First, kill as few patients as possible

That was the name of a humorous book by Oscar London, but there is a serious side to the concept:

For years, Don Berwick and his colleagues at the Institute for Healthcare Improvement have been proselytizing and working to improve care in the nations' hospitals. They conduct important research and offer training programs for all types of hospitals, medical staff, and administrators. Recently, they have offered a metric that is the grandaddy of all metrics, the
hospital standardized mortality ratio. This is a disease and procedure based, risk-adjusted single number that tells you how you are doing in term of deaths compared to the average and compared to other hospitals. According to IHI, "the HSMR, appropriately adjusted for multiple variables such as population characteristics and diagnoses, provides an essential starting point in improving care and reducing mortality. "

In shorthand, for us lay people, the metric gives a sense of your likelihood to die at a specific hospital compared to other hospitals. If your hospital has a value of 1.0, it is average. If you have below 1.0, it is better than average. If you have above 1.0, it is worse than average. [Note: See correction to this statement in my comment below.] As with all metrics, you can quibble with the components and argue with the calculations, but it is as powerful a tool as I have seen. It is rapidly becoming the touchstone for many hospitals as they review their safety and quality programs.

IHI offers this tool to help people do better. It is not meant for advertising purposes or punitive purposes. As they note: "Many hospital deaths could be prevented if all the factors that contribute to them were better understood. Each hospital death provides an opportunity for learning -- by understanding and addressing local conditions that contribute to mortality."

We recently asked a group of outside experts from places with the strongest national programs to review BIDMC's progress in patient safety and quality. We received a good grade, but we also received a number of thoughtful and helpful suggestions for improvement. We have high aspirations. Our goal is to set audacious targets for improvement in overuse, underuse, misuse, and waste in the care of patients -- to set plans and milestones for doing so -- and to manage towards those targets.

Academic medical centers have a special responsibility in this regard, to create within the safety and quality program an academically rigorous examination of what works and what does not in various health care settings. I have given you a few examples in the postings below, entitled "What Works". But no single hospital has a monopoly on ideas when it comes to this field, and the first step is for all of us to disclose publicly how we are doing.

This HSMR number is not published anywhere unmasked by name, but if you contact IHI they will give you your own data, which is what we did. To relieve your suspense, 0urs is 0.71, which just puts us in the top ten percent in the nation. (Frankly, if a Harvard-affiliated academic medical center were not better than average, everyone would have a reason to wonder why.)

I wonder if my academic medical center colleagues in Boston and around the country would similarly be willing to post their HSMR number publicly on their own and to authorize IHI to maintain a publicly available list on their website. With a national debate swirling about the cost of care and value of academic medical centers, what would be more powerful than a grand display of openness about our progress in trying to kill fewer people?

What Works -- Part 4 -- Central Line Infections

Central line-related bloodstream infections are a serious problem in hospitals. A central line is a port installed directly into a major blood vessel to permit a catheter to be used for the quick delivery of medication for patients in ICUs and in other settings. Because of the direct connection to major blood flow, an infection associated with the installation will flow quickly into the blood stream and to major organs. This article from the Centers for Disease Control attributes a mortality rate of 12 to 25 percent (!) for each infection -- not to mention increasing costs by about $25,000.

The Institute for Healthcare Improvement likewise notes that "up to 4,000 catheterized ICU patients die each year in the US from avoidable infections and organ failure (sepsis) related to central venous catheters (CVCs). . . . Forty-eight percent of ICU patients in the US have central venous catheters, accounting for 15 million central-venous-catheter-days per year in ICUs. . . . Within this population, studies indicate an estimated 4% to 20% (500-4,000) of patients will die from catheter-related bloodstream infections."

Like others in the country, the medical leadership at BIDMC decided that our current rate of central-line infections was too high and set about to change it. When we started, our average rate of central line infections per thousand patient days in the ICUs was about 3. This was better than what we often see nationally, but our doctors were impatient to improve it. After all, each case has a high potential for serious patient injury or death. So the goal is to get to zero.

