Case Study High-Performing Health Care Organization • December 2008 Brigham and Women’s Hospital: “Moving the Needle” Takes People, Processes, and Leadership J ennifer E dwards , D r.P.H. H ealth M anagement A ssociates The mission of The Commonwealth Vital Signs Fund is to promote a high performance Location: Boston, Mass. health care system. The Fund carries out this mandate by supporting Type: Nonprofit teaching hospital, affiliated with Harvard Medical School and a member of independent research on health care the Partners HealthCare System, an integrated health care delivery system that includes issues and making grants to improve Massachusetts General Hospital and other Boston-area facilities. health care practice and policy. Beds: 777 Distinction: Top 5 percent of more than 700 large hospitals (300+ beds) in the portion of patients who gave a rating of 9 or 10 out of 10 when asked how they rate the hospital overall. Timeframe: October 2006 through June 2007. To be included, hospitals must have reported at least 300 surveys. See the Appendix for full methodology. This case study describes the strategies and factors that appear to contribute to high patient satisfaction at Brigham and Women’s Hospital. It is based on information obtained from interviews with key hospital personnel and materials provided by the hospital during September 2008. For more information about this study,      please contact: Jennifer Edwards, Dr.P.H. Summary Health Management Associates jedwards@healthmanagement.com The focus on customer service at Brigham and Women’s Hospital (BWH) dates back to the 1990s, when patient satisfaction surveys were first used. However, a concerted effort to “move the needle” to improve patient satisfaction began in 2002. That year, the new CEO, Gary Gottlieb, M.D., M.B.A., made service excellence one of the hospital’s top priorities. Gottlieb’s leadership on this issue is evident in three initiatives over the past six years: To download this publication and • BWH allocated significant new funding for quality measurement and learn about others as they become process improvement work, including establishing and expanding a available, visit us online at www.commonwealthfund.org and Center for Clinical Excellence; register to receive Fund e-Alerts. Commonwealth Fund pub. 1207 Vol. 6 2T he  C ommonwealth F und • BWH developed a management information BWH has earned numerous awards for quality, system for hospital leaders that tracks patient safety, and patient-centeredness. It has been named and family experiences, along with other hos- one of the top five hospitals in the University pital performance indicators; and HealthSystem Consortium 2007 Quality and Accountability Study. In 2008, it was listed on the U.S. • BWH sought to enhance patients’ experiences News and World Report “Top Hospital” honor roll for by working with frontline staff, including the 15th year in a row. In 2007, for the third year in a implementing new recruitment, training, man- row, BWH was named as one of 33 adult hospitals on agement, and improvement strategies. the Leapfrog Group’s list of “Top Hospitals” for As a result, Brigham and Women’s has seen its making significant strides in improving quality and patient satisfaction scores rise considerably, compared patient safety. with other teaching hospitals. Its experience suggests a few lessons for hospitals seeking to enhance patient Strategies for Success experience: Over the past six years, CEO Gary Gottlieb and the • Achieving high patient satisfaction scores is leadership team have focused on improving the quality possible, even for hospitals that have reached of care and patient satisfaction while maintaining only average performance levels. Brigham and BWH’s status as a leading teaching and research hospi- Women’s Press Ganey survey scores rose dra- tal in a competitive health care market. Key members of matically in six years, with several departments the leadership team include Michael Gustafson, M.D., moving from the 50th to the 90th percentile. M.B.A., vice president for clinical excellence; Anthony Whittemore, M.D., chief medical officer; and Mairead • A single strategy for improvement will not Hickey, R.N., Ph.D., chief nursing officer; as well as work. To raise patient satisfaction scores and the chiefs council of academic department chairs. sustain the gains, Brigham and Women’s pur- sued three strategies simultaneously and delib- Demonstrating Leadership Commitment erately: securing strong leadership commit- The leadership commitment to patient satisfaction is ment; improving care processes; and training a evident in the hospital’s financial commitment to data customer-focused staff. collection, monitoring, and improving; investment in staff to address problems and facilitate improvement; Organization and repeated emphasis of the goals. Quality, patient BWH is a 777-bed teaching hospital located in Boston. safety, and service excellence are part of the agenda at BWH