If man were made to fly . . .

Story in the Boston Globe today.

Blog tests hospital leaders' patience
Beth-Israel CEO jabs competitors

By Liz Kowalczyk, Globe Staff February 23, 2007

There are some things that Boston hospital executives generally believe are best kept quiet. Gripes about competitors are one. The rates of hospital-acquired infections among patients are another, at least at this point.

Then came Paul Levy's blog.

...

He challenged other hospitals to publicize their infection rates.... The Globe asked several other Boston teaching hospitals if they would release their monthly central line infection rates, which they have collected internally for years. They all said no, at least for now, but added they expect to in the near future.

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In his blog, Levy also has needled Partners HealthCare, the parent organization of Mass. General and Brigham and Women's, about their formidable market share of patients, saying they get paid more from insurers because of their size.

Partners executives declined to comment. "What's a blog?" said chief operating officer Thomas Glynn when asked about Levy's blog.

Spokeswoman Petra Langer said that overall, people at Partners are not a blogging group. "They're too busy," she wrote in an e-mail.

'Tis a Gift to be Simple

I am printing this story from today's Boston Herald. My quote is accurate. I assume the others are, too. Hey, this is the only way I could get MGH on the record on this blog!

More seriously, a state-sponsored website could be set up for a few thousand dollars. In fact, I will donate the time of our Chief Information Officer to design the site. Hospitals could voluntarily post their data on three or four categories of infections (e.g., ventilator-associated pneumonia, ICU central line infections) along with any explanation they would like. The public could then watch each hospital's progress month to month and year to year.

This is not a game to compare hospitals one to the other: It is a crusade to see how each hospital improves its own processes. So, Valerie, you don't have to have a standard across all hospitals. Sure, that would be an added bonus, but if you wait for that, you will wait for a long, long time. And, Nancy, the internet obviates the need to have a one-size-fits-all standard.

Don't you have enough faith in the public to let them see what they will actually experience in our hospitals?

State eyes hospital infection reports
By Jessica Fargen, Boston Herald Health & Medical Reporter
Wednesday, February 21, 2007 - Updated: 04:01 AM EST

Patients may soon be able to shop for the safest hospitals thanks to a new $1 million public health plan that will make rates of deadly infections at Bay State medical centers readily available to the public for the first time.

The Department of Public Health team, which has enlisted 50 experts and surveyed 73 hospitals so far, expects to make recommendations in June on how to reduce life-threatening in-hospital infections and put in a place a plan to make the rates public, officials said yesterday.

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Paul Levy, president of Beth Israel Deaconess Medical Center, created a big stir recently when he posted the hospital’s infection rates on his blog and encouraged other hospitals to follow suit without a complicated state mandate.

“Wouldn’t it be easier to try it out voluntarily - see how it goes?” he told the Herald. “My point is these numbers are available in real time. We all keep track of it. All the state has to do is set up a Web site and let us enter our data.”

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But public health officials are taking a more measured approach, hiring experts, doing research and surveying hospitals.

“Just the nature of the patients, the case mix of patients means that there is not a one-size-fits-all solution to the problem,” said Nancy Ridley, director of the Betsy Lehman Center, which is leading the project with the DPH.

Massachusetts General Hospital spokeswoman Valerie Wencis echoed that concern, saying the hospital won’t post its rates until it’s mandated.

“You have to have a standard across all the hospitals,” she said. “That’s something that needs to be taken into consideration before rates would be put online or made public.”

Who do you think you are, anyway?

For those of you not on the inside of the health care system, here is the scuttlebutt around Boston. Some of my colleagues out there are saying to one another, "Who does he think he is, a non-MD, posting clinical information?" "Why is he so far out front on this issue?" "Doesn't he know that these blog postings are bad for academic medicine?" "This is all being done just to make his competitors look bad."

Here is my view. First, let me address the last point. I plead guilty to being highly competitive, but I took over a hospital that was almost driven out of business, both by bad internal management and by aggressive actions taken by other hospitals in town. I think the people at BIDMC -- and I mean everybody -- doctors, nurses, techs, housekeepers, transporters, and food service workers -- have something important to offer the community. I dearly want our place to thrive so they can deliver on that promise, and I will look for a competitive advantage where I can find it.

John McDonough, on the Health Care for All blog, has suggested that high quality care can be a competitive advantage. Maybe, maybe not. I do know, however, that some other hospitals in town can ride on their reputation, rather than on their comparative performance. I also know that some other hospitals in town are reimbursed by insurers based on market share, rather than on quality of care. If people are given accurate data on quality and safety, and if these perceptions and patterns shift as a result of that transparency, so be it.

