Hospitals

CULTURE BEAT: "HOSPITAL" Takes Us Inside Culturally Complex Brooklyn Hospital

Joanne Kenen — Mon, 19 May 2008 15:19:00 -0400

Picture an urban hospital where 67 languages are spoken, the Chinese food is glatt kosher, and the most exotic ethnic species is a blond Nebraskan surfer named Davey doing his medical residency in the E.R. Welcome to Maimonides Medical Center, in Borough Park, Brooklyn.

In HOSPITAL: Man Woman Birth Death Infinity Plus Red Tape Bad Behavior Money God and Diversity on Steroids author Julie Salamon gives rare insight into one year in the life of a large, complex, urban hospital (Read Jackie Judd's interview with Salamon about her new book here). In 2003, Maimonides admitted 38,667 patients, 127,319 were seen in its outpatient clinics, and 81,190 passed through the Emergency Department. More than 6,000 babies were born; more than 1,000 people died.

Julie (we overlapped on a health reporting fellowship last year, although I knew her writing before I knew her) is a cultural critic, not a policy wonk. The narrative she tells is more about the drama and feuds and loves and losses and financial fights and towering egos of doctors, administrators and even the cleaning crews than it is about health policy. In fact, we only meet a handful of patients (most of those she focuses on were poor and dying, depending on the hospital to meet many needs beyond medical care). But she had astonishing access to the people who somehow or other—despite the shockingly abundant "bad behavior"—cared enough not only to keep serving their multiethnic community but to keep trying to do a better job:

Depending on the day or night, life in the hospital could seem full of exquisite promise or pointless despair. The system was tainted by callous disregard for decent and equitable care, by money lust, by corporate influence and by lack of political will. But a great many people who were part of the system wanted something better. Yes individual doctors and nurses behaved badly, sometimes inexcusably so. Clerks were rude to patients and to each other. People made mistakes. Yet I was constantly struck by the sense of urgency that accompanied desires for fairness, for compassionate medicine, for efficiency, for meaning—and yes, for cleaner rooms.

It's an easy read and a rich story.

INNOVATORS: Wisconsin Hospitals Trim Waste and Improve Care

Joanne Kenen — Fri, 11 Apr 2008 15:05:00 -0400

"There are two things we need to do in medicine," a hospital administrator told Guy Boulton of the Milwaukee Journal Sentinel recently. "We need to learn to see waste. And we need to see risk."

The paper wrote a thoughtful two-part series (here and here) recently documenting how ThedaCare, a four-hospital chain in Wisconsin, has used those two guiding principals not just to save money but to improve patient care. They've re-examined everything from washing sheets to heart surgery. They've saved money—and improved outcomes for patients. They've shortened waits for appointments for CT scans. And they've eliminated hundreds of forms.

One example: an uncomplicated heart bypass surgery, including the doctors' fees, cost $30,400 at a ThedaCare hospital. At some other southeastern Wisconsin hospitals, insurers pay more than double that.

A lot of the improvements can be seen in the general medicine unit at ThedaCare's Appleton Medical Center, where they've introduced a model called "Collaborative Care." The unit serves patients with infections, pneumonia, heart failure, and similar problems. The improvements have cut the amount of time patients typically stay in the hospital by 20 percent.

In this context, "Collaborative" is more than a buzzword. Doctors now make rounds with a pharmacist and a nurse. A care manager (who deals with things like insurance coverage or follow up home care) sometimes joins them. The pharmacist can chime in about the doctor's prescription choices, for instance, reducing the risk of errors or dangerous drug interactions. The collaboration also reduces the number of frantic calls to the doctors' pagers. Nurses are more involved in coordinating care; more routine aspects have been turned over to licenses practical nurses or trained aides.

By focusing on reducing waste, ThedaCare is joining a number of hospitals trying to implement Toyota's proven methods of increasing quality and reducing cost. We wrote about the similar journey of Seattle's Virginia Mason Medical Center last month.

Coincidentally, we were attending a conference about reinventing practice sponsored by the Institute of Healthcare Improvement when this article came out. ThedaCare and its culture of change has caught IHI's attention, too.

QUALITY: What If All Patients Could Go to a "Benchmark Hospital"? Part II

Tom Emswiler — Fri, 21 Mar 2008 17:10:00 -0400

Yesterday I posted on this year's "100 Top Hospitals: National Benchmarks for Success" list, released this week by Thomson Healthcare. I promised I would post today about how to get from here to there.

I bet you lost sleep with anticipation!

Again, I want to quote Steven Pearlstein's column last year on this issue, specifically the story of how Winchester Medical Center in Virginia responded to its "somewhat disappointing" report a few years ago:

Winchester Medical Center set a goal of making the Top 100 list by 2008. It hired a consultant, altered its executive compensation to put a bigger emphasis on quality and organized teams in every department to implement small changes in procedures that translate into big improvements in its quality score.

After nurses took extra time to take fuller medical histories, and body hair was clipped rather than shaved before surgery, and the timing was changed on when antibiotics were administered, for example, surgical infection rates fell by 75 percent.

And by creating special emergency teams to focus on heart attack patients as soon as they were picked up by an ambulance, Winchester reduced the time it took to get a patient to a catheterization lab to 40 minutes from an average of 120.

This is proof that hospitals can learn. While Winchester indeed learned a new way of doing things, we need to move towards a better way to disseminate health best practices, so that other hospitals can more easily learn from Winchester's hard work.

A recent paper by Thomas Bodenheimer takes a look at the "Science of Spread" - or, how dissemination in the health world differs from the non-health world. Donald Berwick's life's work is to disseminate best practices, but also has written an academic how-to manual on spreading innovations in health care in one's own organization.

Relevant and rewarding non-health dissemination works include Malcolm Gladwell's The Tipping Point and Made to Stick by Chip and Dan Heath, as well as Everett Rogers' Diffusion of Innovations, which Bodenheimer cites as the seminal work on the topic.

Here at the New America Foundation, we are trying to do our part. My boss Len Nichols and I are putting the finishing touches on a case study of the Hill Physicians Medical Group, an independent practice association in northern California that is helping its affiliated-yet-independent physicians improve the quality of care they provide by gaining their trust and then working with them as collaborators. We'll post a link on the NHD blog when it's finished.