is a founding member of Partners HealthCare all senior leadership meetings. System, the largest integrated health care delivery net- Hospital leaders encourage multidisciplinary work in New England, and a major teaching site for collaborations, particularly among physicians and Harvard Medical School. In 2007, inpatient admissions nurses, to improve patient experiences. Many improve- at BWH totaled approximately 44,000. ment projects are co-led by a physician and a nurse. Like a growing number of hospitals, Brigham Setting an example, Whittemore, the chief medical and Women’s posts quality scores on its public Web officer, and Hickey, the chief nursing officer, chair site. Notably, it also posts the Joint Commission’s many committees together. Though it is sometimes most recent review of the hospital, including plans to hard to get physicians to pay attention to quality address deficiencies. improvement initiatives, having the chief or the depart- ment chairperson involved has helped greatly. B righam and Women ’s H ospital : “M oving the N eedle ” Takes P eople , P rocesses , and L eadership 3 Hearing from Patients find these data useful or compelling. However, BWH Measuring patient satisfaction began at BWH in the has been able to demonstrate that patient dissatisfac- late 1990s, with the use of a Picker Institute survey tion as measured on Press Ganey surveys tracks con- that assessed the patient-centeredness of clinical care, sistently with complaints lodged directly to the hospital hospitality features of the hospital, and patients and as well as with malpractice claims against individual families’ interpersonal experiences with staff. In 2001, physicians. Gustafson says these trends have encour- the hospital began using the Press Ganey survey, aged physicians to pay attention to the survey results. which includes many of the same concepts but collects more detailed information for multiple parts of Bidirectional Performance Analysis patients’ care experiences. It has the additional benefit and Improvement of being used by many hospitals, against which BWH The detailed information that BWH has generated can benchmark its performance. Public reporting of from Press Ganey surveys has facilitated the develop- Press Ganey patient satisfaction data began in 2004. ment of what Dorothy Goulart, R.N., M.S., director of The hospital’s sampling strategy has grown over performance improvement, calls a “bidirectional per- time, so that 70 percent of all discharged patients are spective.” She and her staff of performance improve- now surveyed within a week of discharge. A relatively ment specialists look across the dozen departments or high proportion of patients and families—between 30 service lines reviewed in the survey as well as along and 35 percent—respond, probably due in part to the its 11 sections, and plot performance on these two survey reaching them soon after discharge, when their dimensions. This type of analysis made them aware hospital experience is still vivid. Because BWH that, when pain management improves, other scores receives 10,000 to 12,000 responses each year, the not directly related to pain, such as satisfaction with hospital’s Center for Clinical Excellence staff are able other aspects of nursing care, also rise. Similarly, satis- to examine the data in multiple ways, including by faction with room service raises patients’ satisfaction nursing unit, clinical area, and department. with their overall hospital experience. The survey data Every doctor for whom at least 20 to 30 patient have thus led to improvement strategies specific to responses per year are available receives a report on particular services as well as cross-department strategies. their patients’ experiences. At first, doctors did not As one example of the performance improve- ment work undertaken over the last seven years, Patient and Family Advisory Council in the NICU A small but growing number of hospitals are using Patient and Family Advisory Councils to gain insights into patients and families’ concerns.1 BWH recently invited two parents of former neonatal intensive care unit (NICU) patients to work with the unit’s physician, nursing, and administrative leaders to identify ways the unit could better serve their needs. These five individuals took a training course to learn how to work as an advisory council, then began regular meetings. The early discussions focused on facility issues, which were relatively easy to address. Having developed some trust and confidence, the group is now moving into the much more challenging area of communication. Families at BWH, as at many hospitals, often feel out of the loop and isolated when their child is in the NICU. At the recommendation of the Advisory Council, families are now included in daily rounds, visiting policies have been revised, and a Web-based communication portal has been established. Hickey, the CNO, says, “The process has been very informative for NICU staff. When a patient or family member raises an issue, it is front and center with the staff. Hearing it from the family member’s perspective takes its importance to a new level.” 