But I believe that the more important issue for all of us running hospitals, and especially academic medical centers, is that our standing as institutions in American society is in jeopardy. In many respects, people do not trust that we are there to serve them carefully and efficiently. Some think, too, that we do not have proper respect and concern for our workers. Some also think that we do not have sufficient involvement in the community. Here in Boston, the hospitals are now the largest corporations in the city, in terms of staffing, revenues, physical facilities, purchasing, energy use, and the like. By virtue of that standing, we are now expected to meet a higher public standard than has ever been the case.

I know that the people at BIDMC are trying to meet that higher standard. We may falter, and we will make mistakes (sometimes really bad ones), but we are setting ourselves to carry forth the legacy of our two antecedent institutions, the New England Deaconess Hospital and the Beth Israel Hospital.

The description of the Deaconess -- "where science and kindliness unite in combating disease" -- was also the watchword for Beth Israel. Fortunately, the combined institution that resulted from the merger ten years ago maintains that set of values. BIDMC stands as a place where patients know they will be treated with warmth, friendliness, respect, and dignity. We do our best to treat each person as we would want a member of our own family to be treated. This is not just a saying: It is part of the culture of the place, and we deliver on that promise every day and night in the great majority of cases. We aim to continue to show our patients that level of caring and respect.

But this has to be combined with excellence in the delivery of patient care -- and particularly minimizing the probability of causing harm to patients. Clinical quality emanates from the judgment and experience and skills of world-class doctors working with world-class associates like nurses and technicians. But even that expertise sometimes needs help and new management approaches to overcome systemic problems in the organization. As I have tried to reflect in the postings below, we have aspirations to be as good as we can possibly be in that arena. We believe that public disclosure of our progress is one tool in reaching those aspirations.

I hope you agree that more widespread disclosure by all the Boston hospitals would enhance the performance of us all and would build public confidence in the great academic medical centers in our community. I like to think that we will eventually live up to the expectations set forth so clearly by Patient Dave in his heartrending comment on the posting below:

NOBODY has more right to that information than the patient in need. NOBODY.

This is REALLY personal, believe me. If we can easily get info on the best used cars (hardly a matter of life and death), we certainly ought to have free access to information on who has high and low outcomes and accident rates.

We owe it to ourselves and the community to make sure Dave and all other patients get what they need.

We saved one person's life. Can we keep it going?

Here is the latest month's result in our program to eliminate central line infection rates. Remember, this is measured in cases per thousand patient days in our ICUs. For the full story, view my postings on December 17 and January 23.

This month's figure covers 1853 patient days. If we had had our previous average of "3" in January, five to six people would have had an infection. Statistically speaking, one would have likely died. It could have been anybody's mother, father, sister, brother, daughter, or son. It is MUCH better this way! Let's see if we can keep it going.

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
Nov 06 ----- 2.38
Dec 06 ----- 1.87
Jan 07 ----- 0.00

Can I ask a question? If I can post these rates for BIDMC, why can't people from other hospitals? Cleve, Charlie, and Jim: Why can't the insurance companies (Blue Cross, Harvard Pilgrim, and Tufts) post them? Governor Patrick and Secretary Bigby: Why can't the state of Massachusetts? And, where are the public health advocates on this topic? As I have shown, the data are collected regularly. I am seeking no competitive advantage here. This is an attempt to get past a culture of blame and litigation and persuade people that transparency works: Real-time public disclosure of key indicators like this (not the untimely publication of "process" metrics) can be mutually instructive and can help provide an incentive to all of us to do better.

Governing Safety and Quality

Here in Massachusetts -- and probably elsewhere -- a hospital's board of trustees has the statutory responsibility for ensuring the quality and safety of patient care. Think about it: A lay group of volunteer citizens has the final authority for how well you are treated in the hospital. Of course, doctors and nurses and other licensed professionals have their own responsibilities under the law, too, and can be held accountable by various regulatory agencies. But what can and should we expect from the lawyers, real estate investors, bankers, corporate executives, community activists and others who happen to find themselves on the board of a hospital?

The full board's involvement is often entrusted in the first instance to its patient care assessment committee (PCAC). This is a combined trustee/medical staff committee that reviews adverse events, the procedures used by the medical staff to investigate errors and omissions, and the range of programs in the hospital that are designed to reduce medical errors and otherwise enhance quality. The PCAC reports on a regular basis to the full board.

In our place, we supplemented the PCAC reports with a monthly report on the quality indicators that are collected and posted by our accreditation body, by Medicare, and by other insurers (e.g., the percentage of heart attack patients who receive aspirin upon arrival). This "dashboard" covers a variety of such measures and provides a quick visual scan of how the hospital is doing relative to national benchmarks on each one. On the dashboard, measures that are in compliance are shown in green, those with slight trouble are in yellow, and those that are substandard are shown in red. In addition, we would have a presentation by doctors and nurses about particularly interesting quality or safety initiatives.

