But take a look anyway, if you have an interest in process improvement in hospitals. This is a collection of my best posts on this topic.

Monday, November 24, 2008

The ad I would buy

I was joking with a friend the other day that the Boston Globe Spotlight team (their investigative group) has managed to become a profit center for the newspaper, rather than a cost center. How so? Well, the main subject of two recent articles, Partners HealthCare, has been buying a series of editorial page ads in anticipation of the articles and today published a full page ad in response to them.

Relying on the placement of MGH and Brigham and Women's Hospital in the top ten of U.S News & World Report the ad notes that:

[T]here are real differences in quality between hospitals. Year after year Partners HealthCare hospitals rise to the top of this list because of investments in teaching, research, safety, and technology. Our patients continue to choose us time and again, especially for complex treatment. And the ultimate measure of quality is that physicians and other hospitals in the area frequently send their most challenging cases to our teaching hospitals.

We realize that there are costs associated with excellence. teaching hospitals, including MGH and Brigham and Women's, care for the sickest patients, the most complex diseases. We subsidize a broad range of service, some of which lose money, such as psychiatry and community health centers.

I can't afford these kind of ads, so I'll offer some thoughts here.

Can we please start by agreeing that these are two very impressive hospitals, staffed by superb physicians, nurses, and others, and deserving of substantial praise in many, many respects? We can also agree that they are destinations for very sick patients and that they subsidize many important services that receive insufficient reimbursement from private and public payers.

But, can we also agree that the differential in rates received by these two hospitals and the doctors working in them is not related to documented, quantifiable differences in quality between them and, say, BIDMC and Tufts Medical Center, two academic medical centers that are also acknowledged for their excellence and that are also destinations for very sick patients and that also subsidize many important services that receive insufficient reimbursement from private and public payers?

Can we also agree that, likewise, there is no documented, quantifiable difference in quality between Partners' community hospitals (like North Shore Hospital) and other community hospitals (like Beverly Hospital)? And yet, the rates received by those community hospitals and the doctors working therein are generally higher than the non-Partners community hospitals.

And finally, can we agree that the higher rates received by community primary care doctors and specialists in the Partners system are not related to documented, quantifiable differences in quality between them and non-Partners community doctors?

When you cut through it all, that is what the Globe stories were about. Everybody knows that Partners is able to achieve higher rates from private insurers because it has more market power than others in the Boston area. The Globe simply documented the figures that we have all heard about for years. Who can quarrel with this business model, envisioned at the creation of Partners years ago and executed superbly?

The issue for today, it seems to me, is whether in a region characterized essentially by nonprofit hospitals and nonprofit insurance companies, the government agencies that supervise those charitable institutions should care that this imbalance exists. This is more a question to be asked of the insurers than of the providers.

Now, here's the heart of the question. Is this a zero sum game? Is there some fixed pot of insurance premiums to be allocated, so that if rates for other hospitals were to rise, those for Partners hospitals would have to fall?

Regular readers of this blog know that my answer to this will be, "Wrong question." The correct question is how much money could be saved in the health care delivery system if we were all to invest in quality and safety and other process improvements. The answer is, "A lot." The first step, though, is to move towards basing rates on the quality of care delivered -- to give the proper incentives to make progress in this direction. Sorry, not quality as portrayed by a magazine, but as documented from actual clinical records, the kinds of records maintained by all of us, in real time, every day of the year.

Let's measure improvement in avoiding central line infections, ventilator associated pneumonia, "codes" on medical floors, and other preventable harm. I'm not saying that reimbursement rates should be mainly based on a comparison of hospital A's to hospital B's infection rate. Perhaps it would actually be more effective to emphasize the rate of safety and quality improvement within each hospital as an entity. And, please, let's get away from pay-for-performance reimbursement systems that use process measurements of the type collected (and two years late) by the government. (By the way, some of these have uncertain validity or perhaps harmful clinical results, e.g., 4-6 hour timing of the first dose of antibiotic for patients with pneumonia in the face of an uncertain diagnosis.)