1 See http://www.ahrq.gov/qual/advisorycouncil/adcouncil2.htm. 4T he  C ommonwealth F und Goulart describes the hospital’s work on the obstetrics dipping and so tried new improvement strategies. They unit. “When we started looking at data, our labor and trained nurses and other frontline staff in ways to delivery scores were very high, but the postpartum interact with patients and family members. Staff were scores were low, around the 65th percentile,” she says. coached on words and phrases that would be appropri- Hickey, Gustafson, and then director of women and ate in different circumstances and encouraged to make newborn nursing, Paula Gillette, partnered with IDEO, eye contact with patients and family members. Similar a consulting firm, and the hospital’s Center for Clinical types of training for staff from such departments as Excellence to develop several interventions to match transport, environmental services, and dietary have staffing to the needs of patients. The first intervention proven effective. was to find the right staff for the positions. This Nurse managers and other departmental super- involved enlisting the help of frontline staff in inter- visors took a four-hour training course on communica- viewing new hires to ensure they understood the job tion methods. They are tasked with setting clear expec- and were well suited to the unit. Staff also wrote val- tations for their staff, observing patient interactions, ues statements to reflect how they wanted to perform and providing feedback. Additional interventions are their jobs. The hospital reinforced positive perfor- under way to improve patients’ postpartum experiences, mance though a program called “Caught in the Act,” including streamlining room turnover, discharge pro- which recognized when someone exceeded expecta- cesses, and the transporting of mothers and babies to tions in their work. Employees received small gifts waiting vehicles. BWH continues to track data to see if such as movie tickets, along with recognition by peers these interventions achieve greater patient satisfaction. and in hospital newsletters. In addition, the staff rewrote the patient educa- Balanced Scorecard tion materials, providing better information on postna- In 2001, Brigham and Women’s developed a Balanced tal care, breastfeeding, and support for mothers and Scorecard, which enables them to track changes in babies after discharge. After these changes, patients’ performance on a number of indicators (Figures 1 and ratings of their postpartum care rose. 2). The term “balanced” reflects a shift from only But in 2005, three years after initiating these monitoring financial performance or productivity to changes, BWH saw their scores on postpartum care tracking customer and employee satisfaction, as well. Figure 1. Balanced Scorecard Strategy Map Source: Brigham and Women's Hospital, 2008. B righam and Women ’s H ospital : “M oving the N eedle ” Takes P eople , P rocesses , and L eadership 5 FigureFigure 2. Balanced Scorecard Sample Page 2: Balanced Scorecard Sample Page Source: www.brighamandwomens.org, fall 2008. BWH was one of the first health care organizations to team facilitation, and high-level project management. adapt this manufacturing industry tool to health care. BWH leaders believe the Center for Clinical The four quadrants on BWH’s Balanced Excellence has been one of the cornerstones of their Scorecard are: Quality and Efficiency of Care; successful efforts to improve patient and staff satisfac- Commitment to People, Teaching, and Research; tion, as well as quality outcomes and patient safety. Financial Performance; and Service Excellence and Growth. The latter category tracks patient and family Results experiences, as well as levels of satisfaction among BWH has seen their performance on Press Ganey referring physicians and hospitals. Together, these patient satisfaction surveys rise over the last seven groups comprise BWH’s key external customers. The years—moving closer to the goal of achieving 85.3 Press Ganey data supply the inpatient measures of percent overall satisfaction, which would rank the hos- patient and family experience. Other surveys assess pital in the 90th percentile compared with other large the experiences of patients who use the emergency teaching hospitals. They have achieved this goal in department and ambulatory care services. several departments, though the hospital-wide average shows there is still room for improvement. Figure 3 Center for Clinical Excellence shows the performance trends over time. The bench- To support quality and efficiency in patient care, BWH mark is all teaching hospitals with 500 or more beds. created a Center for Clinical Excellence in 2001. Hospital Consumer Assessment of Healthcare Reflecting a major institutional commitment, the Providers and