“We set the bar high”: LIHI creators and hospital leaders on what makes a great hospital
How do we shift the way we think about hospital performance to incorporate more than just patient outcomes? What are the top hospitals in the country doing to excel in all three categories on the Lown Hospitals Index? At a recent event hosted by the Lown Institute, Washington Monthly, and Open Markets Institute, the creators of the Lown Index and leaders of some of the winning hospitals discussed how hospitals can go from good to great.
How the Index started
The Lown Institute Hospitals Index is a new hospital ranking that provides a 360-degree view of hospital performance, by taking into account hospitals’ civic leadership and avoidance of overuse, as well as patient outcomes. The Washington Monthly partnered with the Lown Institute to create a list of Best Hospitals for America, powered by the rankings.
Where did the idea for the Lown Index come from? Philip Longman, policy director at Open Markets Institute, and co-author of “An Epidemic of Greed” in the special issue of Washington Monthly, explained the origins of the project. In 1999, Longman’s wife was being treated for breast cancer at a prestigious hospital. Even though the hospital was highly-ranked by US News & World Report, Longman was alarmed by mistakes the hospital made, “from losing tests to losing the patient.” The experience “opened my mind to the reality that there could be a large disconnect between the reputation a hospital might enjoy and its actual performance,” said Longman.
“The way we rank institutions in society really matters. If we rank institutions so that prestige and financial resources get allocated away from those that put mission before margin…that’s a real problem.”Philip Longman
Soon after, in doing research for her book Overtreated, Shannon Brownlee discovered that hospitals highly ranked on the US News list tend to be particularly egregious in their overuse of unnecessary or ineffective health care services. And Paul Glastris, editor in chief of the Washington Monthly, was questioning popular college rankings. The three of them started discussing the idea of creating a new hospitals ranking in 2010, but it wasn’t until ten years later after Shannon had joined the Lown Institute that their vision could become a reality.
How the index was built
Dr. Vikas Saini, president of the Lown Institute, took the metaphorical stage to explain how the Lown Hospitals Index was created and the results of the ranking. What sets the Index apart is its inclusion of metrics never used before in a hospital ranking, such as pay equity, community benefit spending, patient inclusivity, and overuse.
“Our overarching objective as we created these metrics was really to create a new lens to think differently about what we know and what we need to know about health care, in order to be able to truly measure all the performance that matters,” said Saini.
One of the key challenges in building the Index was the availability of data. Saini wanted to include both commercial claims data and Medicare data in the ranking, but once gatekeepers realized the commercial data would be used to rank hospitals, it was suddenly not available. The unavailability of commercial data is “a problem with any ranking system to date, and an area that needs to get fixed,” said Saini.
“How much CEO compensation is reasonable? The variability of pay equity is a conversation we need to have.”Dr. Vikas Saini
Another challenge was deciding how to measure metrics like community benefit and pay equity, where reporting across hospitals in uneven. The hope is that including these metrics, though maybe not perfect, can start a conversation about how we evaluate hospital civic leadership and what data we need to best evaluate these elements. For example, some of the hospital CEOs on the Lown Index make 32 times what other hospital workers make. “How much CEO compensation is reasonable? How much of the social good is met? The variability of pay equity is a conversation we need to have,” said Saini.
When the results came in, Saini was a bit surprised to find that none of the prestigious hospitals that usually rank highly on the US News ranking came close to the Lown Index top ten. “We knew that the new index would not yield the usual suspects, but we didn’t understand how high a bar we set,” said Saini.
One of the central findings of the Index is that there is a major disconnect between clinical outcomes and civic leadership; many of the hospitals that have terrific patient outcomes scores on the Index do poorly on serving everyone in their community or paying their workers fairly. On the other hand, the hospitals that are contributing the most to community health and serving all people regardless of race or income — often these are safety net hospitals– tend to have worse patient outcomes scores, which Saini suggests is a combination of differences in social determinants of health among communities and the under-resourcing of safety net hospitals.
“Mortality rates carry some effect from hospital care but also carry a whole lot of social determinants. How much credit or blame should go to hospitals [for their patient outcomes] is not known,” said Saini.
What are hospitals doing right?
However, there are several hospitals that have been able to achieve great patient outcomes while also serving all members of their community and not overtreating them. Some of these hospital leaders were on the panel to provide insight on how they accomplished all three goals.
Kate Walsh, president and CEO of the Boston Medical Center (which ranked #11 on the Lown Index nationally and #2 in the state) said that a lot of their success has to do with their history and commitment to their mission. BMC was formed by the merger of the public Boston City Hospital and the Boston University School of Medicine hospital in 1996. BMC has long had a reputation for serving everyone who needs care; their motto is “Exceptional care, without exception.” They have also invested heavily in community health initiatives that address the social determinants of health, such as a therapeutic food pantry to combat food insecurity and stable housing.
“People may look askance at hospitals investing in housing, but in this pandemic, one of the best things we can do for our patients is making sure they have a place to shelter,” said Walsh. “Our programs help plug the safety net that is increasingly frayed.”
Dr. Abhijit Desai, cardiologist at Mercy Health West in Cincinnati, OH (ranked #5 in the nation) shared how engaging their community has been a deliberate effort. In 2013, a new hospital was created in the West Side of Cincinnati offering cardiac procedures that were previously unavailable to residents. But “just opening the door and having a new facility won’t bring people in the door,” said Desai. “We had to work extra hard to earn the respect of these folks and get them to come in the hospital.”
“Just opening the door and having a new facility won’t bring people in the door. We had to work extra hard to earn the respect of these folks and get them to come in the hospital.”Dr. Abhijit Desai
Dr. Robert Early, CEO of JPS Health System in Fort Worth, TX, (ranked #1 on the Lown Index) credited the 115-year-old hospital’s culture for their high scores. All of the staff at JPS, from neurosurgeons to administrative staff, follow the rules: Take pride in the successes of the hospital and acknowledges the challenges; seek joy in the face of stress; and don’t be a jerk. “We have 7,200 people all moving in the same direction. When you have Covid-19 to deal with, moving in the same direction is powerful,” said Early.
Similar to BMC, JPS has partnered with community groups to address non-medical conditions in their community. One such program gives patients with diabetes who live in food deserts access to three meals a day. “We are one of the only institutions that want fewer patients,” said Early. “To get there we want to change lifestyles.”
“We are one of the only institutions that want fewer patients. To get there, we want to change lifestyles.”Dr. Robert Early
The panelists discussed what conditions should be put on hospital bailouts and how federal policies can help drive hospitals to be great. “Telehealth has been a game-changer,” said Walsh. “It incredibly important, particularly for people with substance abuse disorder. Reimbursement for telehealth has to stay.” Dr. Desai identified fee-for-service reimbursement as a federal policy that needs to change. “We need to be compensated for preventing disease, not just doing the procedures. We should be compensated more for these kinds of things than stents and angioplasties,” said Desai.