Beth Israel Hospital (BI) in Boston, Massachusetts, is a hospital with a three-faceted identity. First of all it is a hospital for patients from Boston and the surroundings. The second role is as a research institution and the last role is as a trainings institution where Harvard Medical School faculty members can be trained. Despite the hospital is one of the best, some people called the organization “an unruly mob”. Malcom Weinier, vice president of clinical and support services, told that the BI hospital has a structure that’s typical for a hospital. It is part hierarchy, part team, and part matrix, but more team than anything else. ” It works like a strong triangle, a nurse, an administrator and a physician manages the service. The hierarchy is for getting things done, the team is for communication. Industry issues In the medical world, the quality thinking is penetrated. This leads to different types of questions and issues like: how can we measure quality, how to handle the enormous pressure of time, how can we pay and which hospital is the best for certain complaints.
The Joint Commission for the Accreditation of Health Care Organizations (JCAHO) shifted its attention from auditing safety regulations to insisting that hospitals review all the cases for quality and act on the results. Hospitals are struggling with the question how can we measure quality. In the next paragraphs we will tell more about it. What happened in the BI hospital characterizes the industry. The increasing attention on quality and the reducing of costs ensures pressure on nurses and physicians to rapidly move the patient through the system.
It has a negative impact on the quality and the patient is being treated as an number instead of a human being. Another issue, maybe correlated with time pressure, is the responsibility of physicians for the patient. A lot of patients are stuck in a web of specialists and are driven from pillar tot post. In the past decennia the federal government was the largest single customer. Now, people have to pay it by themselves or through insurance. Pennsylvania and Colorado are now lobbying for a kind of marketplace where patients are able to choose a hospital based on price and performance.
In sum, quality is increasing important but to measure quality in a right manner, there’s a lot of research needed. Mission and priorities Delivering patient care of the highest quality in both scientific and human terms, concentrating on a patient-centered environment that encouraged learning and collaboration is very important for the BI hospital. Thus, providing excellent patient care is the mission of the hospital. Patients can’t be numbers but should be human being an must be treated as human beings. There’s a problem by measuring this mission because excellence is an elusive concept.
How can we measure quality? That’s the question we have to answer before measuring the mission. Ideally, the right patients would receive the right treatment, at the right time and in the right way, for the right price. Here the problems comes from a different point of view. Each ‘right’ is the responsibility of another physician. For example, the cost and prices are the responsibility of the fiscal group and the treatment is the responsibility of the nurses. Measuring quality is one issue, but how to compare the quality with previous years or with other hospitals is the second issue.
There’s a lack of similar measurements and a lack of data that can be compared. Eugene Wallace, chief financial officer, would like to develop a database that match with this kind of problems. Priorities like quality, the measurement of excellence, treatment of the patient, training and research and so on, are important issues for the BI hospital and can be regarded as their priorities. Quality and Challenges According to the CFO of Beth Israel quality is a concept that can’t be judged trough a set of data. It’s obvious that the number of patients that has died while having a heart surgery can be measured very easily.
But with what number of casualties must one be satisfied and can be seen as quality? Obviously this is a very delicate example, but it’s reality. Quality at Beth Israel, as stated in the example above, is very context-dependent and seen from a Beth Israel point of view unclear. This is because every departments manages and defines quality in different ways. The department of medicine for instance focuses on the revenue, number of research grants acquired, difficulty to recruit, reputation of current staff, productive use of space and whether the hospital is filled or not.
Managing the medical quality at the department of medicine happens by intensive one on one supervision trough the different layers of the organization. Another way to measure medical quality at Beth Israel is the weekly morbidity/mortality conference. The house staff present a difficult or unusual case to stimulate discussion. This way of quality management differs from the quarterly medical quality assurance meetings concentrating especially on errors. At the quarterly meetings statistics, specific cases, trends and problem areas will be reviewed.
At the department of cardiology quality is being measured and managed by the means of daily and weekly conferences and on-site supervision. The department of surgery manages quality by organizing weekly open meetings where there will be spoken and judged about complicated situations. As you can see, quality at Beth Israel is being measured and dealt with on a lot of different ways. Every department has his own idea of and perception on quality. This is what it makes it so difficult to judge and manage quality at Beth Israel from an objective perspective on the top layer of the organization or as outsider.
As seen in the case the JCAHO standards are just barely being met and are seen as compulsive and bureaucratic. So the big challenge at Beth Israel is to create a system that makes it possible to measure and compare quality at and between the different departments at Beth Israel. Also a moral change need to take place, the staff of Beth Israel needs to realize that quality measurement is needed to achieve the goal of offering better and better patient care. Recommendations
It is of great importance that Beth Israel understands the importance of a clear and sensible communication towards their employees regarding how to deal with quality measurement/management. Currently there’s a lack of integration among the different departments from a quality measurement, quality management and information system point of view. There is also little to no coherence among the different departments concerning points of evaluation and incentives which causes a conflict of interest towards both BI and the customers. This also causes the difficulty to properly maintain and improve the quality of the care delivered.
So what we recommend to Beth Israel is firstly to organize a meeting with the executives of the different departments and decide together with them what universal quality measures can be used at all departments and what improvements in terms of quality can be made. Implement the new quality measurements with the needed improvements in one system which is accessible by every department. Obviously not every important quality measurement can be made universal, that’s why a set of departmental specific quality measurements needs to be sustained by the head of the different departments.
Along with this we recommend developing an universal information system accessible by al departments which integrates both information about patients and the new universal quality measurement system. This integration will provide every department at any time with the needed information about the patients and about the other departments. In such a way quality can be compared between the different departments and will feed reinforcements of feedback and coherence between the different departments. A feeling of unity is key to empower the willingness to improve quality and share experiences in such a way it will positively impact the quality.