Preface

If you knew a way to save thousands of lives and billions of dollars, wouldn't you want to share it? Eugene Litvak knows how and for nearly two decades has battled to apply his methods for improving the quality of hospital care and reducing the cost of that care while better protecting patients.

To be clear, Eugene Litvak, PhD, is not a physician. And though he is a well-regarded researcher in the field of hospital operations, Litvak did not study medicine or healthcare at the prestigious colleges he attended in the former Soviet Union. He is that uniquely American creation - the immigrant who built a better mousetrap: in his case, a tested method of improving patient flow and patient care that saves lives, as well as billions of dollars in unnecessary spending.

Litvak laments that between 250,000 and 440,000 people die unnecessarily each year because of hospital admissions issues, according to multiple reputable researchers.1 That's 10% of US yearly deaths, making it the third leading cause of fatalities after heart disease and cancer (pre-COVID pandemic), according to the US Centers for Disease Control and Prevention (CDC).2 Litvak is aware that while there is no organized reporting and data collection system tracking medical errors, it is widely acknowledged that hundreds of thousands are reported each year attributable to hospitals; errors that can result in death, costly hospitalizations, and permanent harm. He also knows that as much as one-quarter to one-third of all US healthcare current spending, $4.1 trillion, is considered wasteful or avoidable and that much of that cost, pain, and suffering could be spared.3 Healthcare costs continue to grow exponentially and are predicted to reach $6 trillion by 2027.4

This book details Litvak's story and chronicles his battle to save lives and money and improve care in American hospitals by changing the way they operate. Litvak, born in the Ukrainian city of Kiev in the former USSR, was an applied mathematician there and a rising star in the field of operations management, sometimes referred to as industrial engineering. There, he helped improve the reliability of the telecommunications and computer networks and enhanced the process of efficiently building railroads.

After achieving worldwide recognition for his research in the 1970s in the USSR, Litvak began receiving offers to present his work in other countries. One invitation came from a personal hero, Claude Shannon of the Massachusetts Institute of Technology (MIT), the father of information theory. But Soviet bureaucrats prohibited Litvak from traveling abroad, fearing that, as a Jew, he would not return. So in 1977 he and his wife, Ella, applied to emigrate and requested permission to leave the country. The government also refused that request and Litvak, and his wife immediately lost their jobs and became refuseniks: Soviet citizens, often Jews, who sought to leave the USSR, but whose applications for exit visas were refused and their careers halted.

After years of working menial positions and suffering government persecution and anti-Semitism, including recruitment attempts by the dreaded KGB, the Litvaks and their parents finally received exit visas and joined a Jewish Diaspora fleeing the dying Soviet state. The six émigrés first landed in Vienna before arriving in the United States in 1988, where they initially stayed with relatives and plotted their new lives in Boston.

"The start of our emigration was not very easy," Litvak recalls. "We could take from the USSR no more than $150 each. We had two pairs of old, sick parents, no jobs and little English."5

But Litvak has battled bureaucracy his entire life, joking that his time as a refusenik, fighting to emigrate, prepared him for decades of butting heads with America's healthcare bureaucracy. "I truly believe there's a need for a great public uproar and awakening about our healthcare system," he states. "All of us will need advocates to care for us if nothing changes."6

Litvak's first encounter with the US healthcare system came when his father, a decorated soldier who had been badly wounded in World War II, was hospitalized at Beth Israel Hospital in Boston the day after the family arrived on US shores. "He was helpless. I couldn't speak English. But I was really impressed with the hospital and the respect and attention of healthcare providers towards my parents and me," Litvak recalls. "I never experienced that in Russia. I knew my father was sick and I had to do something. I felt it was my responsibility to save him, since I brought him to America."7

That was 36 years ago. "He received excellent care then," Litvak remembers. "Though today the drugs and equipment are better, the respect, quality of care, and personalized attention are worse than at that time."8

For the last two decades as a hospital consultant and co-founder of the not-for-profit Boston-based Institute for Healthcare Optimization, Litvak has combed through hospital finances, quality reporting, and staffing data to track the process of how patients flow through typical American hospitals from admission to discharge. His groundbreaking work in healthcare was driven by a powerful motivator.

"My first incentive to work in this field was hunger," recalls Litvak, who accepted a position as a postdoctoral fellow at the Harvard School of Public Health several years after arriving in the United States. Prior to that, he'd worked as a night manager in a small inn.

"I simultaneously felt like a prince and a pauper," he says. "On one hand, I had recommendations from distinguished scientists. But on the other hand, every company I applied to told me that I was overqualified."9

Harvard's School of Public Health wasn't sure how to capitalize on Litvak's skills. He was first assigned to explore testing for the growing HIV/AIDS epidemic and discovered a new screening protocol to detect the virus in donated blood. He and his colleagues developed a method that substantially reduced the cost of screening and significantly improved its accuracy, but faced government health agency intransigence because of the influence of powerful test kit manufacturers.

It was one of Litvak's first battles with American bureaucracies. Later, he worked as an outside consultant at Massachusetts General Hospital in Boston, where managers of its stress lab were seeking more money to grapple with a growing demand. Litvak discovered that the lab was operating with 30% unused capacity, yet still claimed it needed more space to expand.

Working with Mass General researchers, he found similar problems in the hospital's operating rooms and in other departments. He employed complex mathematical theories and algorithms to understand why the Operating Rooms (ORs) and Emergency Rooms (ERs) became overcrowded and how that impacted the cost, quality, and efficiency of care. He learned what creates these predictable weekly overcrowding events there and within most of the nation's 5,000 acute care hospitals.

Emboldened by his findings, Litvak sent letters to every Massachusetts hospital offering to share his research. "Very few even replied, except to say, 'No thanks,'" Litvak recalls. In that era, health maintenance organizations (HMOs), a new health insurance model that achieved savings for its members by cutting healthcare costs and reducing services, began penetrating the Massachusetts market. "Finally, people were talking about healthcare costs," he attests.10

Hospital overcrowding, he discovered, isn't just annoying to patients tired of waiting. Well-documented research proves it frequently leads to bad health outcomes and occasionally even death for patients and great stress on the doctors and nurses who care for them. Ambulances are diverted when hospital emergency rooms are backed up and have no space, postponing lifesaving care for patients desperately needing treatment. ER patients lay in hallways and lobbies awaiting space in treatment rooms. Doctors and nurses are stretched thin, working extra shifts caring for ever-growing numbers of patients.

And this was before the COVID pandemic. It has worsened since.

During overcrowding episodes, ER patients requiring hospital admission can wait hours without care or be transferred to open beds, but in inappropriate units. Surgical patients, for example, may be moved to cancer wards because surgical unit beds are unavailable. Sometimes problems occur in the ensuing chaos.

Patients with planned surgeries see their procedures postponed or canceled, causing personal stress and inconvenience and adverse health outcomes. Meanwhile hospitals lose millions in well-reimbursed payments from health insurance plans, revenues that they required more than ever during the pandemic. Declining revenues, often due to canceled surgeries, have contributed to hospital closures around the country.

Litvak has studied these logjams and discovered both the source of the problem and its operational solution. Both relate to patient flow, the journey of a patient through the hospitalization process.

He has widely published the results of his research in prestigious medical journals from the Journal of the American Medical Association (JAMA) to the New England Journal of Medicine (NEJM) and Health Affairs.

His...