What makes a hospital a "best"? A smart, caring workforce armed with the latest technology? Of course. But if that were the magic formula, the only names you'd see in the "America's Best Hospitals" rankings would be those of high-profile, big-money centers that can afford to lure top talent and purchase every new device. Hospitals that fly below the radar, like the 17 facilities in the heart rankings that were cited by fewer than 1 percent of heart specialists who responded to our annual survey, would never appear.
A great hospital is different because of an internal culture of excellence. Set at the top and embraced by caregivers, medical standards are high and emphasize not only doing well but striving to do better—to hammer down the number of infections, to boost survival of high-risk surgery patients, to systematically squeeze out errors rather than painting a scarlet "E" on those who make them. If such goals cannot be achieved by using conventional means, invent new ones.
Vanderbilt University Medical Center in Nashville is no stranger to Best Hospitals—last year it ranked in nine of 16 specialties. But this is the first year it has been named, along with only 18 other facilities, to the elite Honor Roll for its high rankings in multiple specialties. The hospital is huge and growing, with 847 beds; more than 1.2 million patients streamed through its doors in 2007. Most come for routine care, but many come because they need the level of advanced care that only a major referral center can provide.
Last month, two U.S. News reporters paid a five-day visit to the sprawling campus to sample the state of medicine practiced there and get at the personality of the place. They found a blend of pioneering and progressive skills, delivered with a healthy dose of humanity and southern gentility and propelled by that all-too-elusive culture of excellence.
Day 1
10:18 A.M. Pneumonia wars. Critical-care nurse Jay DePass cleanses his patient's mouth with an antiseptic swab and mouthwash, then suctions out saliva. When finished, he moves to a computer in the patient's room and clicks on a checkoff list in the patient's electronic medical record. Now DePass is "all green." He has taken proven precautions against pneumonia with all of his patients who are breathing with the help of mechanical ventilators. Performing regular oral care, keeping the head of their beds at 30 degrees, and assessing their individual level of sedation every four hours are a few such steps. Ventilator-associated pneumonia, or VAP, kills an estimated 10,000 intensive-care patients annually, and Vanderbilt is determined to stamp it out. A "VAP dashboard"—a spreadsheet displayed on all monitors in the medical ICU—color-codes the measures. Chores coming due are highlighted in yellow; those needing immediate attention are in red. VAP incidence has dropped by 48 percent since last fall, when the dashboard was activated across all of the center's ICUs.
There's nothing mysterious, difficult, or controversial about the routine, but most hospitals are less systematic than Vanderbilt about making sure all of it is done. Fundamental stuff, says chief hospital epidemiologist Tom Talbott, but elusive. "How do we shift to where everybody does all the basics?" he constantly challenges his team.
11:39 a.m. Smooth handoff. Five nurses and a respiratory therapist chat in an empty patient room in the cardiovascular ICU. A nurse enters. "Rolling call," she announces. It is a signal that a patient is being transferred after surgery. Such "handoffs" are tripwires. Whenever a patient is transferred—from the recovery room to the ICU, from a patient room to X-ray—deadly mistakes can be made. Charts can be mislaid; scribbled notes can be misread; orders can be misunderstood. When the still-anesthetized 49-year-old patient is wheeled in, the waiting caregivers swarm him, checking and charting his vital signs and calling out numbers. ("Urine output is 80.")
Safely out of the way at the foot of the bed, Subhasis Chatterjee, a "fellow" taking additional training in cardiac surgery after finishing his general surgery requirements, recites operative details that will guide the patient's post-op care: He had two coronary arteries bypassed, using the left internal mammary artery and a section of saphenous vein from the leg. He required no blood products during the procedure. He can be "fast-tracked to extubation," meaning the ventilator tube can be removed soon. "Any questions?" asks Chatterjee. There are none.