Systems (HCAHPS) data are newly Center has grown to include 30 full-time employees available, so there are no trends to report. The Table who work throughout the institution on ongoing shows calendar year 2007 data for the hospital. Scores improvement efforts as well as special projects, such are much lower overall than Press Ganey scores, and as launching new services and integrating care across variation between departments cannot be seen in the sites. The resources they bring to a problem include aggregate scores. BWH scored at or near national data, tools, improvement methods, content expertise, averages on many specific measures of patient experi- 6T he  C ommonwealth F und Figure 3. BWH Press Ganey Scores Compared with National Average for Teaching Hospitals with 500+ Beds, 2001–2008 Source: www.brighamandwomens.org, fall 2008. ences. On measures of noise and bathroom cleanliness, in the second quarter of 2008. Total surplus has risen the hospital fell well below national averages. from $23 million in 2002 to exceed $90 million in 2008.1 However, on the two global measures, a patient’s over- all rating of their hospital experience and willingness Lessons Learned to recommend the hospital to friends or family, BWH Brigham and Women’s experience offers the following exceeds national averages by several percentage lessons to other hospitals seeking to improve patients’ points. At BWH, hospital leaders expect to apply the satisfaction with their care: same principals that have helped them to improve per- • Major improvement in patient satisfaction formance on Press Ganey surveys to raise their scores can be achieved. In the case of BWH, HCAHPS scores. Press Ganey scores rose dramatically in the Hospital leaders tie success in achieving patient past six years, with some departments moving satisfaction to the overall financial success of the insti- from the 50th to the 90th percentile. The tution. In particular, the hospital has experienced expectation is that similar strategies will improve higher inpatient and outpatient volumes in recent the hospital’s HCAHPS scores as well. years, including inpatient occupancy rates that average • To raise patient satisfaction scores and sustain over 90 percent. The Boston Business Journal reports the gains, hospitals should pursue many that operating margins have risen during Gottlieb’s improvement strategies at once. Gustafson tenure from 1.9 percent in his first year to 5.2 percent says three simultaneous changes have made a difference at Brigham and Women: strong leadership commitment; improving key care 1 R. Celaschi, “Brigham and Women’s Gottlieb Is a Man with a Mission,” Boston Business Journal, August 15–21, 2008. B righam and Women ’s H ospital : “M oving the N eedle ” Takes P eople , P rocesses , and L eadership 7 delivery processes; and maintaining a cus- to be critical thinkers, identify problems, and get help tomer-focused staff. fixing them and to teach supervisors to support staff in these efforts. The biggest challenge to continuing to improve Gustafson noted another challenge: for BWH to is the complacency that can come when you are balance their two sides, that of a “warm fuzzy hospital already doing well. As an institutional leader, with excellent patient experience” and a top research Gustafson says, it is hard to convince people to do and teaching facility. more when they see strong scores. Goulart says the greatest challenge for frontline For More Information staff is to become problem solvers. Given their train- Contact Michael Gustafson, M.D., M.B.A., vice presi- ing and focus on meeting patients’ immediate needs, it dent for clinical excellence, (617) 732-8937, or is more natural for frontline staff to work around a Dorothy Goulart, R.N., M.S., director of performance problem than to try to solve it for the long term. BWH improvement, (617) 732-7729. is using Lean concepts and tools adapted from the Toyota Production System to encourage frontline staff Table. Brigham and Women’s HCAHPS Scores Compared with National Average, CY 2007 Percent of patients who reported that: BWH National Average Their nurses “always” communicated well. 79% 74% Their doctors “always” communicated well. 81% 80% They “always” received help as soon as they wanted. 63% 63% Their pain was “always” well controlled. 70% 68% Staff “always” explained about medicines before giving it to them. 59% 59% Their room and bathroom were “always” clean. 68% 70% The area around their room was “always” quiet at night. 48% 56% Yes, they were given information about what to do during their recovery at home. 86% 80% Gave their hospital an overall rating of 9 or 10 on a scale from 0 (lowest) to 10 (highest). 76% 64% Yes, they would definitely recommend the hospital. 83% 68% Source: http://www.hospitalcompare.hhs.gov/Hospital/Search/compareHospitals.asp, accessed fall 2008. 