Process Improvement in the Rarefied Environment of Academic Medicine

author: Paul Levy, Beth Israel Deaconess Medical Center
published: July 26, 2010,   recorded: October 2007,   views: 2702

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If, as Paul Levy says, “medicine for the most part remains a cottage industry,” then how can you impose system-wide improvements -- especially if you’re presiding over an academic hospital, where the culture rewards brilliant, independent, free-thinking doctors?

This has been Levy’s challenge since 2002, when he took over an ailing Beth Israel Deaconess Medical Center. The result of a merger between two hospitals in the late ‘90s , BIDMC immediately fell into a “downward spiral,” recounts Levy. Doctors and nurses left, and losses grew to nearly $70 million a year. The hospital burned up $200 million of a $500 million endowment.

When he arrived, Levy recognized that the hospital’s problems had less to do with medicine than with management and organization. For instance, it took 100 days for a bill to go out after the actual service was performed, and bills were often inaccurate, based on a doctor’s hand-scribbled note.

Levy set to work enhancing the hospital’s routines, such as providing an electronic billing system with pull-down menus. He met with demoralized nurses to address their concerns, and succeeded in reversing the 15% turnover rate. Then, says Levy, “we started focusing on what really matters: how well we’re taking care of people, how often are we hurting and killing people and what to do to stop.”

Hospitals, he notes, “are very dangerous places,” with “bugs floating around and mistakes being made.” One common problem at BIDMC, ventilator associated pneumonia, had a 30% mortality rate. The fixes were simple --raising beds, better oral hygiene, hand-washing --but accomplishing them required systemic compliance.

Levy identified doctors who could lead colleagues in the new practices. He attached protractors to beds so nurses could raise them by precisely 45 degrees. “Lots of low-tech solutions must be institutionalized,” says Levy. Mortality due to this pneumonia dropped, and Levy figures the hospital saves 96 lives per year, or $12 million in expenses.

By shadowing nurses and other staff, Levy’s discovered that individuals often find workarounds to problems, but aren’t aware that others might benefit from their solutions. Levy set up a blog to post these solutions and focus the organization as a whole on areas of concern. Supporting good performance, sharing clinical results such as “how many people we hurt and kill” stimulates people in a hospital to do better, he believes. Public exposure goes a long way in helping academic medical staff to understand they must be “held accountable for their actions particularly when it comes to harm.”

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