This turned out to be a multi-faceted problem. Central lines are often inserted by residents who have been trained how to do the insertion by other residents. (Dr. Atul Gawande provides a vivid description of this learning process in his book Complications: A Surgeon's Notes on an Imperfect Science.) Beyond the insertion process, decisions must be made about how long the line should stay in, and how often it should be maintained. Very often, there are only informal rules of thumb in a hospital for these determinations -- and there is often wide variation even within a single hospital.

Our folks set about to make this process more rigorous, analytical, and controlled. Sessions were held among surgeons, medical doctors, anaesthesiologists, nurses, and residents to reach a consensus on the proper method for inserting a central line. A specific kit was designed, so that anyone inserting a line had the full complement of supplies at hand. Detailed rules were established for the protocols surrounding maintenance of the line and its withdrawal. And, a system was set up so that every single infection that occurred would be analyzed to determine its cause -- so corrective measures would be taken going forward.

Here are the month-to-month results for the first year of the program:

Month ----- Infection Rate
Oct 05 ----- 1.67
Nov 05 ----- 1.28
Dec 05 ----- 2.43
Jan 06 ----- 3.07
Feb 06 ----- 1.40
Mar 06 ----- 1.07
Apr 06 ----- 0.00
May 06 ----- 0.59
Jun 06 ----- 1.15
Jul 06 ----- 0.57
Aug 06 ----- 3.03
Sep 06 ----- 2.50
Oct 06 ----- 0.00

As you can see, the figure goes up and down, although progress is good. The key thing is that every single case of infection is analyzed thoroughly, with the results shared across the broad range of hospital staff in the ICUs. What goes wrong? As many things as there are people. For example, one day, our chief of medicine happened to go by as another member of the staff was not following the protocol. When he pointed it out -- and none too gently! -- the person was embarrassed and really had no excuse for doing it wrong. So human nature often comes to play. Sometimes more technical factors arise. Regardless of the cause, each case is used to reinforce the program.

With about 1600 ICU patient days per month at BIDMC, the difference between an infection rate of 0.0 and one of, say, 2.5 is 4 actual people. Over the course of a year, that same difference amounts to 48 people who either get or do not get an infection. Applying the CDC's cited mortality rate of 12 to 25 percent, the difference amounts to saving the lives of 5 to 12 people -- just at our hospital.

When you look at numbers like those, you can see why our medical staff -- and people around the country -- are rabid about making this improvement real and permanent. Doctors and nurses devote their lives to alleviating human suffering caused by disease. They are heartbroken by the thought that their own well-intentioned actions might lead to death, and they are driven to get better and better at what they do.

What Works -- Part 2 -- Clinical Pathways

The Whipple procedure is a complicated and difficult surgical procedure. It is also called a pancreaticoduodenectomy, and it generally encompasses the removal of the gallbladder, common bile duct, part of the duodenum, and the head of the pancreas.This operation was first described by Dr. Alan O. Whipple of New York Memorial Hospital (now Memorial Sloan-Kettering).

The surgeons at BIDMC have developed a "clinical pathway" to guide themselves, related physician specialists, nurses, case managers and other involved in performing Whipples and taking care of patients before, during, and after this surgery. The clinical pathway is intended to assist physicians in clinical decision making by describing a range of generally acceptable interventions and outcomes. In other fields, it might be called a "decision tree." The guidelines attempt to define practices that meet the needs of most patients under most circumstances. While the physician must remain alert to deviations from the expected, the use of the clinical pathway can bring greater predictability to the entire treatment process in many cases.

The introduction of the clinical pathway for Whipple procedures at BIDMC has had very positive results. Here is a summary of the data pre- and post-clinical pathway.

Pre-clinical pathway period: October 2001-January 2004 -- 64 patients (42% male)
Post-clinical pathway period: February 2002-October 2006 -- 121 patients (53% male)

Age distribution: Mean for both periods = 64 (comparable range of ages)

ASA class of patients (degree of disease/difficulty)
Pre-clinical pathway: I (1.6%); II (51.6%); III (46.8%); IV (0%)
Post-clinical pathway: I(0.8%); II (39.7%); III (54.5%); IV (5.0%)

Pre-clinical pathway mortality = 1 death (1.6%)
Post-clinical pathway mortality = 2 deaths (1.7%)

Pre-clinical pathway ICU admissions = 8 patients (12.5%)
Post-clinical pathway ICU admissions = 16 patients (13.2%)

Pre-clinical pathway of stay/cost = 10.8 days/$23,536
Post-clinical pathway length of stay/cost = 9.8 days/$19,999

Pre-clinical pathway readmission/reoperation = 4 (6.3%)/4 (6.3%)
Post-clinical pathway readmission/reoperation = 10 (8.3%)/7 (5.8%)
(Both readmission and reoperation are measured within 30 days.)