In summary, I don't think Partners needs to defend itself for executing a thoughtful business plan. I think it is the public officials who supervise the nonprofits in the health care sector who should feel some time pressure. They need to figure out, and quickly, how to fix the disconnect between reimbursement rates and the degree to which hospitals achieve quality and safety improvements. It is the pursuit of those improvements that offers us the first and best hope to control the rise in health care spending in Massachusetts.

Thursday, November 20, 2008

Farr better

Another wonderful application of Lean process improvements on one of our floors, done in conjunction with our BIDMC SPIRIT program. A seemingly simple reorganization of the supply closet. It always seems to prompt the question, why didn't we do this before? Well, the answer is that people are so busy doing work-arounds and getting by that they don't have time to get better. (By the way, the title of this post is a play on words: The work was done on the 5th floor of our Farr building.)

A note from our Lean guru, Alice Lee:

I know there was a comment in your blog asking if RNs should be organizing a supply room. Well, they are among the primary users of the supply room and know best what items need to be co-located, what items can be retired, what additional items need to be added, what the correct par level is (after analyzing usage trends). There is a true sense of ownership with full participation at all levels so the work is sustained.

The RNs and PCTs as well as MDs go in the supply room many times a day and waste many, many minutes a day searching for things, not finding them even if they are, there due to the disorganization and overstock of so many items.
We have a place for everything now that makes sense and locates the most frequently used items at eye level. As we transform each unit, the nurse manager and medical director marvels at how much of a crowd pleaser this is with the staff. Morale boost!
I know there have been comments also about whether the rapid improvement approach is the right one. Most of the work is actually parsed and distributed throughout a month in preparation for the 2 day concentrated effort to make the physical changes needed. It is hard work that is fun and builds a closer team. It brings people together that may have had an adversarial relationship previously (Unit staff & distribution staff). This is not unlike the ED and Lab working together to solve the hemolysis problem.

Even the meal tray

As far as I'm concerned, you can take all those posted quality metrics and throw them out the window when you get a letter like this one that I received from a patient:

BIDMC is a special place. The nursing care deflates your stress about being in the hospital. The doctor's talent makes you believe you have the best possible care. The atmosphere makes you feel that people like their jobs and feel invested in them, so you feel that everybody is paying attention, whether they are cleaners, food service, transport, department heads, trustees.

I especially noticed the employees' investment in their jobs. (NURSE: "Doctor, I noticed you are testing Ms. X for TB. If we believe she might have TB, should we institute those protocols now?" TRANSPORT: "The nurses are really busy. I'll reconnect your oxygen so you can go back to bed and I'll tell them that I did." NURSE: Let's not wait for the bed to be changed. I want it to be dry for you when you have these fevers." She changed the bed and me three times that night.)

Symbol of cooperation regardless of rank or function: Nobody left my room without taking my meal tray with them.

Thursday, November 13, 2008

No retreat by the Boards

About a year ago, the Boards of BIDMC and BID~Needham met in an educational and planning retreat to decide on their priorities for both hospitals, one a large academic medical center, the other a small community hospital. The result was a four-year commitment to eliminate preventable harm and to dramatically improve patient satisfaction in the two hospitals.

Today, the governing bodies again met to reaffirm these goals, to learn more about how to achieve them, and to plan their agendas for the coming year. They were assisted by some special guests.

First was Steven Spear, Senior Fellow at both the Institute for Healthcare Improvement and the MIT Engineering Systems Division. I have written before about some of Steven's ideas and research. Here, too, he discussed the manner in which the best complex organizations deal with the problem of how to obtain process improvement. He noted that the first step in improving a complex system is being transparent about what is going wrong because "we need to know it's a problem we need to solve." As opposed to a transactional mindset, in which the emphasis is on making decisions because you assume you know enough to make the right choice, he emphasized the value of a discovery mindset. Under this approach, you have to have humility that an educated guess is not likely to be right, but that it provides an opportunity for learning. You also need to be sufficiently optimistic that you will achieve improvement over time, aided by iterative discovery. In short, the key is "humble optimism."

