(This continues our blog series on our recent papers on health care quality published by the Commonwealth Fund. Last week we focused on the Hill Physicians Medical Group. Now we turn to Baylor.)

Baylor Health Care System (BHCS) is a nonprofit integrated delivery system based in the Dallas/Fort Worth area. Len Nichols and I have profiled their work improving quality through a multitude of initiatives in a just-released case study published by The Commonwealth Fund.

Founded more than a century ago, Baylor Health has grown from a one-building hospital to a 3,000-bed integrated system that uses electronic health records and numerous quality improvement tools. The system owns a 450-physician medical group subsidiary and is affiliated with 3,000 independent physicians who deliver care at 15 Baylor-owned, leased, or affiliated hospitals and six "short-stay" hospitals. Baylor uses training programs, as well as physicians, to encourage system-wide initiatives and cement its quality mission across the entire system. The system has successfully implemented electronic medical records, decreased mortality rates, and standardized care.

Highly-esteemed integrated systems like the Mayo Clinic are sometimes derided by health reform pessimists as laudable organizations that exist purely because they reside in remote areas or were founded before 21st century business pressures. Baylor, however, demonstrates that substantial health care delivery improvement can occur in just a decade.

This is the first of three posts on the Baylor Health Care System. Today we'll look at the Best Care Committee, tomorrow we'll discuss physician leadership in quality, and finally we'll examine their innovative training program and look at the exportable lessons.

Best Care Committee

Integral to Baylor's quality improvement strategy is the Best Care Committee. Formed in 2001, the Best Care Committee began as a forum to define, discuss, and develop implementation strategies for care improvement initiatives. In March 2005, the committee was re-formed to become a legislature-like body with more than 100 voting members.

The Best Care Committee's  current co-chairs are the chief medical officer and the chief nursing officer of the Baylor system. Members includes the system's chief quality officer, patient safety officer, and chief medical informatics officer, as well as hospital presidents, chief nursing officers, medical staff presidents, health care improvement directors and chief operating officers. Other members include Physician Champions (to be discussed tomorrow), nursing leaders, and others representing the patient safety, equity, patient-centeredness, finance, and business development areas of Baylor.

Since March 2005, the Best Care Committee has passed more than two dozen major quality initiatives. Committee members take on the responsibility of implementing these initiatives at their home hospitals. The ground rules state: "Once the BCC passes an initiative, it is to be adopted across all facilities; BCC members will promote the adoption of these Best Care initiatives across all facilities; adoption and impact will be monitored and used to promote continuous improvement of the care that we deliver." In other words, as Baylor Health's Physician Champion leader Dr. Carl Couch told us, the committee becomes the answer to "Who Says?" As Baylor Health's clinical authority, it is the chief counterargument to the statement of local autonomy, "That's not the way we do it here."

The Best Care Committee has no explicit executive authority. It achieves success via persuasion, common alignment of goals, and focused implementation efforts. Committee initiatives are not enforced, but are implemented. This is accomplished through a monthly reporting of process and/or outcome metrics to the Best Care Executive Committee, local hospital committees, and ultimately to the hospital and system boards. Implementation is driven by "Physician Champions," who are recruited from Baylor's physician ranks and, importantly, are compensated for the time they devote to quality initiatives.

The Best Care Executive Committee establishes the strategy and agenda for the full committee, and ensures that it follows the six aims established by the Institute of Medicine: care that is safe, timely, effective, efficient, equitable, and patient-centered. The Executive Committee also steered the committee as Baylor participated in the Institute for Healthcare Improvement's 100,000 Lives Campaign. Although the Campaign's goal was a 5 percent reduction in mortality, Baylor reduced risk-adjusted mortality 10.1 percent across the system from July 2004 to June 2006 (fiscal years 2005 and 2006). During the following 12 months, risk-adjusted mortality continued to decline by 11.4 percent.

 * Hospital Standardized Mortality Ratio (HSMR) represents the ratio of observed deaths divided by expected deaths across all eight BHCS acute care hospitals. Expected deaths are determined using the State of Texas Public Use Data File for the calendar year 2004 as a normative source of mortality rates for each APR-DRG / Risk of Mortality pair. A value of 1.0 would represent an average outcome for patient care in Texas during 2004. Admissions for all patients are shown in the solid line; the dashed line represents the exclusion of patient admissions that involved formal end of life care (hospice or specialty level palliative care services and live discharges to post-discharge hospice care). (Source: BHCS)