Boston’s Brigham and Women’s Hospital (75 Francis Street; a subsidiary of Brigham and Women’s Healthcare) is a major teaching hospital of Harvard Medical School and among the best regarded acute care referral centers in the United States 1. In 1980, three separate hospitals were merged to constitute the present center 2. As of its 2012 Strategy Report, the hospital had 793 inpatient beds and 63 operating rooms (main facility), and employed over 15,000 dedicated staff 2. According to US News and World Reports, Brigham and Women’s had 45,352 patient admissions, 62,098 emergency department visits, and performed 18,626 inpatient and 13,325 outpatient procedures during the most recent year reported (unspecified) 1.
According to its website 2, Brigham and Women’s Hospital’s mission centers on these 4 activities (which are worth keeping in mind as we review its performance metrics and consider possible management actions):
- Serving the needs of our local and global community,
- Providing the highest quality health care to patients and their families,
- Expanding the boundaries of medicine through research,
- Educating the next generation of health care professionals.
Quality of Care Measures
The official United States government website for Medicare services (medicare.gov) provides hospital comparison data on the quality of care delivered at over 4,000 Medicare-certified hospitals nationwide. The following Brigham and Women’s Hospital data, organized into six summary categories – 1) patients’ experiences, 2) timeliness and effectiveness of care, 3) complications, 4) readmissions and deaths, 5) use of medical imaging, and 6) payment and value of care – was obtained from medicare.gov/hospitalcompare/ unless otherwise noted.
The national survey Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which asks patients to evaluate their experiences during a recent encounter with the health system, is a standardized data collection instrument created by the US federal government’s Centers for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality (AHRQ) that has been in use since 2006 specifically to provide consumers with the information necessary to “make fair and objective comparisons between hospitals with state and national averages on important measures of patients’ perspectives of care”.
The survey uses 11 measures of patient satisfaction centered on communication, responsiveness, pain control, patient education, and cleanliness of facilities, and concludes with an overall evaluation and willingness to recommend the hospital to family and friends.
Brigham and Women’s Hospital was rated at or above its state (Massachusetts) average in 9 of the 11 measures and at or above the national average in 7 of the 11. Seventy-seven percent of patients rated the hospital 9 or higher on a 10-point scale, and 86% reported they’d definitely recommend the hospital. The hospital earned a 4/5 star patient survey summary rating.
Timely & Effective Care
The timeliness and effectiveness of care is evaluated across a large number of specialty and disease-specific services addressing the degree to which the hospital’s services comply with “best practices”. These evaluated domains include heart attack, heart failure, pneumonia, surgical, emergency, preventive, childhood asthma, stroke, blood clot prevention, and pregnancy and delivery care services.
Timeliness of Care
In most care-specific categories for which data is available, Brigham and Women’s Hospital’s timeliness measures are within a few percentage points (+/-) of the state and national means. Notable exceptions include emergency wait times (44 minutes vs. 56 and 54 minutes at the state and national levels, respectively) and ischemic stroke care (defined as the percentage of patients who received appropriate blood clot medications within 2 days of arriving at hospital), in which BWH performed below state and national standards (92% vs. 99% and 98%, respectively).
Effectiveness of Care
Similarly, Brigham and Women’s care-specific effectiveness measures are within a small range of the references of comparison. In areas like giving heart failure patients instructions at discharge and discharging blood clot patients with blood thinners and instructions for appropriate use, BWH performed above state and national means. Meanwhile, education of ischemic or hemorrhagic stroke patients lags behind both state and national averages. BWH’s healthcare workers also receive influenza vaccination at a significantly lower rate than those at other Massachusetts hospitals.
Complications, Readmissions, & Deaths
Best practices in clinical care can be measured along many axes beyond timing and effectiveness. Some of the most critical aggregate measures for patients are the rates of complications, readmissions, and deaths following the provision of care services – which are shockingly high in some cases. How likely are patients to be harmed by BWH when compared to state and national means?
According to the Agency for Healthcare Research and Quality, Brigham and Women’s Hospital performed “worse than the national rate” (0.81%) for “serious complications”, though in the specific contexts of 1) complications following hip or knee replacements and 2) deaths from serious complications, its performances were reported as “no different” than the national averages. Brigham and Women’s Hospital actually performed above the national rate in deaths among pneumonia patients, but, its hospital-wide rate of unplanned readmission following discharge was worse than the national mean rate.
Use of (outpatient) Medical Imaging
A hospital’s use of medical imaging tests (mammograms, CT or MRI scans, etc.) can be appropriate (when benefits outweigh the harms and costs) or inappropriate. Ideally, patients’ benefits are thoughtfully weighed against risks in every case as a reflection of the institution’s culture and values, though reality often falls short of this standard for a variety of reasons. By measuring and comparing an institution’s aggregate rates of use, one may gain an important insight into its degree of patient centeredness.