To put all this into English, after the introduction of the clinical pathway, nothwithstanding a greater percentage of sicker patients, cost and length of stay decreased without negatively affecting mortality, readmission, or reoperation rates.
Patients and families also like the new pathway because they receive a roadmap of what to expect and when to expect it, and they can literally follow their own progress by looking at a chart on the wall of their room.

I don't mean to suggest that we are the only place to have clinical pathways, but they remain less prevalent than you might think. This is but one example to show how effective they can be when well designed and implemented by the entire medical team.

What Works -- Part 1 -- PatientSite

The first in a series of innovations that work (!) and make a difference in patients' lives:

A recent story on MSNBC called "Tired of waiting for the doctor?" made reference to PatientSite, our user-friendly, personalized electronic communications link between patients and their doctors, using a secure website:

Most patients have experienced playing phone-tag to get test results. That’s at least partly because of the traditional paper-based method of relaying information. Test results are transcribed onto paper, then given to the doctor, who then phones or snail-mails them to patients.

At Boston’s Beth Israel Deaconess Medical Center, patients can get test results electronically the same time as the doctor through a private online account called PatientSite. “There is no waiting for paper printouts to arrive by mail,” said Dr. John Halamka. All test results show up on the site, except those involving diagnosing cancer or HIV, “assuming that this news should be delivered in person,” he said.

PatientSite has been up and running for many years, well ahead of most of the industry. Patients like the fact that they can use it for a variety of routine functions -- from requesting prescription renewals, to making appointments and getting referrals, to viewing their own electronic medical records, including medications, allergies and test results, radiology reports and electrocardiograms. Doctors like it, too, because it frees them up to spend person-to-person time with patients on more important matters.

The long-term success of PatientSite also means that it can be used to study other new ways to improve care. Here is an example funded by the Robert Wood Johnson Foundation.

Try out the demo!

Errors, Improvement, and Discipline

This posting is long, but I think the final point is very important, so please bear with me. Last year, one of our doctors violated one of our safety regulations, and although there was no harm to the patient, we disciplined him with a temporary suspension of privileges. The fact that we took this action ended up in the newspapers. Now, this doctor is one of the experts in his field and very well regarded in the region and often takes on cases that are so difficult that others will refuse to take them. A number of people in the hospital and from other hospitals contacted me about the case, wondering how we could treat such an exemplary doctor in such a manner. It occurred to me that the case would be an opportunity to remind everyone in our hospital about our standards and procedures, and I did so in the email that follows.

But after you quickly read my email, take the time to slowly read the one that I received from a nurse a day later. That's the message that really hits home.

Here's mine:

Dear Colleagues, I received a number of comments following last week's press report regarding disciplinary action against one of our physicians. Many of you were proud that you work in an organization that engages fully in the internal and external processes designed to improve care and ensure safety. However, some of you expressed surprise and concern and asked "Why couldn't this be limited to an internal process?" I thought it would be worthwhile to explain. We know that we all have the best of intentions in treating patients at BIDMC. In the vast majority of our hundreds of thousands of patient encounters each year, things go well. Every now and then, though, there is an unexpected adverse patient event or a near miss. This could result from a series of unexpected events that may be the fault of no one. Sometimes, though, it results from potentially avoidable medical error, a care process that does not work effectively enough to prevent errors, or from poor judgment of a member of our medical staff.

