with the group and it was adopted by the sister hospitals. The group also sets the agenda for the monthly trustees' quality meeting.
Commitment from the Top
A strong sentiment among those trying to improve quality at Beth Israel Medical Center is that the most essential ingredient for success has been commitment and action from the top—the CEO, CMO, Board of Trustees, and the physician and nurse champions. Not only did the board and executive administrators establish new committees, positions, and procedures related to quality, but they illustrated their commitment by example on a daily basis, worked with clinical departments to effectively communicate what was expected of them, and provided resources to obtain tools and personnel needed to do the job right. Through these actions, hospital leadership established quality as an institutional priority.
Outside Requirements and Public Reporting
Hospitals in New York are heavily regulated in terms of quality control. The state's Department of Health requires hospitals to submit data on every adverse patient outcome through the New York Patient Occurrence Reporting and Tracking System (NYPORTS), and the individuals interviewed for this case study maintained that this helped rather than hindered their QI efforts. The negative events mentioned earlier, along with the shift in state reporting to the QI department, provided the impetus and means for Beth Israel to begin using NYPORTS as a tool to address problems. Hospitals are able to query the database to compare their experience with reported events to the statewide, regional, or peer group experience. The state Department of Health was also helpful in setting up multi-hospital work groups through which hospitals could learn new strategies and share best practices.
As noted above, the JCAHO Core Measures introduced during the study period served as a key focus of QI efforts at Beth Israel. Other outside standards used at Beth Israel are those developed by professional organizations, and national or regional benchmarks. Consultants have been brought in as well, and have generally been taken seriously by hospital personnel.
Although not a factor during the 2002–2004 study period, hospital leaders mention that the current CMS pay-for-performance initiative (based on Core Measures) is now a strong impetus for improving performance. In general, the QI leaders believed that people pay attention to publicly reported information on hospital performance.
Monitoring Results
Beth Israel measures its success in QI by tracking such data as mortality, Core Measures, patient satisfaction, and other information that may be specific to certain departments or conditions. With the help and coordination of QI personnel, all departments see data on their own performance, along with comparisons with past data, sister hospitals (in the Continuum system), and regional or national benchmarks. Beth Israel's information technology was not very advanced during the study period. Yet, reporting of the Core Measures through a streamlined, Web-based system beginning around 2002 facilitated QI by providing more accurate, user-friendly data. The departments present the data across (to the departments) and up the hospital chain to the hospital leadership and the Board of Trustees.
Challenges and Obstacles
Need to Change Mind-Set, Incorporate QI into Daily Routine One of the biggest challenges to establishing quality as a priority during and just prior to the study period was changing the mind-set of physicians, nurses, and other staff. While virtually all personnel agreed in theory on the need to reduce errors, there was nevertheless resistance to some of the actions associated with the new priority. New reporting requirements, for example, were viewed by many nurses as an additional burden, rather than an integral part of the daily routine. Physicians had to give up some autonomy and independence when asked to adopt best practices, and as their behaviors and practices were more closely scrutinized.
To address these challenges, the VP and director of QI engaged heavily in educating staff. The most effective educational strategy was through small groups. For example, "continuous quality improvement" (CQI) training involved 24 people at a time over two days. Also effective were one-on-one meetings with a nurse manager, in which participants explored how QI could be helpful to clinicians. The QI personnel stressed to the other staff the non-punitive nature of the new QI focus, such as the ability to report errors and problems anonymously on the QI hotline.
To help engage nurses specifically, the hospital created a forum for the nursing department to demonstrate ways in which nurses can affect quality of care. It was critical for nursing leadership to be engaged and supportive of the changes. Also, the QI director attended nurse manager staff meetings, using poster boards and other techniques to explain measures, data, and trends.
Most instrumental for getting the physicians on board was the involvement of the physician leadership. The chief medical officer and the division chief of quality were true champions of quality. They engaged the medical staff in the Core Measures, and drove efforts based on evidence-based medicine. Another effective strategy for getting physician buy-in was to allow physicians to choose their own indicators; this gave them more control and ownership of the QI process. It was also noted that while a few "old world" physicians never quite embraced QI philosophy, a new generation of clinicians was generally more open to it.
The transfer of state reporting duties—along with a broader shift in emphasis from risk management to quality improvement described above—resulted in tension between these two departments initially. It took time, as well as handholding and an emphasis on inclusiveness in the QI process, to diminish the rift.
Difficult Financial Environment and Lack of Resources
After increasing the number of staff in the QI department in 2000–2001, a difficult financial environment forced cuts across the hospital in subsequent years. QI lost four full-time equivalent employees, and was forced to spread an increasing workload across fewer individuals. QI addressed this by looking to the clinical departments to step up their role in QI projects. This was often a struggle, since those departments experienced cutbacks as well, and the QI department continues to grapple with the problem. Financial constraints also limited the acquisition of new health information technology that could serve as helpful tools in quality improvement.
Lack of Strong Consequences
While quality has been increasingly monitored and egregious violations have resulted in dismissals, in general there has been a lack of serious consequences or financial incentives tied to quality improvement. QI leaders at Beth Israel are proud of what they have accomplished despite this lack of strong accountability. This is an area in which the current CEO is considering changes for the future.
Financial Implications
Beth Israel leadership stressed the importance of balancing financial and quality goals. Improving quality often requires an increase in expenditures, and may or may not result in reduced costs over the short term. Some interventions, such as reducing infection rates, do have near-immediate cost savings in terms of reduced resources expended and reduced length of stay. Other QI interventions do not have an immediate financial payoff. Rather than depending on a business case, therefore, hospital leaders need to balance QI and cost reduction, along with service goals, to drive improvements in all of these areas. Over the long term, improved quality and services should enhance market share and result in growth and improved financial performance.
Lessons
It Takes Time
Once a commitment is made, systems are restructured, and resources are invested, it still takes time to see results. It takes time to build a QI staff, get line staff—including nurses, physicians, and other hospital personnel—on board and motivated, investigate weaknesses, develop action plans, and incorporate new procedures on a systematic basis before seeing changes in practices or health status. Thus, it is important to be patient but unrelenting, and gauge progress with process indicators as well as outcomes.
Standardization Is Needed
Currently, Beth Israel and other hospitals have many different options and requirements related to performance measurement from reputable sources such as CMS, JCAHO, the Institute for Healthcare Improvement, and the Leapfrog Group. Each of these sources has developed indicators, but they are not uniform, and this can be confusing and complicated for hospitals. Public policy could facilitate the QI process by helping to test and standardize performance measures, and to limit them to those that make the greatest impact.
QI leaders at Beth Israel suggest that public policy can also play a role in monitoring public reporting to ensure that measures are accurate and presented in a clear way. Government could educate consumers in interpreting the information and using it appropriately.
Acknowledgments
The authors would like to thank the following individuals at Beth Israel Medical Center who generously offered their time and insights for this case study: Joanne Coffin, vice president, administration; David Shulkin, M.D., president/CEO; Mary Walsh, R.N., chief nurse, director of patient care services; and Donna Wilson, R.N., M.P.H., M.S.J., C.P.H.Q., director of quality improvement.
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.