In all but 1 of the 6 measured imaging use scenarios, BWH was at or below the state and national utilization means – a categorically positive sign that the hospital has been intentional and proactive in rationalizing the way its clinicians deliberate and practice.
Payment & Value of Care
By analyzing Medicare spending per beneficiary, one may identify efficiencies as well as excesses of a given hospital compared to the national average. Unfortunately, such data has been suppressed and is not publicly available through medicare.gov. However, the website does make other, similar data available, organized by primary presenting condition (limited to heart attack and pneumonia). Though total payments to Brigham and Women’s Hospital (and affiliated clinicians, facilities, and services) during the 30 days following a heart attack or pneumonia patient’s admission are consistent with national averages, payments to the BWH network for heart failure care are higher without the expected reduction in the death rate among the same patients, indicating an area of poor value (assuming all other variables being equal – an almost always dubious assumption).
In summary, Brigham and Women’s Hospital performs near the state and national averages in most objective measures, though patient satisfaction with BWH’s services is slightly higher. Notably, reduction in unnecessary imaging utilization appears to be a strength of the hospital, while serious complication and unplanned readmission rates are important areas for improvement.
Potential Management Actions
As with any large organization delivery highly technical, costly, and complex goods and services in a dynamic environment of diverse payers, regulatory bodies, customers, stakeholders, and legal mandates, simply continuing to exist is sufficient challenge; to grow is harder still; to improve is most difficult by far. How can Brigham and Women’s Hospital improve (in the metrics discussed) beyond its current performance in both quality and efficiency? Importantly, would improving in the areas measured necessarily improve the overall health and well-being of its patients? Would the resources required at the point of care to improve these metrics better achieve health and well-being for BWH’s patients as well as the larger community if invested in areas more fundamental to the causes of ill health and harm (such as education, housing, employment and wealth disparity-reduction, sanitation, community infrastructure, and the promotion of healthy behaviors)? Put simply, could BWH do more ‘public health’?
These questions are critical yet extremely difficult to address because the western health care system, especially in the United States, is currently built to deliver resource-intensive curative or disease-managing “sick care”. Remember BWH’s mission statement? 3 of its 4 missions are specific to this “sick care” model: providing sick care, expanding sick care, and training sick care professionals. Yet, Brigham and Women’s highest mission isn’t necessarily dependent on the others: “the needs of our local and global community” may best be served, not through more (or even more effective) sick care, but through less sickness and more health and well-being. What fundamental factors predominantly underlie unwellness in American society? What are the “causes of the causes” – that is, the actual or root causes of most morbidity and mortality in the United States? It’s the fabric of society itself – the highly stratifying biases of classism and racism that are deeply embedded in our worldview and in our institutions that drive disparities in education, in resources like wealth, income and housing, in political and social influence and representation, in opportunities and behaviors, and in the systems of incentives and disincentives that ultimately increase or decrease wellbeing 3,4. Even more fundamentally, it is the organizing principles of our society (such as capitalism 5) that, once accepted, give the inequalities in wealth and health we observe the appearance of being a part of the natural order of things because they follow so naturally from the principles’ premises.
Given Brigham and Women’s Hospital’s interest in serving the needs of its local and global community, it might consider investing its resources and energies into fundamental preventions – that is, prevention of the “causes of the causes” of ill-health and disease, such as socioeconomic and racial inequalities that follow from unequal access to all that is necessary for health and well-being 6. More concretely, BWH could establish the theme of prevention in all its clinical services, clinician training programs, and research endeavors by requiring a single question be central to every one of the institution’s enterprises: what more can we do to make sure people don’t need sick care in the future?
- Brigham and Women’s Hospital in Boston, MA – US News Best Hospitals [Internet]. [cited 2015 Oct 3];Available from: http://health.usnews.com/best-hospitals/area/ma/brigham-and-womens-hospital-6140215
- Our Mission – Brigham and Women’s Hospital [Internet]. [cited 2015 Oct 3];Available from: http://www.brighamandwomens.org/about_bwh/mission.aspx
- Cohen L. When Policy Meets Profit. Health Aff (Millwood) [Internet] 2014 [cited 2015 Sep 22];33(11):2077–9. Available from: http://content.healthaffairs.org/content/33/11/2077
- Galea S, Tracy M, Hoggatt KJ, DiMaggio C, Karpati A. Estimated Deaths Attributable to Social Factors in the United States. Am J Public Health [Internet] 2011 [cited 2015 Sep 27];101(8):1456–65. Available from: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2010.300086
- Haynes M. Capitalism, class, health and medicine – International Socialism [Internet]. 2009 [cited 2015 Sep 15];Available from: http://isj.org.uk/capitalism-class-health-and-medicine/
- Institute of Medicine. The Future of Public Health [Internet]. Washington, DC: The National Academies Press; 1988. Available from: http://www.nap.edu/catalog/1091/the-future-of-public-health