Our board was not satisfied with this. To them, it did not answer the underlying questions: How well are we doing on quality and safety? Where could we do better? Is the place safe? They asked us to bring in an outside visiting committee of national safety and quality experts to offer an assessment of our programs and advice on how they, as board members, could make sure they were doing their job as well as possible. We did this, and here is what we learned.

We learned that our policies, procedures, and actual quality and safety programs were quite good, with a supportive corporate culture and sound underlying systems and knowledgeable and enthusiastic people who wanted to move things up a notch and get even better. But we were advised that a change in focus was needed to reach our potential. And, interestingly, the key to our success would be to change the relationship with our governing body. While there were several detailed suggestions, here were the two main ideas:

First, said our advisers, the board of trustees is seeing too much green. Don't bother showing them a quality dashboard that mainly displays your success in complying with detailed national quality metrics. That is distracting and boring and an ineffective governance and management tool. Instead, focus the board's attention on where you are doing harm to patients, and tell them how you are going to stop injuring and killing people.

Second, do more to tap the intelligence, skills, and experience of the board members to prompt them to offer advice from their own personal and professional lives that could be useful in designing, implementing, and monitoring progress. During discussions of quality and safety, board members are often intimidated by their lack of medical expertise. Give them the means to participate in thoughtful discussions on these topics. They are bound to have many good ideas. If the board is not spending as much, or more, time on quality and safety as on hospital financial and other business matters during their meetings, something is wrong.

As is often the case, these two simple themes have changed our perspective. At all levels in the organization, we focus less on detailed compliance with regulatory standards and more on how to eliminate harm. This rises up from the units in the hospital, to the divisions and departments, to the medical executive committee, to PCAC, and to the full board. You have seen some examples on this blog: My postings on central line infection and ventilator-associated pneumonia are drawn directly from the work and presentations in the hospital and include many of the same details seen by our board.

The second point is also being implemented. More meeting time is devoted to these topics. Even better, the presentations we have made during the last several months have, indeed, prompted more board discussion and insights from the board members themselves. They have become confident that they can be as "expert" on quality and safety issues as on business issues. They have found this to be engaging and useful, as have the staff.

In summary, we are all learning how to do this better. There is no monopoly on good ideas. I welcome comments from those of you out there who want to share your own experiences.

Little ideas work, too

As a follow-up to yesterday's posting, I want to give two examples of changes instituted in one of our departments, neurology, that are indicative of ideas that bubble up and help improve access and results. Please understand, I am not saying these are necessarily state-of-the-art or haven't been done elsewhere or are world-shattering in scope. They are simply two examples of creative thinking that originated with the medical leadership that were put into place with no fuss, and that work well for patients.

First, we noticed that people who wanted to see neurologists on a semi-emergent basis, i.e., in a day or two, were finding an appointment lag of several weeks. Why? Because all the doctors were booked well in advance. So our chief of neurology instructed his faculty to leave their schedules open for a portion of each session, to be available for last-minute patient requests. The doctors were worried, though, that they would have wasted clinical time during their days, that those reserved open hours would never be filled.

What happened? Just the opposite. The reserved open hours were always filled with patients with more immediate needs. And, those patients had a much better record of actually showing up for their appointments than people who had made appointments several weeks in advance. And, doctors had a chance to see patients while they were freshly suffering from neurological symptoms, instead of hearing about those symptoms weeks after the fact. End result: Happier patients, better clinical diagnoses, and more productive doctors.

Second, every hospital has a "mortality and morbidity" conference procedure to review cases with adverse outcomes. But what about the normal, day-to-day cases? How do you audit for quality control? I don't mean questions about proper documentation. I mean review of the doctor's decision-making. Even the best of doctors will make mistakes and omissions in the course of treating a patient, most of which are not crucial, but many of which can be instructive if they are pointed out. Here, too, our chief of neurology put in place a simple idea, which he calls a "biopsy" of the medical record. Here's how it works.

Each faculty member in the department, from most junior to most senior, is asked to anonymously review the patient record of a colleague. He or she then offers a "grade" on the quality of the diagnosis and treatment, with minimal or extensive commentary depending on what he or she finds. That written review is then shared with the attending physician on the case.

What is going on here? Let's remember, first, that these doctors are extremely well intentioned and quite expert and really don't need an incentive to treat patients as well as possible. Through this gentle, non-threatening, but direct, peer review process, they are told by an equally expert colleague how they can do better. The reviewer, too, benefits by thinking through an interesting case and reflecting on his or her own practice. Since everybody gets to be a judge and part of the review team, the likelihood of defensive behavior or denial is reduced.

Not a big deal, you say? Maybe not. On the other hand, it is a thoughtful and effective process that is respectful of the expertise of the faculty while providing a gentle nudge towards more consistent clinical excellence. I like how it works, and I like what it stands for: A underlying value system of collegial behavior in service to the patients.

