Better grades on VAP

Good progress on implementing steps to reduce ventilator-associated pneumonia. Recall my story in January on this topic.

Our goal is to make sure we are carrying out the five-part Institute for Healthcare Improvement "bundle" to reduce the incidence of this disease. As I noted back then, if you want to reduce VAP, you institute this bundle 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. Here are the monthly stats:

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: 93%
February 07: 98%
March 07: 100% (to date)

In addition, our folks are working on instituting improved oral hygiene for these patients, another aspect of reducing the VAP problem. There we have gone from 58% (in April 06) to 91% (in March 07).

But, I want to make clear that these are process metrics. This differs from the central line infection story I have mentioned elsewhere, where we measure the actual number of cases. My folks tell me that actual VAP rates themselves may not be accurate because it is the most subjective of all nosocomial infections and the most difficult to track. We are currently engaged in refining our methodology for actual VAP surveillance.

Finally, I want to point out that this effort requires a variety of specialties to work together -- several types of doctors, nurses, respiratory therapists, and pharmacists. In this case, 14 people serve in the VAP Working Group. They develop protocols, data monitoring, and training programs and then have to persuade dozens of other people to engage in the program on a sustained basis. As I have noted below, the unique environment of academic medical centers creates interesting challenges in process improvement. These folks deserve a lot of credit for what they have accomplished, but the real test will be to see if they can keep it going. Knowing the people involved, I am optimistic.

These things happen

I was reminded of this by our Chief of Medicine. In the movie, It's a Mad, Mad, Mad, Mad World, Ethel Merman, playing Mrs. Marcus, says:

Now what kind of an attitude is that, 'these things happen?' They only happen because this whole country is just full of people who, when these things happen, they just say 'these things happen,' and that's why they happen! We gotta have control of what happens to us."

I am struck by the relevance of this to running a hospital.

Several years ago, we had that attitude in our hospital with regard to certain types of medical outcomes. For example, we were content with our level of central line infections because we were below the national average. After all, these things happen. Then our chiefs of medicine and surgery said, "No, they don't have to happen. When they happen, people die. We are going to insist that we achieve zero central line infections." And then they got to work. As I have noted below, it is not an easy problem to solve, but it is worth the effort, and you can improve.

One way to encourage organizational improvement is to publicize the results of your program. I have done that below for our hospital, and I have made the suggestion that others in the city could do the same. As I noted, I did not make the suggestion for competitive purposes -- after all, I don't know if our numbers are better or worse than those of other hospitals -- but because public exposure of all our efforts will drive all of us to do better. Also, it will build, rather than erode, public confidence in the academic medical centers in our city.

The response, as you have seen from the press reports, ranges from simple recalcitrance to technically sophistic arguments about comparability of data. Please, does anyone argue that the goal should not be zero? If it is zero, it does not matter whether the data is measured in cases per thousand patient-days, cases per thousand catheter-days, or just the raw number of cases.

We all keep track of these numbers in some form or another. We could easily post them in real time voluntarily on a website maintained by the state or an insurance company, along with our own explanations of how and what we measure. (And perhaps, over time, we will agree on what single metric is most useful.)

People can and will understand this. They already spend hours on the Internet reading medical websites. Why do we give them so little credit? It will demonstrate to the public that we care about this problem, and will show our individual progress towards our ultimate goal.

Finally, it will enhance the reputation and credibility of all of the academic medical centers, two aspects of our character that will be more and more under siege because of the broader problems of the health care system.

Addendum (November 2010): Here's the video clip from the movie:

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.

...

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.

...

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.”

...

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.