Spear emphasized that one of the jobs of a governing board of a hospital committed to transparency is to stand by the medical and clinical leadership and staff during the inevitable periods in which there will be adverse publicity resulting from this openness. "Watch their back," he advised.

The next session consisted of a panel comprising doctors and nurses from the two hospitals, focusing on their perspective on the progress towards quality and safety improvement and receiving their advice for activities by the Boards that could support these objectives. They were unanimous in their support for the importance of transparency as a key part of process improvement.

Following break-out sessions in which the Boards and their respective committees planned their agendas for the coming six months, they heard from Lee Carter, former Chair of the Board of Cincinnati Children's Hospital, a national leader in hospital quality and safety. He mentioned the key elements of board involvement in the quality agenda:

-- Pay attention and understand what people on the front line are doing so that they know they are appreciated. Improving quality is very difficult and takes extra work. "You need to let them know that you appreciate them."
-- Encourage transparency. "It is powerful and absolutely necessary. Until you identify what you need to improve you never will improve."
-- Establish and maintain a culture of trust, because without it, you cannot obtain transparency.
-- Measure progress, rigorously and accurately. Quoting IHI's Jim Conway, Lee noted, "Some is not a number; soon is not a time." Quantifiable objectives, with specific deadlines, are key, as is measuring progress towards both the objectives and the timeliness of achieving them.

He left the board members with the following lessons from Cincinnati: (1) We are never as good at something as we think we are; (2) it is very hard work to make transformational, as opposed to incremental, change; (3) we always have slower progress than we think we will, and the board needs to understand that and be supportive; (4) it takes persistence, and the role of the board is to support the attempt and be cheerleaders for the transformation. Confirming Spear, he stated that the board needs to let the clinical and administrative leadership know that "I've got your back" during periods of public scrutiny and the adverse publicity that often accompanies transparency. Finally, says Lee, (5), "After all this, it works" and will save lives and will result in better patient care overall.

About 80 lay leaders left the 12-hour session with a renewed sense of purpose and commitment, enthusiastic in their attempt to improve care not only at their hospitals, but also cognizant that they are partners in a national movement to do the same.

Wednesday, November 12, 2008

Transparency works! Better than you can imagine.

I just saw clear evidence of the importance of transparency with regard to the reporting of important adverse events and medical errors. Bear with me through the details, but I will not keep you in suspense regarding the conclusion: The wide disclosure of a "never" event in a blame-free manner resulted in an intensity of focus and communal effort to solve an important systemic problem, resulting in redesign of clinical procedures, buy-in from hundreds of relevant staff people, and an audit system that will monitor the effectiveness of the new approach and leave open the possibility for ongoing improvement. If you ever needed a clear example of the power of transparency, here it is.

Back in early July, a patient experienced a wrong-side surgery in our hospital because the staff failed to carry out the required time-out. We disseminated the story of this event to all staff in the hospital. There was a full investigation of the matter, both internally and by the state DPH, and some immediate improvements were made in our procedures. But the more important work was being done by a Safety Culture Operational Task Force co-chaired by a nurse, a surgeon, and an anesthesiologist, and engaging almost two dozen other people from a variety of disciplines and positions in the hospital. Its charge and mission:

To implement and embed the Culture of Safety at the point of care in Perioperative Services, with an emphasis on teamwork and enhanced communications.

They adopted the following principles of patient safety:
-- Building in redundancies and cross checks
-- Standardization
-- Simplification
-- Forcing functions
-- Empowering the grassroots to lead change

They set forth a number of objectives, the first of which were to assure compliance with the time-out Universal Protocol; to script the time-out; and to design and oversee time-out audits. In so doing, they wanted to review and adopt not only the WHO Safety Checklist, but also to incorporate forthcoming 2009 Joint Commission regulations.

