The Problem: The Bronx, home to Montefiore Medical Center, is one of the poorest urban communities in the United States. In 2004, about 80 percent of the Bronx's 1.3 million residents were Latino (48 percent) or African American (31 percent).
Montefiore had a long history of providing integrated health care services in the Bronx, but the not-for-profit, academic medical center had never collected racial and ethnic data on its patient population in a standardized way. "We hadn't talked about quality of care through the lens of disparities," said Rohit Bhalla, M.D., M.P.H., Montefiore's chief quality officer, and the project director of the site in Expecting Success: Excellence in Cardiac Care, a program funded by the Robert Wood Johnson Foundation (RWJF). The medical center needed better data capabilities to determine which interventions reduced disparities and improved care for Latino and African-American heart patients.
Grantee Background: Montefiore Medical Center provides 30 percent of all hospital care received by Bronx residents. In addition to hospital-based services, the medical center operates a network of 24 community-based primary care sites and offers school- and home-based health care and an extensive array of specialty services, which likewise account for about 30 percent of the outpatient services for Bronx residents.
Its strategies to meet the needs of a diverse population include providing translation services, cultural competency training, peer education and outreach to the borough's faith-based communities.
The Project: A multidisciplinary team redesigned Montefiore Medical Center's patient registration system to collect data on race, ethnicity and preferred language, and developed a procedure to provide faster treatment for heart attack patients. Led by Rohit Bhalla, the team included the heads of health information management and research, cardiologists, primary care physicians, cardiac nurse managers and nurse practitioners.
RWJF supported this work through its national program: Expecting Success: Excellence in Cardiac Care from 2005 to 2008.
In redesigning the patient registration system, the Montefiore team sought input about data collection from a broad cross-section of medical center leadership, and representatives of its 600-plus registration staff. Based on their feedback, the team created educational materials about health care disparities, developed possible scripts for use by registration staff and provided training in the new system.
The medical center adopted the race and ethnicity categories used by the federal Office of Management and Budget, and retooled its information technology system to accommodate the additional data. Initially, staff was nervous about asking patients personal questions relating to race and ethnicity. "We were very careful to explain how getting the information would improve patient care," said Caryl Greaves, M.P.A., R.H.I.A., director of Health Information Management at Montefiore.
With the additional demographic information, Montefiore was able to present standardized data on 23 cardiovascular inpatient performance measures, stratified by race, ethnicity and primary language. Measures included the provision of smoking cessation counseling and appropriate medication on arrival and discharge.
A second major emphasis of Montefiore's Expecting Success initiative was improving door-to-balloon time. Door-to-balloon time is the amount of time between a heart attack patient's arrival at the hospital and receipt of angioplasty to open blocked arteries by inserting and blowing up a tiny balloon inside them. Guidelines recommend that door-to-balloon time be 90 minutes or less.
The project director convened Emergency Department personnel, cardiologists and nurses for strategy sessions, and they decided to develop a telecommunications system that would improve their response.
Cardiologists on call, nurses, technicians in the catheterization laboratory (where angioplasty is done) and Emergency Department physicians all received pre-programmed cell phones. When a patient with a heart attack arrives, the Emergency Department doctor pushes one button to instantly call the cardiology team. "Within one minute there's a two-way dialogue among all of the people who need to know," said Bhalla. "This has saved 30–40 minutes." Emergency Department staff also use text paging as a notification tool.
Other steps to speed up the door-to-balloon time included assembling kits containing all possible medications a doctor might order for a heart attack patient, and having Emergency Department staff prepare patients for catheterization.
After each case, the cardiologist sends out an e-mail to debrief the group. "If you want to be successful, you have to have honest communication when things don't go well, as well as when they do," said Bhalla.
Results: Montefiore Medical Center reported the following results from its Expecting Success project.
- After implementing the redesigned patient registration system with data on race, ethnicity and preferred language in September 2006:
- Hospital discharges in which a patient's preferred language was unknown declined from 97 to 3 percent.
- Hospital discharges in which a patient's race or ethnicity was unknown decreased from 47 to 29 percent and 62 to 9 percent, respectively.
- Montefiore has used its redesigned data-collection capacities to introduce more patient-centered interventions. For example, in response to data showing higher readmission rates for Spanish-speaking patients, Montefiore started a discharge phone call program to reinforce compliance with discharge medications and follow-up appointments. The service is now used throughout the hospital. Knowing the patient's preferred language also enabled the medical center to use patient education materials and to print consent forms in that language.
- Montefiore implemented quality improvement strategies focused on personnel, workflow, information technology, clinical practice and documentation in order to improve its performance on standardized measures of inpatient care for heart attacks and heart failure. As a result:
- 83 percent of heart attack patients received all recommended care in 2007, compared to 72 percent in 2005.
- 60 percent of heart failure patients received all recommended care in 2007, compared to 46 percent in 2006.
- Heart attack patients receiving angioplasty within 90 minutes increased from 17 percent at the start of Expecting Success to 100 percent by the end of the program.
Montefiore continues to use the procedures it developed to speed door-to-balloon time. Also, paramedics en route to Montefiore now notify the hospital when they are bringing in a heart attack patient.
- Montefiore's neurology department has modeled efforts to increase the use of a clot-busting drug for stroke patients on the door-to-balloon time procedures. This drug can help some people recover more fully from a stroke, but it must be administered within three hours of the stroke to be effective.
RWJF Perspective: RWJF is committed to ensuring that all Americans receive quality health care. Racial and ethnic disparities were especially likely to occur in treating heart disease, according to the Institute of Medicine. RWJF's Expecting Success program engaged 10 acute-care hospitals in identifying cardiac care disparities and developing and sharing tools to improve care for African-American and Latino patients. RWJF focused Expecting Success on cardiac care because disparities are well documented and the recommended standard of care is widely accepted and easily measured.
"These hospitals courageously led the way in using data to discover and correct their own racial and ethnic gaps in care. Their hard work demonstrates that we cannot have high quality of care for all until providers see eliminating disparities in care as an essential function of mainstream quality improvement," said Pamela S. Dickson, M.B.A., assistant vice president for RWJF's Health Care Group.