Making hospitals better

As a teenager in New Britain, Conn., Elizabeth H. Bradley, Ph.D., volunteered at the local hospital, but she had little interest in being a physician. “The adults I knew were in manufacturing as engineers or management,” says Bradley. “To me, the interesting part of a hospital was how it was organized and managed—and how much it was not like a regular business.”

Now a professor of public health at the School of Medicine, director of its Health Management Program and co-director of the Robert Wood Johnson Clinical Scholars Program, Bradley is still drawn to the organizational aspects of health care. “I guess I’ve never changed,” she says.

After receiving her undergraduate degree at Harvard University, Bradley went on to earn an M.B.A. in health administration at the University of Chicago Graduate School of Business. She then completed an administrative fellowship at Massachusetts General Hospital in Boston, where she stayed on as an administrator for several years.

“As a hospital administrator at Mass General, I helped make lots of changes—in staffing levels, work flow, admissions practices,” Bradley says, “but we never had the time to evaluate whether the changes were making a difference.” Physicians conduct randomized trials to assess the safety and effectiveness of drugs and procedures, but Bradley says there was no equivalent scrutiny of organizational changes made by hospital managers. “I was eager to step back from what I was doing and apply the same rigorous methodology to evaluate management practices as those used to evaluate medical care,” she says.

After obtaining her Ph.D. in public health from Yale in 1996, Bradley embarked on just the kind of management systems research she felt was lacking. She has since published many research articles on the organizational and other factors involved in translating our best health care knowledge into the best possible systems of care for real-world patients. Bradley has worked in the areas of hospital care, long-term care, and hospice care; since 1996 she has collaborated with the John D. Thompson Hospice Institute for Education, Training and Research, Inc., in Branford, Conn.

Recently, Bradley was part of a team led by Harlan M. Krumholz, M.D., the Harold H. Hines Jr. Professor of Medicine, that enlisted researchers from the School of Medicine, the School of Nursing, Yale-New Haven Hospital and several other institutions to devise ways to shorten “door-to-balloon time,” the critical period between a heart attack patient’s arrival at a hospital and the completion of an angioplasty procedure in a cardiac catheterization lab. The group identified six best practice strategies, published in the New England Journal of Medicine in 2006,which have formed the basis for a national alliance of more than 800 hospitals devoted to improving outcomes for heart attack patients.

There are large differences among hospitals in severity-adjusted mortality rates after heart attack, and the two researchers now plan to determine which organizational strategies are linked to reduced mortality.

Bradley is also using her management skills in Ethiopia, where government officials requested help in improving hospital care. With a team of 23 Yale-Clinton Foundation Fellows in International Healthcare Management, she has developed a strategy to implement fundamental elements of good hospital management, including triage systems, inventory management, practices to reduce hospital-acquired infections, and quality improvement methods.

Although her work in Ethiopia might seem far removed from streamlining heart attack patients’ trips to the catheterization lab, Bradley says the goal in both cases is encouraging hospitals to adopt best practices.

Both projects also include an evaluation component, ensuring that these practices are supported by objective evidence.

“We want to learn what distinguishes the hospitals that get the best results,” Bradley says, but she won’t settle for assumptions or anecdotes. “We need the evidence to back it up.”