The result is pictured above. The document above is the check list that went into use today for all surgical procedures in our hospital. Not shown above is a corresponding computer screen version of the checklist that will be filled out in real time by the circulating nurse as the time out proceeds.

Responsibilities and the order of events is clearly laid out, even to the point of requiring that any radio in the OR is shut off during the time-out so as to avoid aural distraction. Note the forcing function at the very top of the form: No blades, needles, specula or bronchoscopes can be within reach of the surgeon until the full time-out is completed. Also, a system of "secret shoppers" has been set up to quietly audit compliance with these procedures. These are people from a variety of disciplines who normally work in the ORs who have been given this additional job responsibility.

This material was presented today in interdisciplinary grand rounds attended by about 300 people -- doctors, nurses, surgical techs. The response was enthusiastic, as everyone realized the vast improvement this would make in patient safety. And yet, even at this last moment, there were suggestions from the floor that made the process even better.

And then, I just attended a meeting of our Chiefs of Service and senior administrators. I suggested that this kind of effort and the responsiveness seen by our staff would not have happened if they had adopted the traditional approach to a "never" event -- i.e., a quiet discussion among the leadership with a directive to avoid the problem. The response from the three Task Force co-chairs was unanimous: It was because our leadership had the confidence in our staff to go public with this event that the improvement process took on life and energy.

One of our nurse managers today told me that the American Academy of Orthopaedic Surgeons reports that in a 35-year career, an orthopaedic surgeon has a 1 in 4 chance of performing a wrong-side surgery. Three years ago, people in our hospital might have said, "These things happen." We have now learned that they only happen because we let them happen. We let them happen because of our own silence and fear.

No longer.

Thursday, November 6, 2008

Getting specimens to the lab

Not to overwhelm you, but this stuff is really exciting for our staff, and I hope you can understand why. I present another result from BIDMC SPIRIT, this one having to do with the collection of specimens. Can you think of anything more vital to how a hospital runs every day? Note that it was called out by a transporter, and see how this caused a varied group of people to work together. What better way to demonstrate our respect for each and every person working here?

This one took a while to fix because it was a pretty convoluted, complicated, and broken process.
For those reading this series of posts, please note, though, the repetition of key steps in the improvement process. Part of what is going on here is that staff members at multiple levels in the hospital are learning a consistent way to address process improvement. Thus, the organization as whole grows while individual problem areas are solved.

Where did we start?

On 5/13/08, callout made by transporter regarding amount of time spent and uncertainty re: value added reconciling GI specimens.

After discussion among staff from all departments involved (including front line staff, managers and Sr. VPs), the group determined that the entire process of tracking and transporting specimens from the procedure room to the lab (not just transporter specimen sign-out) offered multiple opportunities for process improvement:

Problems identified included:

§ Location of the specimen tray was far from the procedure rooms;

§ It was deemed unnecessarily time consuming for every individual specimen to be “signed out” by a transporter and not clear that it added safety;

§ There wasn’t an opportunity built into the system for the GI physician to interact with the GI nursing staff so that information could be compared on the specimen requisition and the specimen jar label;

§ Paperwork to accompany specimen was not always completed in a timely and uniform manner;

§ Confusion about transport pick-up times;

§ No reconciliation taking place when specimens arrived in Pathology and no immediate feedback to GI of missing specimens;

§ Time and “peaks and valleys” of volume of specimens delivered to pathology caused operational challenges for pathology;

§ Not all steps were defined and standardized;

§ Process resulted in delays;

§ Opportunities for staff time in all 3 areas to be more productive and satisfied;

§ # and process for hand-offs created opportunities to lose specimens;

§ Frustration/tension among departments (GI, transport, Pathology);

§ Project was good one to provide opportunity for many BIDMC staff to apply Lean/SPIRIT principles.

What process did we use to design new process?

