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How do you measure the quality of a hospital? Infection rates, mortality rates, national rankings, and industry accolades, taken together, can paint an impressionistic picture of performance. But a lack of standardized tools for data collection and analysis confounds practical comparisons. The New York State Department of Health, in acknowledging this limitation, reports that “indicators do not currently exist to measure how well hospitals treat every type of illness or patient that they care for.” Instead, it describes quality more broadly as “doing the right thing, at the right time, in the right way—and having the best possible results.”

Few institutions nationwide have embraced and operationalized this credo like �ٺ���Ƶ Hospital—Brooklyn in the southwest Brooklyn neighborhood of Sunset Park. The hospital’s performance metrics and accolades are unrivaled in the borough, and match or best those of the top academic medical centers in the United States. But it’s the animating philosophy behind those metrics—and the culture it inspires—that explain the hospital’s extraordinary success and offer valuable lessons for other health systems.

Since 2016, when the 444-bed hospital, formerly known as Lutheran Medical Center, fully merged with �ٺ���Ƶ Health, �ٺ���Ƶ Hospital—Brooklyn has quietly set a new standard of care in a borough long strained by stark health inequities. The latest evidence of its transformation was documented in a showing a 33 percent drop in the mortality rate of patients hospitalized at �ٺ���Ƶ Hospital—Brooklyn since the outset of the merger.

“To see that kind of rapid decline in just a few years is almost unheard of,” says Robert I. Grossman, MD, CEO of �ٺ���Ƶ and dean of NYU Grossman School of Medicine. “It’s truly amazing.”

Colliding with a crush of Omicron headlines, news of the hospital’s remarkable turnaround flew under the radar, but its significance looms large for the future of hospital mergers and the delivery of healthcare to poor communities. In more meaningful terms, a 33 percent drop in mortality rates translates to thousands of lives saved.

The figure is particularly notable because �ٺ���Ƶ Hospital—Brooklyn serves a community with the highest percentage of Medicaid patients in the nation. Lacking routine access to high-quality healthcare, and burdened with higher rates of obesity, diabetes, and high blood pressure, low-income patients with government insurance or no insurance at all tend to arrive at the hospital in worse health, experience more complications, and stay longer than patients with private insurance.

Although mortality rate was its primary focus, the study also showed a 39 percent reduction in central line infections, a 33 percent drop in catheter-associated urinary tract infections, and a higher likelihood of patients recommending the hospital or giving it a top-tier ranking.

These performance metrics stand apart in Brooklyn, where one in five residents live below the poverty line and hospitals have buckled under financial strain. In 2017, a study by the healthcare nonprofit Leapfrog Group ranked Brooklyn hospitals among the worst in the nation. Today, �ٺ���Ƶ Hospital—Brooklyn is the only hospital in the borough to earn Leapfrog’s “A” rating, as well as five stars, the highest score, from the Centers for Medicare and Medicaid Services. This year, the hospital became the first and only hospital in Brooklyn to receive Magnet® recognition for excellence in nursing from the American Nurses Credentialing Center.

The hospital’s mortality rate doesn’t just outperform other Brooklyn hospitals; it’s among the lowest in the nation when factoring in the proportion of patients who arrive with advanced illness. Institutions that care for sicker patients typically have higher mortality rates, but �ٺ���Ƶ Hospital—Brooklyn has proven the exception to the rule.

The dramatic transformation challenges an entrenched narrative that hospital mergers are bad for patients. Most studies show that as hospital competition decreases, overall mortality increases and patient satisfaction can also decline. Martin Gaynor, PhD, an economist at Carnegie Mellon University who studies the consequences of hospital consolidation, told The New York Times that “evidence from three decades of hospital mergers does not support the claim that consolidation improves quality.”

So how did �ٺ���Ƶ carve a different path? The JAMA Network Open study points to a confluence of factors, but its success begins with a core philosophy about quality—that is, about “doing the right thing, at the right time, in the right way”—and doing it consistently to deliver one high standard of care and raise the bar for everyone, not just privately insured patients living in wealthier zip codes. “We began with the premise that we cannot accept any lower standards for the patients we care for in Brooklyn than the patients we care for in Manhattan,” says Bret J. Rudy, MD, senior vice president and chief of hospital operations at �ٺ���Ƶ Hospital—Brooklyn and the senior author of the study. “The goal has always been one standard of care for all patients, no matter where they live.”

