AAMC Reporter: August 2007

Through the Looking Glass: Montefiore Integrates Care in the Bronx

Attendants oversee Montefiore's medical tracking system, Carecast, in a central control room.

—By Gina Shaw, special to the Reporter

In many ways, Montefiore Medical Center in the Bronx, N.Y., looks like most other academic medical centers. In other ways, however, Montefiore is far from typical. To care for its community of some 2 million people in the Bronx and lower Westchester County—and to maximize the quality of that care—Montefiore has created a fully integrated delivery system that covers the entire continuum of a patient's needs. The system's exceptionally wide array of services includes primary care, home health care, 20 ambulatory sites, and community service programs, all directly under the Montefiore umbrella.

This unusual level of integration allows the system's quality initiatives to extend into corners of the health care continuum where other programs could not. It is just one of several key elements that have put Montefiore at the forefront of the hospital quality movement for more than a decade. In October, Montefiore was named one of the nation's top hospitals by the Leapfrog Group, a national organization that surveys hospitals on quality and patient safety standards.

Montefiore's push for broad quality initiatives began in 1993 with a study of patients with congestive heart failure. The hospital wanted to use the study's results to try and convince physicians that patients were not getting timely care. The six-month study found it took an average of two to three days to get congestive heart failure under control after admission. Montefiore leadership initiated an intervention to get patients under control in one day. It took another six months of chart review to demonstrate that it worked.

After that, the hospital's leadership was persuaded both of the effectiveness of quality interventions, and of the daunting task of implementing them, especially without a universal record-keeping system. So by 1995, Montefiore had adopted the Carecast system, a lifetime electronic medical record network with a master patient index that helps track quality improvement initiatives. Since 1999, Montefiore physicians have entered all lab tests, prescriptions, imaging, and other orders through Carecast.

"Wherever you are, at Montefiore or anywhere in the world, we can access all our accumulated information on patients," said Steven Safyer, M.D., Montefiore's chief medical officer. "It's highly tailored, with some 600 pathways embedded to coach physicians to do everything from order a better or cheaper drug, order a test for renal function, or stop ordering a drug because a patient is allergic."

All data are continuously fed into a data warehouse dubbed the "clinical looking glass," which is used for decision support, outcomes measurement, performance improvement, and investigation.

"It allows us to ask just about any question," Safyer said.

"What is the average hemoglobin A1c level for all patients with diabetes? What about a particular clinic, or a particular doctor's panel? We can almost instantaneously learn how an intervention went."

Carecast's creation paved the way for a slew of specific quality improvement measures. Some of those measures include:

• A push for continuous intravenous insulin therapy in intensive care units, which led to a 6 percent decrease in average patient glucose levels;

• The introduction of an infection control bundle in intensive care units, resulting in a 48 percent reduction in catheter-related bloodstream infections;

• The "Bronx Diabeters," a program in Montefiore's Family Health Center Office aimed at key measures of diabetes control. It led to a 13 percent reduction in the average hemoglobin A1c levels of its focus population; and

• A pharmacist order-review program, which resulted in a 26 percent reduction in baseline potential prescribing errors, and a computerized physician order entry system, which reduced remaining potential errors by 86 percent.

Montefiore's push for better quality does not end with technology.

"Just doing high-tech things and not observing how well you're doing, or tailoring interventions—that won't get you good outcomes," said Safyer.

"We have critical-care boarded physicians in the hospital around the clock supervising all critical care units. Technology is critical to our success, but it's also the culture, our focus on 'high-people, low-tech' solutions that gives us tremendous outcomes."

Another less technical aspect of Montefiore's quality system lies in the fact that both the primary care medical group and all clinical faculty of the affiliated medical school, Albert Einstein College of Medicine, are employed directly by the medical center. Safyer said that allows Montefiore to "incentivize people to do the right thing."

For example, part of physician compensation is based on quality and safety benchmarks. Physicians are encouraged to keep patients within the continuum of the Montefiore system, where the institution can exert control over quality. Physicians are also motivated to keep patients out of the hospital through preemptive measures.

"We do a lot of prevention, screening, home visits, case management, and outreach," Safyer said.

This integrated commitment to quality has paid tangible dividends. Between 1997 and 2005, Montefiore's mortality rate plunged by 40 percent.

"Early on, we saw that this focus on quality was the right thing to do," said Safyer. "The hospital believed in it as a compelling organizational principle, and this was galvanizing in terms of bringing along the physicians, and ultimately, the patients and the community."

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