1:10 p.m. Custom-designed birth. It's an ordinary C-section, but 17-year-old Brittney King is not an ordinary patient. She was three months pregnant last December when her Pontiac Sunfire flipped off a slick road and slammed into a creek, crushing her spinal cord and paralyzing her below the midchest. Pregnant patients like King are rare—even in a heavily trafficked hospital like Vanderbilt, doctors might deliver two or three a year with such severe spinal-cord injuries.
Obstetricians and anesthesiologists huddled; a C-section was scheduled. It would be risky. The main connection between King's brain and most of her body was gone, but normally painful or uncomfortable sensations—perhaps the touch of the surgeon's knife or pressure from a full bladder—could reach the brain through other pathways. Her blood pressure would shoot up, and the brain, unable to signal her body below the chest, would be helpless to damp it down. She could have a seizure or a killer stroke. Mining published case reports, obstetric anesthesiologist Jill Boyle settled on a combination of spinal and epidural anesthesia to completely block all potentially deadly impulses. The scheme worked. Just-born Kaydence rests on the pillow, next to her mother's tired but glowing face.
3:27 p.m. More than a haircut. "Whatever you do, don't touch the controls on that bed," Emma Harris orders 63-year-old Jerry Siers with mock sternness as she snips his silvery mane. The proprietress of the Vanderbilt Medical Center Hair Salon has come to Siers because he is too weak—he has idiopathic pulmonary fibrosis, a progressive condition that stiffens the lungs—to make an appointment in her domain. "Sideburns about halfway down and square in the back," huffs Siers, who is being assessed for a possible lung transplant. "That's how Elvis did it, and that's how old I am."
Harris is a legend, and not just because in 31 years at Vanderbilt she has coiffed uncounted local celebs, like Vanderbilt alum Will Perdue, a former NBA championship player. She is undeterred by barriers that hospitalization puts in the way of a decent haircut: She'll disinfect the salon and wear gloves and a mask to protect a weakened immune system. She'll wash and cut the hair of patients adorned with a halo, a metal frame screwed to the skull to prevent movement following some spinal surgeries. Right now she is trimming Siers's mustache, working around the oxygen-delivering fixture below his nose. In a place that can feel lonely, Harris offers a dose of dignity. "I just appreciate getting you up here," Siers murmurs as she applies finishing touches. "Very much."
3:51 p.m. Musical moment. Yesterday, a tractor ran over Dennis Caldwell, breaking his pelvis and lacerating his face. Helicoptered to Vanderbilt, about 140 miles from a hospital in Paducah, Ky., Caldwell, 57, is propped up in the trauma ICU awaiting surgery to mend his pelvis. He is attached to many tubes and his face is scraped, but he beams and taps his fingers as two young men with guitars spiritedly knock out a country song at his bedside. "We hope we rocked your day a little bit," says David Oakleaf. LB & Oakleaf, as the two are known professionally, have serenaded patients in the trauma, dialysis, and transplant units for the past couple of hours. They are volunteers with "Musicians On Call," a nonprofit group that brings live and recorded music to patient bedsides. The organization started a Nashville chapter last year, and Vanderbilt sponsors the visits. "It lifted my spirits," says Caldwell. "It gets boring lying in this bed all day long."
Day 2
8:57 a.m. Timeout. Only the left leg and hip of the man on the OR table are uncovered. A dark "geh" on his hip, scrawled by orthopedic surgeon Ginger Holt with a black Sharpie an hour earlier, is unmistakable. Activity stops. The clink of surgical tools being laid out is silenced. Holt and her team run down a checklist, announcing the patient's name, diagnosis, and procedure—excision of a tumor from his buttock—and verify that it is on the left side. These "timeouts" were made mandatory at Vanderbilt in 2003 (there were two "wrong-site surgeries" in the previous two years, neither involving amputation or removal of the wrong organ) and are now standard practice at many hospitals. But Vanderbilt tacked on extra precautions: Patient and site verification and timing of infection-preventing antibiotics and initial incision are entered into a computer and time-stamped for later analysis. Following implementation of the timeout protocol, there has been one operation on the wrong portion of the spine. This represents a wrong-site rate of 1 per 185,000 cases across the entire facility. "I see my initials," says Holt, the last check before she cuts. "We're ready to operate."
