Maimonides Medical Center
|Eight years ago when Pamela Brier arrived on the scene at Maimonides Medical Center in Brooklyn, N.Y., the teaching hospital still was relying on key punch cards to keep information flowing. "Vendors had given up on us," says Brier, the 639-bed hospital's executive vice president.|
Maimonides' substantial investment in information technology in the years since-one-half of a $20 million
As executives will tell you, benchmark hospitals such as Maimonides are not built on technology, but merely supported by it along with a host of other factors that set them apart from their peers.
If all of the more than 1,000 hospitals performing open-heart surgery and the hundreds more offering medical cardiology programs behaved as the 100 top heart hospitals did, it would save nearly 4,400 lives each year, according to the Solucient study. Nearly $880 million in costs could be saved annually-an average savings of more than $1,400 in cardiology costs for each patient in a peer, nonbenchmark hospital. Infections after surgery would drop by nearly 18% and 26% fewer patients would suffer post-procedural bleeding problems. Cardiac patients nationwide would shave a half day off their hospital stays, saving the nation's heart hospitals in total as much as 402,000 patient days a year, according to Solucient's research. That's the equivalent of 1,100 patient years if you do the arithmetic.
Solucient's study breaks the 100 top hospitals into three peer groups: teaching hospitals with cardiovascular residency programs, teaching hospitals without cardiovascular residency programs and community hospitals. The hospitals were compared against their peers using seven measures of clinical quality and operational efficiency: volume, medical mortality, surgical mortality, complications, length of stay, cost and percentage of heart bypass patients in which the mammary artery was used. All hospitals that had treated at least 30 patients in each of four categories-heart attack, congestive heart failure, coronary angioplasty and coronary artery bypass graft surgery-were included in the study.
The study revealed some striking findings, one a potential blockbuster for minimally invasive bypass surgery (See related story, here). Perhaps one of the most important overall findings concerns the variance in volume for community hospitals, says Jean Chenoweth, executive director of Solucient. The larger number of surgeries performed at benchmark community hospitals played a more critical role in setting them apart from their peer group than it did at teaching hospitals, she says, indicating a shift in where patients are seeking heart care.
Benchmark community hospitals performed at least twice as many angioplasty and bypass surgeries as their peers in 1999 and 2000, according to the study. At the same time, volume is starting to shrink at teaching hospitals, "which means enough people have been trained and they have become sophisticated enough to be spread across the country-and that's basically what those major teaching hospitals are supposed to do," Chenoweth says.
Partners, yet competitors
Procedure volume has been growing in Ocala, Fla., where two community hospitals across the street from each other-323-bed Munroe Regional Medical Center and 210-bed Ocala Regional Medical Center-appear on the 100 top hospitals list for the fourth consecutive year. The two hospitals opened their programs with a joint certificate of need in the mid-1980s, even though Munroe Regional, a not-for-profit, and Ocala, a for-profit owned by Nashville-based HCA, compete for patients. Considering cardiology is its most profitable service line, Munroe Regional heavily markets its service to the community and tries to make residents well aware that they can get exemplary open-heart surgery in Ocala rather than traveling to an academic medical center, says Earline Piscitelli, the hospital's vice president of corporate development.
Munroe Regional has greater market share than its neighbor thanks to aggressive invasive cardiologists who have pumped up the volume in the catheterization laboratory, which in turn leads to more surgeries, she says. It has paid off. The hospital plans to double the size of its surgery suites and increase the size of its recovery intensive-care unit to 14 beds from eight.
"We think volumes keep us more efficient and keep the profit margin up," Piscitelli says. "As a not-for-profit, we need that profit to subsidize other service lines."
In the Solucient study, volume as a quality measure also takes a significant detour from the Leapfrog Group, a powerful coalition of employers that is trying to set standards for hospital quality. Although the Leapfrog Group considers volume the prevalent criteria for performance evaluation, Solucient researchers say they believe that it offers only a partial explanation for exemplary outcomes. As such, volume is just one of several measures in this year's study whereas in previous years it played a more prominent role.