1. Front line staff and managers from each area described current practice and problems.

2. Included GI physician in design process.

3. Drew process flow for entire current process, listing all problems/potential for errors.

4. Group described “ideal” state (using “Lean” principles described below). New process flow drawn.

5. Entire group developed specific steps for each activity in process, understanding each others’ roles.

6. Tweaked process flow as specifics required.

7. Challenged any step that was inconsistent with “design principles” to get closer to “ideal”.

8. Rolled out new process; called out outstanding issues – continued to tweak process; managers shadowed staff; process improved continuously when problems arose.

9. Deemed successful and ready to be “spread” to other procedural areas.

“Lean” principles used to shape “Ideal” new process

“Activity” Principle: Specify all steps in process;

“Connection” Principle: Ensure communication and hand-offs can be carried out appropriately;

“Pathway” Principle: Include no (or minimum) “forks” or “loops”, i.e., each member of the team should have one clear path to follow;

“Improvement” Principle: Use scientific method (data driven, evidence based, willingness to experiment), involve front line staff, keep improving -- “call out” when unable to perform step as specified.

Major Elements of New GI Specimen Tracking/Transport Process

-- Specimen tracking book moved to more convenient central location in GI, reducing delays and distance staff need to walk.

-- Binary connections between staff members: Procedure RN and MD interact directly (when possible) with resource nurse at time of dropping off specimen and req so discrepancies can be discovered and remedied at time of hand-off.

-- Consolidation of responsibility: One resource nurse designated to “tag” all specimens. As a result, process occurs in more timely fashion and specimens are delivered more uniformly to pathology.

-- Modification of Sign-Out Sheet: Transporter no longer has to sign out each individual specimen by patient name.

-- Each patient’s specimen placed in single clear bag (easy for nurse to count/identify).

-- Each patient bag placed in large disposable clear bag with single letter designation eliminating need for Transport to return to GI in between and bags to be tracked to Pathology.

-- Completion of reconciliation process in Pathology.

-- Rounds occur more frequently/consistently which GI can count on and delivers more consistent number of specimens to be delivered to Pathology (did not require adding resources as transporter time freed up by not having to complete individual test reconciliation as noted below).

-- Log created so Transport could indicate what time they arrived/which lettered bag they dropped up. This also includes a column for Pathology to indicate # number of specimens that were actually in the bag.

Bottom Line

-- A reduction of 57% in the amount of time between when a specimen was ready for transport and when transport arrived to pick the specimen up.

-- A reduction of 61% in the time it took to transport specimens to Pathology.

-- Freeing up of hours of transport time/day without sacrificing the safety associated with this task.

-- Much improved workflow for the pathology techs.

-- Improved communication between nursing and physician staff, further reducing instances of mismatched information between the specimen label and requisition.

What does this mean to BIDMC?

Reduction in time-wasted activities by staff
Clarity in role responsibilities re: specimen tracking
Consistent and standard process from point specimen is taken to point specimen is received in pathology
Improved Patient Care/Safety Controls + Improved Employee Satisfaction and Collaboration + Better Use of Resources

Next Steps

Spread this standardized process (with refinements as needed given the specific operations and physical layout of each department) to all departments in the medical center that collect and send tissue specimens bound for the department of Pathology.

Wednesday, November 5, 2008

Fixing bad blood tests

Here's another example of process improvement that typifies BIDMC SPIRIT, with remarkable success resulting from application of Lean principles, applied with advice from our small, but able, Business Transformation group. I supply an edited version of the narrative given to me:

What do you get when you cross well intentioned Emergency Department (ED) Nurses (RNs) with fastidious laboratory technologists? You get a problem, an opportunity, and a bevy of talented professionals poised to collaborate on a mutual solution.

Why would ED RNs do anything that might delay treatment? Why would a lab technologist take an extra 56 minutes to provide a potassium test result? Why…because each role cares deeply about the patient; but in divergent ways. This divergence spoke to us. We had two groups not understanding the impact they had on each other, and combined, their impact on patient care.