9:21 a.m. Safer aneurysm surgery. "Don't move," Tom Naslund, chief of vascular surgery, instructs his elderly patient. "Don't breathe." Naslund fixes his eyes on an X-ray monitor that displays the progress of a flexible tube, or catheter, as it is snaked through a small incision in an artery in the groin to a ballooned-out protrusion in the aorta, the body's largest blood vessel. The balloon is an abdominal aortic aneurysm—a weak spot in the wall where the aorta dives down through the abdomen and forks to supply the legs. If it ruptures, death could occur in hours or even minutes. This patient's aneurysm is just above the divide. Naslund will implant a stent graft above and below the split, a pipe within a pipe that isolates the vulnerable part of the wall. It is made of Gore-Tex, backed by a stiff but flexible mesh. In place, it will look like a pair of pants.
Naslund edges the folded-up first portion up to the aneurysm. Bridget Ostrow, a Memphis surgeon here to hone her technique, observes. "Just let it flower out," Naslund says. He releases the stent, which instantly expands into a one-legged pant and grabs the vessel wall with tiny clawlike hooks. Minutes later, the other leg is similarly installed.
Naslund is an advocate for stent-grafting aneurysms through a catheter rather than opening the abdomen and repairing the weak spot. He says recuperation is less painful, the chance of male sexual dysfunction is lessened, and the operation is less drastic for elderly patients. While stent grafts can shift and sometimes seal imperfectly, allowing blood to leak into the aneurysm, fewer than 50 patients out of more than 700 Naslund has treated since the early 1990s have needed another go-round because of such complications. He places the grafts only in patients who commit to lifelong follow-up, usually involving regular ct scans to see how the devices hold up. (Out-of-town patients can send him their scans on cds.) "It's not a safe situation to have a stent graft and not have follow-up," he says.
12:03 p.m. Bypass insurance. Heart surgeons and cardiac interventionalists, who implant stents and perform other heart repairs through catheters, often compete vigorously for patients and don't always see eye to eye. At many hospitals, they are on different floors or even in different buildings. But in 2005, Vanderbilt created a hybrid or, where surgeons and catheter specialists can work separately or together. Four more are planned. Today, David Zhao is adding a measure of safety to a bypass procedure. Zhao prepares to do a coronary angiogram, an X-ray movie that uses a contrast dye to highlight the coronary arteries. It is usually a diagnostic tool, the "gold standard" that points to surgery or stenting, if major blockages are found. But the woman on the table has just had triple-bypass surgery—her chest is still open. Zhao injects a slug of the dye into each of the three bypass grafts one by one and watches on a screen as it quickly highlights the interior of the vessel. Vanderbilt may be the first hospital to use angiography after a bypass to see if a vein graft is kinked or twisted (it happens about 12 percent of the time, says cardiac surgery chief John Byrne). "It proves we did what we came to do," says Byrne, who championed the follow-up.
1:13 p.m. Undrugging patients. ICU nurse Jessica Robertson gently awakens a 55-year-old woman with a breathing tube in her throat and asks her to make eye contact to judge her brain function and depth of sedation. Her patient cannot speak, so Robertson asks simple yes-or-no questions ("Will a stone float on water?") and spells out words, instructing the woman to squeeze her hand only when she hears an "a." Some common ICU sedatives used to calm ventilated patients have been linked by critical-care specialist Wes Ely to longer stays, higher death rates, greater cost, and a likelihood of long-lasting dementialike symptoms, so the goal is to minimize medication and remove the breathing tube as soon as possible. This January, the Lancet published "Wake Up and Breathe," a program devised by Ely and others for weaning patients from ventilators. Patients are periodically roused, and their IV sedative is shut off. If they show pain, respiratory distress, or anxiety, they're restarted—at half the original dose. "You systematically build drug reduction in," says Ely. If a patient can go without drugs for four hours, the ventilator is switched off. The tube stays in and is removed if the patient can then breathe on her own for two hours. The Lancet paper researchers found that compared with standard treatment—turning off the ventilator each morning to see if a patient can do without it for two hours—the "wake up and breathe" patients had four fewer ICU days, three fewer ventilator days, and four fewer days in the hospital, and 56 vs. 42 percent were alive after a year.