Dr. Rudy’s appointment to head the hospital’s administrative team in 2016 was the first in a long series of decisions by �ٺ���Ƶ’s leadership that would underscore this guiding philosophy. Dr. Rudy began his career as an adolescent medicine specialist at the University of Pennsylvania treating underserved teens with HIV from Philadelphia’s poorest communities. “The abject poverty was stunning,” Dr. Rudy recalls. “The kids in our care were wonderful but truly disadvantaged. So even though I was working at a big academic medical center, I had to stay very connected to the community and collaborate with community-based organizations.” Dr. Rudy’s experience in Philadelphia burnished a career-long conviction that the cutting-edge care of an academic medical center can and should be extended to everyone. “It didn’t matter if you were on Medicaid and coming from West Philly or you were wealthy enough to fly in from another state because you wanted to see a particular specialist,” he says. “Every patient was treated equally.”

Two Hospitals, One Standard

To ensure equitable and measurable care at �ٺ���Ƶ Hospital—Brooklyn, the health system’s senior leadership advocated for a full-asset merger that would result in a unified administration with shared goals and expectations. “The only way to deliver the same level of care in Brooklyn as we do in Manhattan was to put everyone on the same footing and compare everyone the same way,” says Joseph Lhota, executive vice president and vice dean, chief of staff.

This all-in approach is atypical among hospital consolidations, in part because it incurs substantial risk. Lutheran Medical Center’s high population of Medicaid patients and its lower reimbursement rates would make it challenging to generate the surplus revenue needed to reinvest in staff, modern facilities, and new technology. Moreover, a full-asset merger stood to jeopardize �ٺ���Ƶ’s top rankings, since the institution would absorb Lutheran Medical Center’s troubling performance data. Most hospital mergers divide administrations, operationally creating two separate hospitals. That configuration, in effect, creates a firewall, so if metrics lag at one hospital, the decline won’t impact those at the other hospital. In the case of �ٺ���Ƶ Hospital—Brooklyn, “their metrics would be our metrics,” says Dr. Grossman. “Their results, our results.”

The implications were debated among senior leadership and the Board of Directors. “We were concerned, absolutely,” Dr. Grossman explains. “As an institution, we had spent a decade making our quality standards some of the best in the nation. To suddenly merge with an institution that had poor quality meant thinking long and hard about how it would affect us. In the end, the answer was pretty simple. We said, ‘We’re going to fix it.’”

Andrew W. Brotman, MD, executive vice president and vice dean for clinical affairs and strategy, chief clinical officer, says the literature on hospital mergers reflects a dominant model at the expense of uncommon alternatives. “When studies say that mergers are bad for patients, what they’re really referring to is a model in which a health system puts its name on a hospital, raises the rates, and doesn’t do much else,” says Dr. Brotman. “That’s not what we did. It wasn’t about transferring patients to Manhattan or filling beds. We set out to create a high-quality healthcare system in southwest Brooklyn—and we did it. It really is a different philosophy.”

By 2017, �ٺ���Ƶ hadn’t just absorbed Lutheran Medical Center’s metrics, it understood them in granular, real-time detail. One year after the merger, it had installed its electronic health record, Epic, throughout �ٺ���Ƶ Hospital—Brooklyn, including 22 inpatient and outpatient locations. Representing an $80 million investment, Epic would unify a patchwork of record keeping systems, including paper records, to monitor some 1.7 million patients. That includes its Family Health Centers at �ٺ���Ƶ, a network of more than 40 Federally Qualified Health Center clinics with a longstanding history of serving underserved and immigrant communities in southwest Brooklyn. The Family Health Centers at �ٺ���Ƶ offers primary care to more than 100,000 patients and accommodates over 600,000 visits each year.

The digital record-keeping system meant that hospital physicians seeing patients referred from the Family Health Centers at �ٺ���Ƶ—and other �ٺ���Ƶ locations—would have instant access to their patients’ medical histories, enabling faster, more seamless care. It also meant that patients could schedule appointments using their mobile phones and receive text messages alerting them to upcoming appointments. “It doesn’t matter how rich you are or where you come from, everybody in this country has a smartphone,” says Lhota. “If you send somebody a text message and tell them that they have an appointment, they’re more likely to make that appointment.”

Building on Epic, �ٺ���Ƶ installed its signature suite of clinical dashboards that tracks more than 800 performance metrics and puts the data at the fingertips of every clinician in the system. “Having access to real-time data that is accurate and actionable is critical,” notes Dr. Rudy. “I probably use the dashboards 10 times a day.”

The dashboards brought transparency and accountability to everyone, and served as a valuable tool for standardizing care. “If every doctor does what they alone think is right, the care will be variable,” says Joseph M. Weisstuch, MD, chief medical officer of �ٺ���Ƶ Hospital—Brooklyn. “We’ve standardized our treatments and set an expectation that everyone would fall in line because it’s the right way to take care of patients. It requires buy-in and people who are committed to making things better for patients, not just for themselves.”