As this scenario shows, many patients cross multiple departments and value streams as they receive care. The departments knew that quality was a problem but wanted to benchmark how they stood in relation to the rest of the hospital. One measure of quality in the ED is the hemolysis rate (the rate of defect specimens that skew a patient’s laboratory test results). Data was collected by the ED nurses and laboratory technologists and was then presented in a rapid improvement event to uncover the root cause of the quality problem.

The hemolysis rate for lab specimens collected in the ED was found to be 22.4%, approximately five times their counterparts on the inpatient units (3.9%). This rate had several deleterious effects: patient’s hemolyzed specimens often had to be recollected and retested, therefore these patients had to wait on average 56 minutes longer for lab results, and frustration levels in both the ED and the laboratory were high.

As we knew, hemolysis is a byproduct of improper specimen collection and has an unintended effect on lab results. The effects on results can be can be minor, moderate, or actually cause inaccurate and incorrect results. One test in particular, potassium, is significantly impacted by hemolysis. It is a very significant test for heart patients where small changes can be noteworthy. We saw an opportunity to examine practice, past studies, and identify opportunities for improvement. A decreased hemolysis rate would result in improved ED throughput, reduced length of stay for the patient, fewer recollections (savings in both time and materials), and better patient satisfaction.

To address the high rate of hemolysis in the ED, two in-depth studies were completed. The first was to obtain the hemolysis rates for collections via an IV insertion versus a peripheral blood draw (venipuncture). The second study focused on hemolysis for specimens drawn through the IV using one of three methods: Vacutainer, extension tubing, or syringe. The data indicated that specimens collected during IV insertion showed a much higher rate of hemolysis, especially when using a vacutainer (the ED’s current preferred method).

We also assembled other hospital experts. The phlebotomy manager and a venous access nurse came to our event to observe, comment, and critique our ED nurses and ED techs as they simulated current practices (on a dummy arm). Each of us learned a lot and took note of areas in the process where we noticed a lack of standardization. We were most struck by the variability of practice, not only staff in the ED but of staff around the medical center. Thus, we had a great opportunity to standardize and create best practice for the medical center. A mistake-proof, proper technique is the key to preventing hemolysis.

Our goals were simple: develop a standardized method of drawing labs in the ED by engaging the ED and lab staff who do the work and strive for the common goal of reducing the hemolysis rate by over 18%. This would generate a cost and time savings as a result of fewer patient re-sticks, fewer repeat tests, improved quality due to better sample integrity, and potentially contribute to higher patient and staff satisfaction.

Our intent was not to place blame but rather to really understand the root of the problem. We gathered data from other areas of the hospital which also collected specimens during an IV insertion. Each area reported no problems with hemolysis, but our investigation uncovered they did, in fact, have a problem. None of the tests they ordered were impacted by hemolysis; so these groups were unintentionally blind to the problem. But this showed us that the individual technique of the person collecting the specimens although variable, is less of the root cause.

As we talked about hemolysis, we broadened our outlook and realized how complicated this is to operations. Due to the unpredictable patient flow, changing clinical needs of each patient, and variability of each RN, ED Tech and MD practice-styles, this was a very complex process to define. But we were committed to finding a solution. Each area owned this problem and for various reasons wanted to find a solution. The lab would have fewer critical values to repeat, call, and document. The ED would have fewer patients to re-stick, faster results, and happier patients.

During our time working on this issue we learned and communicated the following to the respective Lab, and ED staff:

• Long tourniquet time (>1 minute) increases Hemolysis
• IV product manufacturer does not support blood draws from IV equipment.
• Medical center IV and Phlebotomy Experts do not teach or recommend IV Draws
• Most ED staff worried about sticking the patient twice (once to set-up an IV and again to draw blood through venipuncture) - creating a negative experience for the patient. However, almost 30% of the time they did stick people twice due to Hemolysis which created a 56 minute delay.

