America's Best Hospitals

Five days at an Honor Roll medical center

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Photo Gallery: Diary of a Hospital

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.