Richard Smith: How to turn around a failing hospital

Richard SmithEngland is said to have 30 hospitals that are failing so badly that they may be taken over by the private sector. So there might be a lot of interest in a case study posted this week on the Health Foundation website that describes how a major academic hospital in Boston was saved from failure. 

The hospital is the Beth Israel Deaconess, one of the Harvard affiliate hospitals. Its problems began when two of its great rivals—the Massachusetts General Hospital and the Brigham and Women’s Hospital—merged in order to have more power when debating payments with insurance companies. The Beth Israel and the Deaconess hospitals decided that they too would have to merge, but as with most mergers it was actually a take over. The Beth Israel swallowed up the Deaconess.

Both were faith based hospitals, but one, the Deaconess, began with a Christian missionary zeal, while the other, the Beth Israel, began because Jewish doctors were not accepted in the other hospitals and Jewish patients were denied care. When the hospitals merged the bigger Beth Israel (made famous, by the way, through its depiction in the best selling but brutal House of God) crushed the culture of the Deaconess. The doctors and nurses from the Beth Israel derided those from the Deaconess, and many of the Deaconess staff, including the whole anaesthetics department, left.

(The case study on the Health Foundation website doesn’t give the full gory detail, but I had the chance to hear at a seminar an unvarnished—but perhaps inevitably partial—account from Paul Levy, the hospital’s chief executive who led the turnaround.)

Full understanding of the story depends on understanding the unique Boston culture. It’s a town full to the brim with talented and charming people, but many of them are arrogant, opinionated, and delight in doing down rivals. It has, said Levy, a belligerent, aggressive, hostile atmosphere where rival hospitals hate each other. You can learn something about the town by reading Henry James’s The Bostonians, a novel that most Bostonians dislike.

The “merger” of the two hospitals combined with the increased power of its rivals led the newly merged hospital into a “spiral of decline.” Over the next five years the hospital, a charity, burnt through $200m of its endowment, and in the final year before the turnaround it was losing nearly $100m a year. The state gave it six months to turnaround or it would be sold, and Larry Summers, who was then president of Harvard (and a true Bostonian character), said that if it was sold it would lose its Harvard affiliation. At that point many of the doctors would leave.

So the hospital was close to ruin when Levy took over. He had no experience of running a hospital but did have 30 years experience of management in the public sector and was known to many of the senior doctors at the hospital because he had been the administrative dean of Harvard Medical School. He’s also a man who loves a serious problem and is bored by business as usual.

His first step was to make clear to everybody how near to failure the hospital was and how their futures depended on turning the hospital round. Amazingly, this hadn’t been clear to people before—but the ultimatums from the state and Summers made it easy for Levy to show the seriousness of the situation. He also published on the hospital website a report from some consultants, the Hunter Group, on what was needed to turn the hospital round financially. These reports, which are notorious among failing hospitals, are usually “kept deep in a vault,” but Levy needed to make clear that the hospital had a “burning platform.” It had to change.

The financial turnaround was the easy bit, said Levy. The hospital developed a plan and created task forces that included no senior staff to implement the plan. The management set targets and published data every month on progress—or the lack of it. Levy didn’t spell out the detail of the financial turnaround and nor does the case study, but he did mention that the hospital made 600 people redundant, saving some $30m a year.

The hospital was quickly turned around financially, but Levy and the case study concentrate on what happened next—how the leaders brought the processes of quality improvement to the very heart of the hospital. It wasn’t clear to me exactly how this happened, and nor, I think, is it entirely clear to Levy. But how it happened is very interesting because mostly it doesn’t happen that whole hospitals become serious about quality improvement.

I’ve been listening to Don Berwick, Brent James, and the other gurus of quality improvement for more than 20 years and been hugely impressed with them and their achievements. The sad truth, however, is that quality improvement in most hospitals remains a marginal activity with a few individuals and departments enthusiastically improving but most going on as usual.

Why has the Beth Israel Deaconess managed to institutionalise quality improvement? Part of the answer is that Levy cares a lot about improvement. He observes that everybody in the hospital wants to their best for patients—and so quality improvement plugs into the fundamental values of the culture. But all clinicians care about doing the very best for patients, yet this doesn’t usually lead to the institutionalising of quality improvement. Levy did, however, have the advantage that he had “saved” the hospital and come to be trusted by the staff because of his “telling it like it was.” He had momentum.

Another advantage was that he had a chief of medicine, Mark Zeidel, who cared very much about improvement. Zeidel was unusual in that he was intolerant of any lack of safety. For example, he aimed to rid the hospital of infected central lines. Many in the hospital were proud that their rate of infection was below the national average and accepted it as inevitable that there would be some infections. Zeidel, in contrast, wanted to drive for zero.

In order to achieve the ambitious targets for quality the hospital has adopted the full rigour and science of quality improvement—training staff, constantly analysing and modifying processes, collecting data on performance and outcomes, and pushing for further improvement.

Then a vital part of the success seems to have happened almost accidentally. Proud of what was being achieved with reducing the infection rates of central lines, Levy posted the data in his blog—without the permission of anybody. It might have been that clinicians would have been horrified, but actually they were pleased. So began a system of publishing data on progress towards targets for improving many of the hospitals activities. Levy, his team, and the case study all think that this transparency, combined with accountability, has been a vital part of turning the hospital round.

Levy’s blog also seem to be important itself. (He blogged about the seminar where I heard him within a few hours.) The blog allows him to communicate directly with the thousands of staff and increasingly beyond the hospital. He writes it at least three times a week. He writes it himself and nobody sees it before it’s posted—no lawyer or public relations person. Importantly it must be interesting and provocative, and one of the most exciting blogs describes how the hospital operated on the wrong patient—minutes after they realised it had happened.

Someone at the seminar asked whether the improvements in the hospital had brought measurable financial benefit, and the answer seems to be yes. One of the largest medical groups in the area had always sent its patients to the Mass General and the Brigham, but they have now switched some of their patients to the Beth Israel Deaconess, substantially improving the margin of the hospital and reducing that of its competitors, which unsurprisingly has caught their attention.

But will the emphasis on quality improvement persist when Levy and Zeidel leave? Nobody knows the answer to that question, but the awful feeling is that the answer may well be “no.”

Richard Smith was the editor of the BMJ until 2004.