We embarked on a pilot project after the event. Our intent was to stop collecting blood specimens at the time of IV insertion. To accomplish that goal, the ED techs (who only can draw via venipuncture) would draw all of the blood. Prior to the implementation, our phlebotomy team retrained the ED techs according to the Pathology venipuncture standards. Once this process was in full swing, the plan was to review all specimens from the ED and check the tubes for hemolysis and feedback the data to all of the parties on a daily basis. Each day the lab reviews over 100 specimens collected from the ED needing potassium results. We post the daily hemolysis rates and investigate each hemolyzed specimen with the RN caring for the patient. The average hemolysis rate over the past few weeks is now averaging 6.5%. As of this past Monday, this trial becomes the official way we draw blood in the ED.

We realized these incredible results by walking in each other’s shoes, touring each other’s areas, and understanding impacts by using data. We talked to each other and brainstormed together and cooperatively moved forward. Lab staff now attend the ED huddles so continued learning and sharing can take place; even after we solve the hemolysis problem.

In the end, it was our collective actions, willingness to put departmental issues aside, strong desire to improve the patient experience, and ultimate respect for each other’s talents and expertise that propelled our project forward.

Name, Role, Title
Gina McCormack, Pathology Admin, Operations Director
Kirsten Boyd, ED Director, Director of ED
Larry Mottley, ED MD, Quality MD
Jane Dufresne, ED CA, Clinical Advisor ED
Steve Wood, ED RN, RN Staff ED
Tammy Galloway, Chemistry, MGN Chem
Manny Alves, Lab West, Lab Supervisor
Blanche Murphy, Venous Access Nurse, RN Staff ED
Susie Fontes, ED RN, RN Staff ED
Pam Hulme, Phlebotomy, Customer Service manager
Kellie Glynn, ED RN, RN Staff ED
Christine Yennaco, ED Tech, Staff Tech ED
Brian Orsatti, ED Tech Supervisor, Tech Supervisor
Alice Lee, Lean, Office of the President
Kimberly Eng, Lean, Office of the President
Brandan Holbrook, Lean, Office of the President
Bonnie Baker, Lean, Office of the President

Sunday, November 2, 2008

Is unilateral public disclosure really necessary?

Regular readers will know that BIDMC is remarkably open in publication of clinical outcomes, taking transparency to a place seldom seen in American hospitals. Our governing boards are comfortable with this and are strongly supportive even though it occasionally leads to publicity of the sort that can sometimes get them nervous.

That happened a few weeks ago when one of our Trustees asked the question explicitly, saying "I understand the power of transparency within the organization, but is it wise to be so open about clinical outcomes with the public? Can we be sure that the incremental value, in terms of staff performance within the hospital, merits the exposure of our warts and flaws to the broad public?"

This is, of course, a legitimate question, in that we live in a very competitive health care environment here in Boston, and we certainly do not want to engage in behavior that would undermine the reputation of the hospital and perhaps hurt its financial performance. My answer had three parts: First, an acknowledgement that what we are doing is an experiment; second, that there has been no evidence at all that it has adversely affected our clinical volume or our standing in the marketplace; and third, that studies of organizational change suggest that public disclosure has extra motivational value in encouraging people to engage in continuous process improvement.

Now frankly, I had no empirical evidence of the last point but was relying on presentations I had heard from MIT's Steven Spear and IHI's Jim Conway on this topic. I trust both of them as experts in this field of process improvement, and both have been extremely helpful to our hospital as we proceed with this adventure.

Then, this weekend, I read a somewhat old article that supports this proposition. It is from Health Affairs and is entitled "Hospital Performance Reports: Impact on Quality, Market Share, and Reputation," by Judith H. Hibbard, Jean Stockard and Martin Tusler. You can read it here. The article concludes, based on several hospitals' actual outcomes, that "making performance data public results in improvements in the clinical areas reported upon."

Intuitively, this feels correct for lots of reasons, but it was interesting to see research supporting the conclusion. I wonder if people reading this know of other studies that reinforce or undermine that result. Please comment.

As a final point, I also want to note that in today's electronic environment, it is virtually impossible to keep data "private" if it is sufficiently distributed to the hospital's staff. So, if you don't want the public to know, don't even tell your own people!