By Mary Jo Feldstein, St. Louis Post-Dispatch, July 4, 2007

Barnes-Jewish Hospital is often cited as one of the nation''s best. But a couple of years ago the government released some surprising findings about how this premier institution cared for heart patients.

The data raised questions about the quality of care at Barnes, inspiring staff to make improvements. But the hospital found reaching its own high standards would require Barnes to rethink how it cared for heart patients and to nudge hospital culture to adapt.

The transformation at Barnes gives a glimpse of what happens inside hospitals when they receive disappointing quality results.

More and more, insurers and government health programs want evidence that the patients are getting good quality care. Many are instituting programs that list recommended protocols and require physicians to document that they have completed the tasks.

There are a couple of reasons for the request. Research shows patients only receive recommended care about half the time. And not only do patients suffer with worse outcomes, but the wrong care often is more expensive.

Doctors, however, have been reluctant. They typically see these efforts, especially those tied to their fees, as attempts to pay them less, not to improve quality. Also offensive is the idea that several years of medical school and decades of experience can be whittled down to a checklist.

Physicians at Barnes were told, "Get over it, we''re going to make those checklists really easy and then we''re going to get to the more complex stuff," said Dr. Jonathan Gottlieb, chief medical officer at Barnes.

As at most hospitals, physicians at Barnes had differing opinions about the validity of results, their impact on patient outcomes and what change should be implemented.

Over time, however, thinking evolved. Several physicians realized that while these few simple measures might have only a slight impact on a patient''s outcome, they often serve as an arrow pointing to larger issues.

"These things tend to metastasize and you find all sorts of other things," said Rick Royer, chief executive of Primaris, the organization overseeing Medicare quality improvement in Missouri. "The data itself is not the answer. The data gets you to start asking questions."

Here''s how it began at Barnes: To cut costs and improve quality, Medicare started asking hospitals nationwide to follow a set of basic best practices, proven to boost heart patients'' success rates.

Some were simple tasks like making sure heart attack patients took an aspirin. Others involved more coordination. One example is getting patients stent implants or angioplasties within a critical two-hour window.

Barnes quickly fixed most of the deficiencies. Patients got their aspirin, recommended prescriptions and discharge instructions. But getting patients into that procedure room before the 120 minutes passed proved tougher.

In 2004, physicians were meeting the standard only 66 percent of the time. That figure jumped to 100 percent this year. Last month, the hospital was found to be one of only 17 nationwide with survival rates for heart attack patients higher than the national average.

Getting there took much more than a checklist. All people involved were put together in one room. Each learned how his or her role fit into the process. That led to a change in process. Preparing the room for the procedure and calling in staff was taking too long, especially during the middle of the night.

Now, the emergency room physician calls in the cardiologist and staff. While they are driving in, the room is readied.

All heart patients are tracked from when they enter the emergency room. The results are posted so the entire staff can see if one area is having difficulty.

Barnes isn''t stopping with heart care. It''s using concepts first designed to improve quality and efficiency in the manufacturing industry to produce the same effects in hospitals.

The hospital is looking at how medications are moved to the floors, how patients are admitted from the emergency room and how laboratory results are reported back to physicians and patients. In each case, the goal is to break down the process, making it more efficient while improving patient care.

"That''s why I''m excited about this whole journey," said Barnes'' Gottlieb. "It just feels good."