8T he  C ommonwealth F und Appendix. Selection Methodology Selection of hospitals for inclusion in this case study series is based on data voluntarily submitted by hospitals to the Centers for Medicare and Medicaid Services (CMS). Between October 2006 and June 2007, hospitals or their sur- vey vendors sent a survey to a random sample of recently discharged patients, asking about aspects of their hospital experience. The survey instrument, called the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), was developed with funding from the Agency for Healthcare Research and Quality (AHRQ). CMS posts the data on the Hospital Compare Web site (www.hospitalcompare.hhs.gov). The survey contains several questions about nurse and physician communication, the physical environment, pain management, and whether the patient would recommend the hospital to family or friends. One question inquires about the patient’s overall experience: “Using any number from 0 to 10, where 0 is the worst hospital possi- ble and 10 is the best hospital possible, what number would you use to rate this hospital during your stay?” HCAHPS is a relatively new survey, and hospitals across the country are not yet achieving very high scores across all of the questions. Nevertheless, some hospitals are scoring significantly better than others. By profiling hospitals that score within the top 5 percent (among those that submitted at least 300 surveys) on the question con- cerning overall experience, this case study series attempts to present factors and strategies that might contribute to and/or improve patient satisfaction. An initial list of top scorers among all hospitals submitting HCAHPS data contained a disproportionate num- ber of very small, southern hospitals.1 Concerned about the ability to generalize experiences and lessons and repli- cate strategies, we profiled one hospital from this list but chose to then examine high scorers among larger hospitals that were more diverse in: region of the country, urban/suburban/rural setting, and teaching/nonteaching status. We thought that such diversity would provide lessons that would be useful to a broader range of U.S. hospitals. Therefore, for this case study series, most hospitals were selected from among 736 large hospitals (300 or more beds), primarily based on their ranking in the percentage of survey respondents giving a 9 or 10 rating on the “overall” HCAHPS question. In the future, we will present case studies of hospitals of different size, ownership sta- tus (e.g., public, private), and other peer groupings. While high HCAHPS ranking was the primary criteria for selection in this series, the hospitals also had to meet the following criteria: ranked within the top half of hospitals in the U.S. on a composite of Health Quality Alliance process-of-care measures as reported to CMS; full accreditation by the Joint Commission; not an outlier in heart attack and/or heart failure mortality; no major recent violations or sanctions; and geographic diversity. 1 Further examination and analysis may reveal reasons for this. B righam and Women ’s H ospital : “M oving the N eedle ” Takes P eople , P rocesses , and L eadership 9 A bout the A uthor Jennifer Edwards, Dr.P.H., M.H.S., is a principal with Health Management Associates’ New York City office. Jennifer has worked for 20 years as a researcher and policy analyst at the state and national levels to design, evaluate, and improve health care coverage programs for vulnerable populations. She worked for four years as senior program officer at The Commonwealth Fund, directing the State Innovations program and the Health in New York City program. She has also worked in quality and patient safety at Memorial Sloan-Kettering Cancer Center, where she was instrumental in launching the hospital’s Patient Safety program. Jennifer earned a Doctor of Public Health degree at the University of Michigan and a Master of Health Science degree at Johns Hopkins University. A cknowledgments We wish to thank Drs. Gustafson and Hickey, and Ms. Goulart for generously sharing their time and experiences with us. Editorial support was provided by Martha Hostetter. This study was based on publicly available information and self-reported data provided by the case study institution(s). The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund’s case studies series is not an endorsement by the Fund for receipt of health care from the institution. The aim of Commonwealth Fund–sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area of interest, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied institutions’ experience that will be helpful in their own efforts to become high performers. It is important to note, however, that even the best-performing organizations may fall short in some areas; doing well in one dimension of quality does not necessarily mean that the same level of quality will be achieved in other dimensions. Similarly, performance may vary from one year to the next. Thus, it is critical to adopt systematic approaches for improving quality and preventing harm to patients and staff.