"Groups such as Leapfrog are showing you get better results with more procedures, but it's not an important enough predictor," says David Foster, Solucient's vice president of clinical informatics. "What the results do show is that in some cases hospitals with small volumes still can achieve excellent results."
This year the study for the first time also added congestive heart failure to the patient groups. Teaching hospitals seem to have a better handle on treating this "major cardiovascular issue," Chenoweth says. The benchmark hospitals overall outperformed the peer group by 22% but among teaching hospitals with cardiovascular residency programs, the variance shrunk to 6%. "So something different is going on in these hospitals with the management of congestive heart failure than in the other two groups of hospitals," Chenoweth says.
Indeed, something different is going on at Maimonides. Recognizing that congestive heart failure was one of its largest admitting diagnoses, Maimonides implemented a special program to address the troublesome number of readmissions, says Jacob Shani, M.D., chairman of the hospital's cardiac institute. The program identified every patient admitted to the hospital with congestive heart failure, and when patients were discharged, nurses followed up with at least three phone calls per week. In addition, patients who did not have private physicians subsequently were called every two weeks to ensure they were complying with their medication regimens and diet restrictions. A readmission rate as high as 20% within 30 days of hospitalization has plummeted to 6.4%.
But Maimonides' success in becoming a benchmark heart hospital for the first time this year has been 25 years in the making. Based on its experience and the experience of others on the list, setting the bar for other hospitals involves a painstaking process that encompasses every facet of a hospital's operation. And once the process is in place, benchmark hospitals compulsively check and recheck their work to see if there is any way to make it better.
For example, Maimonides' road to success began in 1976 when Edgar Lichstein, M.D., chairman of the department of medicine, arrived on the scene and immediately organized the cardiology laboratories so only full-time physicians were performing procedures, the first step in building expertise in the department, he says. More recently, besides investing in technology-a doctor-driven process, Brier says-the hospital studied the community it serves and concentrated on building good working relationships within it. Located in the Orthodox Jewish enclave of Borough Park, Maimonides nevertheless is surrounded by a United Nations of communities. The hospital's patient bill of rights is available in 10 languages.
The hospital's emergency medicine program plays an integral role in the seamless system of programs that have been built around patients rather than the other way around, Brier says. In 1995, approximately 13,000 patients arrived at Maimonides by ambulance through the emergency room. That number has nearly doubled to 21,000 patients per year; ER visits in general will grow to 80,000 this year. The growth translates to higher volume in cardiology, which gets as much as 60% of its referrals from the ER, says Joseph Cunningham, M.D., chairman of the department of surgery.
In the meantime the hospital built a fast track from the ER to cardiology that promises all patients are examined, diagnosed and sometimes treated within a day. Lower lengths of stay have helped pump up capacity to accommodate the burgeoning volume. The system works in large part because of an expert, dedicated staff that knows the system inside out, Shani says.
"Everyone is marching to the same drummer," Brier says.
Setting new standards
Likewise, Robert Colvin, president and chief executive officer of 473-bed Memorial Health in Savannah, Ga., says becoming a benchmark heart hospital for the first time was the result of a conscious decision made three years ago after studying the market. The facility is a teaching hospital without a cardiovascular residency program. He credits Memorial's performance to a concerted effort that brought together physicians and staff from several departments to create a department of cardiovascular medicine that keeps everyone focused on good outcomes. "It was a business decision," Colvin says. "Looking at the region, we determined it was one of the major service areas we could and should enhance." Volume in the catheterization laboratory has grown by 40% since the effort began, Colvin says.
Similar principles apply in Ocala. Standardization is key to the success of that market, where the two hospitals share the heart surgeons who in turn have trained the nurses, says Jim Wood, president and CEO of Ocala Regional. Carol Floyd, director of cardiovascular services at Munroe, says standardization extends to the entire process, including the surgery case packs that are used by every heart surgeon. Another crucial component is teamwork, which they work compulsively at fine-tuning, Floyd says.
Data for the Solucient study were drawn from about 12 million Medicare discharges from the nation's hospitals. Clinical measures relied on data from 1999 and 2000, the most recent years available. Cost and length-of-stay measures were based on 2000 data only.