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IMPROVEMENT IN PRACTICE: BETH ISRAEL DEACONESS CASE STUDY December 2010 How leadership and a focus on quality rescued Beth Israel Deaconess Medical Center Identify Innovate Demonstrate Encourage ‘ HIS STRATEGY WAS TO CREATE A BURNING PLATFORM...ESCAPE WAS ONLY POSSibLE BY MAKING HARD DECISIONS AND BY DOING THINGS RADICALLY DIFFERENT’ The Health Foundation case studies About the Author Our case studies aim to Dr Kamran Abbasi FRCP capture compelling stories about is a doctor and the author of improvement in practice. Writers Improvement in practice: spend time onsite interviewing Beth Israel Deaconess case study. teams and individuals and, where possible, patients affected by the Following five years in hospital changes. medicine, Kamran moved into medical journalism and has been The data used are publicly deputy editor and acting editor available information or self- of the BMJ (British Medical reported data provided by the Journal) and editor of the World case study institution. Using Health Organisation’s Bulletin, an practical examples from our international public health journal. work around the UK or other national and international cases Kamran has played a leading role we create a narrative on the in online learning and knowledge enablers and barriers to effective sharing for health professionals. implementation. He created BMJ Learning, a website providing formal online We hope they inspire and motivate learning for doctors; has been others and prompt further medical director of Dr Foster Ltd questions and investigation. and Chief Executive of OnMedica Ltd, a specialist company in online For more information about us learning technologies in this field. and the work that we do, visit He is also an honorary senior www.health.org.uk lecturer at Imperial College and a Patron of the South Asian The inclusion of an organisation Health Foundation. or health service in one of our case studies should not be regarded Currently, Kamran is editor of as an overall endorsement of that Journal of the Royal Society of organisation and its services. Medicine and editor of the new online journal, JRSM Short Reports. He also writes for cricinfo.com, a highly rated cricket website, © 2010 The Health Foundation and is author of the popular cricket Improvement in practice is blog Pak Spin. published by the Health Foundation 90 Long Acre, London WC2E 9RA HEALTH FOUNDATION COMMENTARY For many NHS leaders, there will be much that is familiar in the challenges faced by Paul Levy. When he became CEO of Beth Israel Deaconess in 2002, the organisation faced financial crisis, deep seated problems with the quality and safety of patient care, poor staff morale and fractious relationships, and all played out in the media spotlight. Commentary ight years later, Levy acknowledges his approach stand out is his belief that that he still has much to do and transparency is key to delivering high that some of the journey has been quality care. By being open with his staff Ethrough stormy waters. But there and with the community that the medical can be little doubt that with his leadership centre serves, he has managed to build a the organisation has salvaged its reputation level of trust which is an essential element and is now thriving in the unforgiving of a culture of continuous improvement. US healthcare environment. Much of the learning from this case study There is much for established and resonates with our understanding about aspiring leaders in the UK health sector to improvement and about leadership for reflect on when they read this case study. improvement. It isn’t easy territory and Levy’s approach was an interesting mix of there are few right answers. A delicate challenge and support. He did not shy away balance of technical and interpersonal skills from revealing the depth of the financial and is required. Success is about conveying a reputational crisis the medical centre faced. compelling vision that focuses on patients Indeed, his strategy was to create a burning and those who use health services. People platform where escape was only possible by respond positively when you engage with making hard decisions and by doing things their core values and internal motivations. radically different. High quality data, and a willingness to be open with the data, underpins success. At the same time, he knew he could only achieve change by impassioning his staff These are not new messages but we all need with a sense of common purpose. He chose reminding of their importance. And herein to advocate an absolute commitment to lies the contribution that stories such as providing high quality care and to using this can make to our understanding of systematic approaches to continuous how to improve patient care. We hope quality improvement. When times have you enjoy reading it and share it with your been hard, it has been Levy’s unrelenting colleagues, and we look forward to hearing focus on quality and safety that has kept the your reflections. ■ organisation moving forward. What makes Beth Israel Deaconess case study 03 SUMMARY ‘ Transparency is an important tool in quality improvement, provided it is linked to accountability’ CHALLENGE PROGRESS TO DATE A competitive healthcare environment Beth Israel Deaconess is now an important in Boston was the backdrop to a player in Boston healthcare, and competes merger between two large hospitals effectively with other major healthcare with differing cultures. organisations. The merger was followed by a period of Quality improvement is central to the uncertainty, staff cuts, and loss of patient organisation’s approach. A culture of confidence, culminating in the threat of transparency and accountability has been financial collapse. established. Challenges remain, but past ones have been overcome by adhering Financial rescue was achieved, but how to these organisational values. would the newly-merged and dysfunctional Beth Israel Deaconess Medical Center become valued by patients, staff, and referrers? LEARNING POINTS Sound leadership principles and a focus on quality can galvanise a troubled institution, STRATEGIES restore patient satisfaction and improve financial performance. The recovery plan was underpinned by sound leadership values that prioritised Transparency is an important tool in transparency and accountability, with a quality improvement, provided it is linked sharp focus on quality improvement for to accountability. better patient outcomes. Data can be used meaningfully to improve quality provided that clinicians feel a sense of ownership in the development of the measures. AGENTS OF CHANGE All staff can be engaged with the financial Chief executive and leadership team, goals of a healthcare institution and participate operational plans, and the publication in setting operational plans. of hospital performance data. 04 Improvement in practice In January 2002, Paul Levy was appointed chief executive of Beth Israel Deaconess Medical Center. The hospital was created in 1996 through the merger of Beth Israel Hospital and Deaconess Hospital and had been a troubled institution from the outset. By 2002, the hospital was facing financial meltdown. Levy was new to healthcare and the Beth Israel Deaconess staff didn’t quite know what to expect. It was a time for strong leadership and Levy had to quickly convert people to his cause or the hospital would become bankrupt. This case study is based on a series of interviews with senior staff at the Beth Israel Deaconess Medical Center in June 2010. The objective is to explain the transformation of the hospital’s financial situation and its subsequent focus on quality improvement, from the perspective of those responsible for managing the organisation through a decade of change. 06 Improvement in practice INTEGRATION OF THE MERGER Healthcare in Boston is a competitive business. The Beth Israel and Deaconess hospitals vied for patients with the Massachusetts General Hospital and the Brigham Women’s Hospital, among others. A merger made business sense as it would create a hospital big enough to compete. However, the Beth Israel Deaconess Medical Center needed to be efficient as well as big, and it was anything but. A challenging environment clash of cultures presented ‘People underestimated the importance of further challenges when it came culture in merging two organisations,’ recalls to integrating the two hospitals. Dr Kenneth Sands, Director of Healthcare ABeth Israel Hospital is fondly Quality. ‘The approach was a giant consensus remembered by staff as having a more casual exercise, which was not possible. The distance management style, emphasising professional between frontline clinicians and the new autonomy and creativity. Deaconess Hospital, hospital’s leadership was too great.’ by contrast, was known for rules-based, Staff joked that all meetings at Beth Israel top-down management. started ten minutes late, while meetings at Both sets of staff were fiercely loyal to their Deaconess began promptly. Nobody could parent organisation and many employees question either hospital’s commitment to were anxious about giving up their hospital’s better patient care, however, and survivors culture and values. After the merger, of the merger believed that this common it was the Beth Israel culture that appeared bond could unite Beth Israel and Deaconess. to dominate, leaving former Deaconess With staff suffering from low morale and employees feeling disempowered and feeling anxious about the future, the press reluctant to stay. Many of the nursing staff, had a field

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