2:01 p.m. Bedside manners. Spotlessly white-coated, Frank Boehm and four medical students crowd around a bed and stare down at the small redheaded woman under the covers. "How does this make you feel?" asks Boehm, a professor of obstetrics and gynecology in Vanderbilt's medical school. "Trapped," peeps 31-year-old Allison McGuire, who has had a C-section. Boehm sits on the edge of her bed, puts his hand on hers, and repeats the question. More comfortable, she says. "We have such high tech, we need high touch," he tells the students. "When you're leading rounds someday, you can do this." Third-year medical students at Vanderbilt go on rounds with Boehm for an hourlong microcourse in bedside manners, created two years ago because the students sought guidance on how to behave in patient rooms. Boehm coaches students through scenarios with the consent of patients like McGuire. Treat her room as if it were her home, says Boehm. Convey respect. Don't be afraid to show emotion.
2:33 p.m. Keeping up with patients. Assistant chief medical officer Jim Jirjis taps out an E-mail on his laptop to a diabetic patient seen earlier in the day. Alerted by his computer that the man's labs are ready, the internist congratulates him for controlling his blood sugar but points out that his cholesterol is high. Jirjis has already called up a list of cholesterol-lowering statin drugs covered by the patient's medical insurance plan. Several have a lower copay than the statin that the man had previously taken. Would he be interested? The patient later messages back that he would, and Jirjis zips off an electronic prescription to his pharmacy. The patient can look over his lab results, too, by logging into his MyHealth@Vandy Web account.
The homegrown system is widely used by Vanderbilt's nurses, doctors, and patients, handling some 38,000 messages a week. Physicians can quickly order tests (grouped for certain diseases so that one click will order all of the necessary tests), store notes from other clinicians in patients' electronic medical records, and set follow-up alerts if a patient hasn't checked a message in a certain number of days.
Day 3
9:56 a.m. Quick discharge. Lisa Hardy, 45-year-old owner of a bar and grill in Lebanon, about 30 miles east of Nashville, had a 4-centimeter tumor removed from the right frontal lobe of her brain 18 hours ago. Now she wants to know if she can go boating Saturday. "It would be better to wait until next weekend," advises nurse practitioner Susie Dengler. Surgeon Reid Thompson had estimated a two- or three-night post-op stay, but Hardy has his go-ahead to head home this afternoon. She has had none of the complications that can occur after a craniotomy—seizure, stroke, inability to speak, bleeding in the brain—and her pain is under control. "The first thing she said to me was, 'I want to go home today,' " says Thompson, director of the Vanderbilt Brain Tumor Center. Wanting to leave suggests an uneventful recuperation, he says. Among U.S. academic medical centers, Vanderbilt patients have among the shortest average length of stay following a craniotomy, according to data from the University HealthSystem Consortium, a group of academic medical centers. Thompson says it is because of careful and coordinated work by the anesthesia, nursing, and surgical teams and steps taken to "be gentle to the brain," his mantra.
1:03 p.m. Monitoring a risky drug. With a few mouse clicks, clinical pharmacist Dan Johnson evaluates all 50 to 60 inpatients taking Coumadin, a blood thinner. Too high a dose can instigate a fatal bleed, and each patient's proper dose can fluctuate daily. Morning blood tests identify patients whose dose needs adjustment. Johnson can arrange the display on his screen by dose amounts, specific lab values, trends, or even by patients overdue for their blood test. Coumadin patients used to be monitored by calling up individual electronic medical records, which for a complex patient could take 30 minutes. But the biggest challenge was finding them, because no system efficiently identified the Coumadin patients for pharmacists. Since the tool became available in January, about 3.3 percent of patients on average are "out of therapeutic range" in a given week, down from 6.8 percent.
