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.

Reducing Ventilator-Associated Pneumonia

Some patients go to the hospital because they have pneumonia. Other people go to the hospital for other reasons (e.g, stroke), are put on ventilators, and get pneumonia. We call this ventilator-associated pneumonia, or VAP. It is a big problem:

• It is common, with 10 to 20% of patients ventilated for two or more days;
• It is lethal, roughly doubling the risk of death;
• It is expensive, adding $20,000 to $40,000 in extra costs per case.

The good news is that it is often preventable, and we could be pretty good at preventing it if we took the right steps all the time. Our good friends at the Institute for Healthcare Improvement suggest the following "bundle" of steps to help avoid VAP:

1. Elevation of the head of the bed;
2. Daily "sedation vacation", i.e., some removal of sedation medication;
3. Daily assessment of readiness to extubate, i.e, don't keep the breathing tube in longer than necessary;
4. Stress ulcer disease prophylaxis, to reduce the risk of upper GI bleeding;
5. Deep venous thrombosis prophylaxis, to prevent formation of embolisms.

So, if you want to reduce VAP, you institute this bundle of of steps. But, like your toughest sixth grade teacher would say, "There is no partial credit!" Unless you carry out all five steps, you do not get a perfect score.
We started working hard on this problem last year at BIDMC. Why? Because we looked at our rate of this disease, and we were not pleased. Here are our compliance scores on the IHI bundle, after lots of analysis, training, and follow-up:

FY06 Q3: 79%
FY06 Q4: 81%
FY07 Q1: 88%
FY07 Q2: 92% (only includes January, through today)

This looks pretty good, right? It appears that we are making constant improvement. Not so. Unfortunately, the quarterly figures mask monthly variations:

April 06: 83%
May 06: 74%
June 06: 82%
July 06: 80%
August 06: 76%
September 06: 86%
October 06: 92%
November 06: 85%
December 06: 87%
January 07: 92%

Still, the trend is good, but the difficulty of carrying out the full bundle for all patients is real. For example, we have virtually 100% compliance with stress ulcer disease prophylaxis; but we do not always carry out a daily assessment of the readiness to extubate. On that metric, we have ranged from 88% to 98%. Sometimes, even when you know what you would like to do, the patient's condition or other exigencies make it impossible. Sometimes, even when you know what you should do, it doesn't get done -- for a variety of reasons: training, follow-up, schedules, competing demands of other patients.

Sometimes, there are unexpected reasons. At one point, we could not elevate some beds properly because other patient-related equipment was in the way! (We fixed that. And, yes, we bought contractors' protractors, the same ones used in construction to measure the angle of a pipe bend. How else will you know if the bed angle is correct?)

IHI has published stories of places with great success in this arena. Congratulations to those hospitals. We hope to be in one of those stories some day.

Why can't we do that?

A recent note from our chief operating officer to several of our clinical chiefs:

I came across the NEJM from 12/28/06 and the article and editorial on catheter-associated blood stream infections done in Michigan (my medical school alma mater!)

In that study of 108 ICU’s in Michigan, the institution of a set of evidence-based interventions reduced the median rates of infection per 1000 catheter days from 2.7 to 0 and the mean rates from 7.7 to 1.4. These impressive gains were held through 18 months of follow-up. If more than half of these ICU’s can virtually eliminate these infections, it seems that we should be able to do so as well. We had 2 months in the last year when we achieved this goal, but the last two months showed a sizable bump. Are we doing everything possible to eliminate these on a sustainable basis? What will we do differently going forward to hold the ‘zero rate’ for every month?

For the record, here are the numbers for BIDMC, updated from my posting of December 17, below.

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

We are serious about this and, like Michigan, we will share any lessons learned with others in the medical community. Recall that we engaged in an intensive training and improvement program in this arena, and the result we want is tantalizingly within reach. Nonetheless, as noted by our COO, we are not yet "best in class," which is our goal.

Here is what we are doing for now: Every single infection is now viewed as a sentinel event, for which we conduct a root cause analysis and from which we learn how to do better. Stay tuned to see how we progress over the coming months.

What Works -- Part 5 -- Team Training

We have all heard stories of cockpit behavior in an airplane that causes a crash. The navigator or first mate says to the pilot, "Watch out for that mountain." The pilot ignores the advice, and the aircraft ends up in flames. This kind of thing can happen in a hierarchical environment.

The same kind of thing can happen in an operating room, where the surgeon is the "pilot" and the nurses and anaesthesiologists are the support crew. Doctors, like pilots, are trained to be in charge and to make split-second decisions.

A few years ago, a series of errors and bad communication in our obstetrics department resulted in the loss of a baby and almost resulted in the death of the mother. For a department that had always prided itself on providing extraordinary care, the event was a shock and caused an intense self-evaluation.

Using the experience of the military -- indeed from those cockpit situations --the Department proceeded on a full-fledged series of courses in team training.

This was not a simple seminar or two. It was a process that took many months. After all, it had to break down barriers and behaviors that had taken years to develop. Nurses had to feel comfortable offering suggestions to doctors, and doctors had to learn how to hear the nurses' comments.

Here's an article that describes the whole thing. I urge you to take the time to read it. Our OB staff would tell you that it has changed their view of practicing medicine. They would also tell you that it has created unusual bonds of collaboration and friendship in their department, even for a group that had always had a strong group ethic. Most important, the program has actually had a measurable difference in clinical results. Our folks now participate in programs across the country to spread the word.

I wish I could tell you that we have taken this experience and have infused it throughout our own hospital. We have not, at least to the extent I would like. Not that we are not trying, but it turns out that the culture of each department and each division is a bit different, even within the same hospital. So it takes longer than you might expect. What might work in OB needs to be modified to work in surgery or orthopaedics. Even within surgery, what might work for the pancreatic surgery group -- see the November 27 discussion below on Whipple procedures (What Works -- Part 2) -- might not be quite right for the transplantation group. Like other medical centers, we are still feeling our way through this issue of the diffusion of practice improvements.

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.