Backed by the dashboards, leaders were empowered to manage to the data and make objective decisions that would directly serve patients. “When you tell a surgeon that his or her infection rate is twice as high as somebody else’s, that’s a powerful statement,” adds Dr. Grossman. “We’re a metric-driven organization, and there’s only one source of truth: the dashboard.”

But analytics, as powerful as they may be, are only as good as the people who can act on them. In 2015, Lutheran Medical Center relied heavily on a network of part-time physicians who attended at other hospitals. Its Level 1 Trauma Center, critical care units, and neonatal intensive care unit were all outsourced to contractors. “If a voluntary doctor brought a patient into the surgical or medical ICU, for example, they would remain the patient’s primary caregiver instead of deferring to the expertise of a dedicated ICU team,” explains Dr. Weisstuch. “That arrangement is never in the best interest of the patient.”

�ٺ���Ƶ replaced most consulting doctors with staff physicians. Clinical chiefs were replaced with �ٺ���Ƶ veterans who understood the transformational changes that had helped bring the institution back from the brink of bankruptcy in 2007 to become one of the top-ranked hospitals in the nation. “Scores of doctors had privileges at three, four, five, six different hospitals and weren’t particularly invested in any one them,” explains Dr. Brotman. “We transitioned that, so now more than 75 percent of �ٺ���Ƶ Hospital—Brooklyn’s doctors are full-time. That alone was a dramatic change.”

Along with plummeting mortality rates, patients were discharged sooner, and they were less likely to wind up back in the hospital. “The longer you stay in the hospital, the higher your risk of infection and the longer you’re away from your family,” notes Dr. Weisstuch. “Our focus is on getting patients safely through their health crisis and home as soon as possible.” Today, the average length of stay and the 30-day readmission rate at �ٺ���Ƶ Hospital—Brooklyn are among the shortest in New York City.

Rather than transferring Brooklyn patients to its Manhattan campus—a consolidation tactic commonly used by other Brooklyn hospitals that have resources in Manhattan—�ٺ���Ƶ has built important new service lines. The Brooklyn hospital now offers reconstructive breast surgery, spine surgery, robotic surgery, advanced endoscopy, and advanced bronchoscopy, among other core services. “Why should people have to travel to Manhattan?” asks Dr. Weisstuch. “Why should anyone living in Sunset Park lack convenient access to state-of-the-art robotic surgery, advanced breast surgery, advanced reconstructive surgery?”

Among an extensive list of infrastructure improvements, the hospital has built a new electrophysiology suite to assess cardiac patients; a new interventional radiology suite where biopsies, diagnoses, and therapies are precisely guided with real-time imaging; new operating rooms; and Perlmutter Cancer Center—Sunset Park, a state-of-the-art ambulatory cancer center run by �ٺ���Ƶ’s distinguished Perlmutter Cancer Center, offering radiation therapy and infusion treatments. This year, it will complete construction of a hybrid operating room that combines a traditional operating room with an image-guided interventional radiology suite to allow for more complex procedures.

“We’re careful with resources across the system,” says Dr. Rudy. “But if there’s a technology that’s expensive but standard of care, we ignore the finances and put in the standard of care. We make sure we do that based on good clinical data.”

Built to Last

�ٺ���Ƶ’s deep investments in infrastructure, technology, and faculty yielded huge dividends during the darkest days of the pandemic. The newly bolstered hospital had the expertise and staffing resources to deliver the best possible care to a community disproportionately impacted by COVID-19. It weathered the crisis with the support of innovative supply chain and facilities teams, top clinical specialists with the latest knowledge on interventions and best practices, a passionate frontline staff, and a nationally recognized that inoculated more than 62,000 patients and members of the local community. “The staff at Lutheran Medical Center would have fought like hell for their patients,” says Frank M. Volpicelli, MD, chief of medicine at �ٺ���Ƶ Hospital—Brooklyn. “I have no doubt about that. But it would have been immeasurably harder without the systems and resources of the larger system.”

That insight holds true with or without the pandemic. The lessons gleaned from �ٺ���Ƶ Hospital—Brooklyn about how to build on an historic community hospital and make it durable for decades to come can be applied to other health systems endeavoring to improve care in underserved communities. “It’s been years of really hard work,” says Dr. Volpicelli. “We’ve done more than throw money at problems. We’re here to build a sustainable model for delivering care to underserved populations that can be replicated around the country. So, yes, we could simply take revenue from �ٺ���Ƶ’s commercially funded population in Manhattan and spend it here to make the metrics better. But that’s not a sustainable model. We intend to serve this community for the long haul.”