2:06 p.m. Giving patients a voice. "Here she comes!" says otolaryngologist Gaelyn Garrett, medical director of the Vanderbilt Voice Center, as she removes a large polyp from an Indiana man's vocal cord. The growth had plagued the high school music teacher for months, eroding his voice to a low rasp. Peering at his voice box through a microscope, Garrett uses scissors with blades an eighth of an inch long and other small-scale devices to delicately tease out the polyp from its cover of skin and then presses the loosened skin back in place. As opposed to the traditional and still-practiced approach of grabbing the growth and snipping it off, this technique minimizes scarring, which could put an end to singing. Polyps usually are caused by too much yelling and other kinds of "voice abuse," so patients often work with speech pathologists after their surgery to learn how to be kinder to their vocal cords. The teacher jokingly blames his polyp on his students, whom he has to ask loudly and often to hush up.
3:51 p.m. Personal bond. Robert Manlove sits on a couch in an office at the Vanderbilt-Ingram Cancer Center. Diagnosed with non-small cell lung cancer four weeks ago, Manlove, 70, has been feeling some knee pain—a potential sign the cancer has spread. But David Carbone, his oncologist and director of Vanderbilt's arm of the National Cancer Institute's Specialized Program of Research Excellence in Lung Cancer, tells him that just-taken X-rays show no new mass. It's positive but not an absolute assurance, he says; this cancer is stealthy and the treatments imperfect. Manlove will begin chemotherapy today. Born and raised in Nashville, the patient sits, pensive, for a few moments. "There is real anxiety associated with having a terrible disease," Carbone says, "and starting on a new treatment and not knowing how well it will work." He reveals his own cancer history to Manlove—a battle with lymphoma that required radiation, chemotherapy, and removal of part of a lung. Manlove is moved by the revelation from an empathetic physician impelled to share a common bond with a patient.
Day 4
8:26 a.m. Saving trauma patients. The usual way to treat badly injured patients who are rapidly losing blood is to pour saline solution into them—"blow them up like the Michelin man," says trauma surgeon Bryan Cotton. But he found that some patients can be saved with a cocktail of red blood cells, platelets, and plasma. The death rate for patients who received "trauma exsanguination protocol," or TEP, is nearly 75 percent less than for those who got usual care, Cotton and others recently reported in the Journal of Trauma. "These are people that are coming in with predeath vital signs and lab values," he says. He recalls a farmer who was hemorrhaging and had no pulse after a bull whacked him into a fence and split his liver. He was eating normally two days after TEP treatment and ready to go home a day later.
10:26 a.m. Personalizing medicine. Imagine the teardrop of a mosquito. "We work with those size cells," says Richard Caprioli, leading the way into a laboratory that may someday revolutionize the treatment of disease. Inside the sun-filled room at the Mass Spectrometry Research Center, which Caprioli directs, researchers and pathologists are using mass spectro-meters to analyze patient biopsies in order to bring the understanding of disease to a new level. The device reads the tissue's "molecular fingerprint" by blasting out charged molecules from the sample. The mix of molecules indicates specific kinds of cells—those most likely to become malignant, for example. "Targeted therapy for specific patients is what it's all about," says Caprioli—to be able to predict which patients, based on their molecular makeup, will develop disease and will benefit from certain treatments. Patients who won't benefit will be spared the risks and side effects of a drug that won't help them.