Our Medical Executive Committee, comprising all of the departmental Chiefs and several other members of the physician staff, establishes rules of procedure and conduct that apply to medical care professionals here at the hospital. Those rules call for review of major adverse events and near misses whenever they occur. (Given industry experience, we can expect about four to six such episodes each month.) We conduct confidential peer reviews of these cases in the following manner: First, appropriate cases are identified at departmental conferences. These are then reported to our Department of Health Care Quality, where they are investigated to determine the root cause. We look for ways to learn from them and make improvements so we can better serve our patients. The vast majority of those reviews do not result in punitive action against a doctor. Indeed, we depend on healthcare professionals to disclose fully all facts so that the process can be accurate and helpful to future patients.

As required by state law, the most serious of the adverse events are reported to the state Board of Registration in Medicine ("BORIM"). Some types of cases must be filed with the state Department of Public Health ("DPH"). The law states that the entire process at the BORIM is protected by the rules of confidentiality as a peer review event, but cases filed with the DPH are not confidential. There are other occasions, however, where a member of the medical staff may have willingly or knowingly violated one of the rules set forth by the Medical Executive Committee ("MEC"). Here, too, a confidential investigation is undertaken, whether that doctor is a full-time faculty member or any physician with privileges at our hospital. If there is a violation, the Chief of that service imposes a penalty that he or she deems appropriate. That case is then reviewed in its entirety by the Medical Executive Committee. Assisted by an internal peer review panel, the MEC can accept or modify the Chief's determination. The record of that case is then forwarded to the BORIM. The Board conducts it own review and takes it own action, which may be similar, more severe, or less severe than that taken by the Medical Executive Committee. It can assess a range of penalties, the ultimate one being a revocation of a license to practice. Unlike the adverse events reports, under state law, disciplinary actions are made public by the Board. We do not seek press coverage of these events, but actions by the state can generate media inquiries. When they do, we provide clear, open, and honest comments to reporters to help put the case in proper context.

This series of processes is governed by the laws of the Commonwealth of Massachusetts. In the case of adverse events, those laws are designed to encourage disclosure by doctors by shielding them from unfair criticism and publicity during a substantive review of a case. The hope is to learn from our mistakes in a helpful and constructive environment. These reviews can often lead to resolving system problems, too. For example, the computerized physician order entry system was largely a response to illegible and incorrect written orders that resulted in medical errors. In the case of disciplinary actions, though, the laws are designed to publicize misbehavior -- to inform the public about the record of a doctor and to deter others from acting in the same manner.

No one takes pleasure from a process in which a highly trained physician who has devoted his or her life to healing patients is put through the agony of this kind of publicity. On the other hand, the public has a right to know if a caregiver has acted in a manner inconsistent with the professional standards established by his or her peers. Men and women who choose to become doctors do so out of a great sense of service to their fellow human beings. The fact that we engage in intense review processes of our own colleagues is a sign of this quest for excellence. On those few occasions when a member of the medical staff is hurt or embarassed by this process, it is because his or her colleagues have acted to prevent patients from potential harm in the future. It is a sign of the strength and commitment of our Medical Center. It is also the law of the land, and we will abide by it.

Sincerely, Paul

Now, here is the nurse's note to me:

I feel inclined to respond to your email with an experience I had today on the floor. Your email proved to be helpful in my circumstance. I am a new nurse at the hospital, and I am currently orienting. On my way to work early this morning I was thinking about the hospital and the recent publicity via this incident with the doctor. I actually felt a huge sense of pride coming into work. Taking the higher road is not always easy but lends it self to a freedom and power that all great institutions must embody. I believe that Beth Isreal's commitment to excellence is a model for both myself and other hospitals to emmulate.

At work today I made a mistake, a medication error. My stomach turned, I felt faint . . . however I recalled my focus earlier in the day: on the integrity of the hospital and the type of light that it shined on my paradigm as I entered my day. I felt an immediate sense of freedom and put my attention on what I needed to do to correct the error. Although embarrassment and fear visited me, I wasn't overwhelmed by the emotions. I contacted the right people, and helped maintain the safety of my patient. It was a very challenging day . . . and I grew. I will go to sleep with integrity; knowing I was honest, feeling I had done all I could.

I know healthcare presents these types of moral dilemas to all of us who choose this challenging field to work in. Beth Isreal is a safe place to honestly confront these dilemnas and strive to achieve the excellence that I know can exist.

** RN