Change must come from within

A personal observation after five years on the job and in this field:

The biggest managerial conundrum facing hospital administrators is how to bring about constructive and lasting change in these large, complex organizations that are known as academic medical centers. People often say that AMCs are behind the times with the application of managerial techniques that are in wide use in other kinds of organizations. That may be so, but I do not think it is an accident or for lack of trying. I think there is something fundamentally different about these hospitals that requires a different point of view and approach.

The first difference is that we do not produce a single product or service. Every patient is different, and every patient expects and deserves personalized service and individualized attention. Not so different, you might argue. There are plenty of businesses that offer service tailored to the individual, and they have learned how to provide that service consistently and efficiently. And it is true that, in medicine, there are general rules and appropriate clinical responses for many patients with one or another disease. For example, I have discussed below the use of clinical pathways to make care decisions more routine, and I have discussed protocols that can be used to avoid ventilator-associated pneumonia, central line infections, and other harm. But, at its core, effective treatment really does require due attention to the individual biology of the patient, his or her state at the exact time of treatment, as well as related factors like family and home situations. It is as much art as science.

The second difference is that the key players in the delivery of medical care -- the doctors -- are not employees of the hospital. They are essentially independent contractors who have chosen one or another AMC for a particular mix of clinical care, research, and teaching that gives them personal satisfaction. Further, they have been taught through medical school, residency training, and their history of academic professional advancement that they will ultimately judged by the results of their personal efforts, not by the progress of the institution within which they work. In baseball parlance, they are all free agents. I do not say this with any inclination to diminish the dedication, expertise, or integrity of these doctors. I offer it, though, as a sociological context for their perspective on the world. (And please, I recognize that I am generalizing a bit here, so I am shortening the description of what is a broad continuum of individuals.)

Red Sox fans know what I mean when I say, "That's Manny being Manny." Our left-fielder is a brilliant baseball player who sometimes lets his individual inclinations interfere with the well-being of the team, but who is admired, respected, and even beloved for his overall contributions on the field. Even when his actions confuse and confound and annoy us, we put up with him because he is a hard-working person usually devoted to doing the best he can -- and because his results in the batter's box can be stunning and change the course of a game or even a season.

Doctors in AMCs are not all "Manny being Manny", but they are thoroughbreds in their own way. Sometimes their behavior can be confusing and even infuriating to hospital administrators. But let us remember: Even those doctors who truly care about the interests of the hospital must make individual decisions in the batter's box when seeing a patient. They know they will ultimately be judged by others -- and by themselves -- for their specific performance in an exam room, an operating room, or on a patient floor. The same holds true for their performance in the research lab and in instructional sessions with medical students or residents.

The rest of us in other jobs think we are being judged as acutely for our own performance, but our performance is often measured in terms of our effectiveness as team members or by our interpersonal skills or by the overall progress of our organization. But now think of how we expect our own doctors to get results. How often have you heard, "Well his bedside manner isn't very good, but he is a great surgeon. If I have to choose, I want a great surgeon." It is not that we intentionally are enablers of bad behavior: It is that we selfishly want good results for ourselves or our loved ones -- and we expect the doctor to deliver it notwithstanding the economics of the health care system, the productivity of the hospital, or any other ancillary concerns.

Here at BIDMC, we are engaged in an experiment, trying to mold the hospital to your expectation of a great hospital experience. As one of my folks put it yesterday, we are trying to be "aggressively patient centered" so that every person is treated as though he or she were a member of our own family. How can we do that, you might ask, if what I say above is true? The answer lies in part in our own history as an organization, a legacy of the underlying values of both the New England Deaconess Hospital and the Beth Israel Hospital. But there was another factor.

Because our hospital went through an exceptionally bad period after the merger that created BIDMC and then almost literally rose from the ashes, those doctors, nurses, and others who stayed with us and have since joined us have an extraordinary degree of loyalty, optimism, and enthusiasm about our ability to work together to deliver the kind of care I describe above. They are collaborative to an outstanding degree. Yes, the doctors are still free agents, but they recognize that even their individual advancement can be enhanced by teamwork and cooperation.

In the postings below entitled "What Works", I have given some examples of their attempts and accomplishments. But here is the key message: Not one of those initiatives was driven by me or other members of the senior management team. The desire for change and improvement came from within, from those very free agents who are viewed by some industry observers as so troublesome.

So here is the five-year takeaway. My management philosophy is remarkably simple. My job as CEO is to help create an environment and provide the resources within which the native creativity of our doctors and other staff can flourish. I don't practice an iota of medicine, but when I do my job right, they are better able to do theirs right.

There is a joke that, "You've seen one AMC, you've seen one AMC." Maybe what I say would not apply elsewhere. We will also get to see if it works even here for the next five years! The jury is still out, but so far, we appear to be headed in the right direction.