1:58 p.m. Efficient transfer. Listening in on physicians' phone conversations is part of Jan Powers's job in the cardiac access center. She and up to three other critical-care nurses take incoming calls from doctors who want to transfer their heart patients to Vanderbilt, connect them with a Heart Institute physician, and stay on the line to note the arrangements to be made for a room, tests, and perhaps surgery. "It sounds like a pretty large clot. We'll determine if he needs surgery or medication management," cardiac surgery chief Byrne tells a doctor 75 miles away who wants to send over an 81-year-old man who arrived in his emergency room short of breath the night before. Powers looks at the online "bed board" that shows the status of every bed in the hospital—full, empty, pending discharge—and enters a request for the incoming patient. She then sends out a page with his diagnosis, estimated arrival, and required tests to about 15 doctors and nurses in the cardiac surgery group. If the patient had needed surgery on arrival, Powers could have turned to look at a large screen that displays the real-time or schedule. Cardiac transfers were broken out from the general transfer center in 2004 after too many instances of physicians put on hold and dumped into voice mail. "Transferring doctors need to talk to a human," says Byrne.
Day 5
9:04 a.m. Ghost town. During the week, the 97-chair main lobby serves as a massive waiting room for families and friends. In grand southern tradition, they often set up with coolers, balloons, and meals for days on end. Saturdays are quiet; now only two or three families keep vigil. Seven operating room cases scroll down the "status board," a large LCD screen affixed to one wall; during the week, all 21 ors are in continual use. The board lists patients' first name and last initial and their status, such as "incision made" or "in recovery." Information is drawn from charting computers used by nurses in the ors, so it is right up to the minute.
10:22 a.m. The problem solver. Tamara Fulk walks briskly through the hallways on her way to a situation on the orthopedics floor that threatens to escalate. As one of five administrative coordinators, she constantly circulates through the massive center's two dozen inpatient units and some outpatient services such as the ER during her 12-hour shift, preventing and putting out fires of various kinds. The most clear-cut is to juggle beds when the hospital is crowded so that incoming patients don't have to be diverted to other hospitals. Other duties are less obvious. There has been a recent outbreak of gang violence in Nashville, and Fulk must keep injured members of rival gangs in completely separate parts of the hospital and conceal their identities.
Today, a recurring problem has surfaced. The girlfriend of a patient complaining of pain on the orthopedic floor was warned repeatedly to stop slipping him her prescription painkillers. She continued and became determinedly uncooperative. If he codes, she told a nurse, she'll do CPR. Fulk has already contacted the university's police force, and when she reaches the orthopedic surgery unit, the nursing staff says that two officers are meeting with the woman. The officers appear and report that when threatened with loss of visitation rights, the girlfriend agreed to lock the medications in her car. "That was a fairly common occurrence," says Fulk as she resumes her rounds. Visitors don't realize that even a seemingly benign dose of Tylenol could interfere with other medications. "Next thing you know," she says, "the patient is coding."
1:16 p.m. Tell us how we're doing. Two nurses in the emergency department's break room eat lunch beneath a bulletin board displaying performance data. Charts show how the team is doing on key patient safety tasks, including weekly errors made administering an EKG (such as improperly placing the leads on the chest) and the average time between ordering and administering antibiotics. But there is more than in-house data. Every patient not admitted to the hospital directly from the ED is called within 48 hours of the visit to solicit feedback. Some of the comments are posted on the wall. They don't reveal the names of their caregivers and generally are positive ("I was treated like a king" and "I have never been to a better ER"), but there is "They could've run more tests on me" and "I didn't see a nurse for an hour and my IV bag ran out." "The bad ones are painful, but we learn from them," says charge nurse Brenda Smith. That's a hospitalwide theme. "Complaining patients are nuggets of gold," says Gerald Hickson, director of Vanderbilt's Center for Patient and Professional Advocacy, which oversees efforts to promote patient safety and professional conduct. "We can't make it right if we don't know about it." But marketing studies suggest that complaints often go unvoiced, especially during a hospitalization. Patients clam up for fear that complaining will affect their care, says Hickson. "Every complaint you hear represents the 20, 30, 40 you don't." His 2008 goal is to surpass the roughly 2,500 anecdotal complaints that came in last year. "We want to reduce the number of people we make unhappy," says Hickson. The secret, he observes, is to hear from more of them.
