Dear JC, give everything away for free

An article by Nina MacLaughlin in the Boston Phoenix entitled "Unlocking Knowledge" reminded me of the extraordinary step taken by MIT a decade ago -- a decision to offer course materials online, free to the world.

Here are the introductory excerpts:

Back in 2000 . . . the MIT faculty had to answer two questions: how is the Internet going to change education? And what are we going to do about it?

Distance learning was about to take off, and there was money to be made. Some MIT professors were already in the habit of posting their course materials online so that students could access them informally. But when monetizing this practice became a possibility, people got concerned that the business model ran counter to the school's mission — a commitment to generate, disseminate, and preserve knowledge.

So they took a step back. "We said, 'Let's stop thinking about money," says Stephen Carson, the director of external affairs of MIT OpenCourseWare, "and start thinking about what we can do to create benefit.' " They asked themselves: what's the Internet good at? (Spreading information widely.) What's MIT good at? (The classroom experience.) The faculty drew up a 10-page report making a case for why the conventional distance-learning model wasn't the right route to take. On top of that report — a one-page memo with a bold statement: let's give everything away for free.

Wow. The result was OpenCourseWare, the Web-based publication of virtually all course content from the graduate and undergraduate subjects taught at MIT. Notes MacLaughlin,

The site now welcomes an average one million visitors per month with the tagline: "Unlocking knowledge, empowering minds. Free lecture notes, exams, and videos from MIT. No registration required." It's a system that means Kunle Adejumo, an engineering student at Ahmadu Bello University in Zaria, Nigeria, can supplement and complement the materials and experience he's getting at his own school, which has limited resources and computer access.

It also means that any interested human can click on the course offerings — pick, say, "Problems of Philosophy" — and select whatever lecture topic might be of most interest.

Let's now view a contrasting approach. The Joint Commission, the main accrediting body for hospitals, recently created a Leading Practice Library. This is an outstanding idea. As the commission conducts its accreditation surveys, it encounters many excellent practices in the hospitals it reviews. The idea of the library is to share these stories more broadly.

But read this description and note the implicit exclusion:

The Leading Practice Library is a complimentary tool available to organizations that are currently accredited or certified by The Joint Commission. The documents in the Library are real life solutions that have been successfully implemented by health care organizations and reviewed by Joint Commission standards experts. The Library was built from solutions that organizations have contributed that support patient safety and quality health care. By accessing the Library link, which is located on each accredited organization’s extranet page, users can browse through specific topics of interest related to their own organization and browse as many documents and topics as needed at any time.

Did you catch it? You have to be a subscribing organization to get access to these helpful stories. Why not, like MIT, open them up to the world? If the library would be of value to accredited hospitals, wouldn't it also be valuable to individual patients and consumers who are involved in their own care or who are working as advocates to improve the health care system in general? Would it not also be useful to private practice physicians who refer patients to hospitals, so they could ask possible referral sites if they have considered these best practices? And, of course, wouldn't it be of value to the thousands of doctors, nurses, lab techs, rad techs, trainees, and others in subscriber hospitals who do not ordinarily know (or even know to ask) the password needed to get into the JC's website.

Also, these case studies could provide fodder for fascinating academic work on process improvement. You could imagine the Joint Commission creating alliances with medical schools and the like to have professors and student study them and write journal articles or white papers that elicit even more interesting things from the cases.

Having met a number of the JC surveyors, I know that this work is an outgrowth of what they have been doing informally for a number of years--sharing the best practices they themselves observed or heard about from their peers. I would guess that the surveyors would be pleased to know that the results of their work are being more broadly distributed.

If that were not enough reason, let us recall that the JC does its work on behalf of the federal government, serving as the accreditation body for Medicare. As such, it is not just a private organization. It is more quasi-public in nature. How could we justify limiting the accessibility of government-sponsored work products in an era of transparency?

Finally, on the business front, when it comes to quality and safety, broader distribution of ideas and programs would also add value to accredited bodies for the fee they pay the Joint Commission. Look at Institute for Healthcare Improvement, with its absolutely free Open School, which gets tens of thousands of viewers. It has not hurt and has probably helped IHI's programs that are revenue producing.

So dear Joint Commission, take a leaf out of MIT's book. Give it away for free. Make it easy for anyone to read.

And if you really want to be social media savvy, check out this last thought from the Phoenix story:

What MIT OCW offers is the content. The school is now pairing with the social learning network OpenStudy, which offers the interactivity to create opportunities to engage with other learners. So when you're scratching your head over a single-variable calculus problem, you can connect with others taking the same course and puzzle through it together.

Imagine the potential!

Washington hospitals lead again

What is in the water out there in Washington? I have written before about the leadership displayed by the Washington State Hospital Association with regard to transparency and process improvement. Now they go and win the annual John M. Eisenberg Patient Safety and Quality Award from the Joint Commission and the National Quality Forum.

According to this release, "This organization is recognized for its Safe Tables Learning Collaborative program. The program provides the infrastructure for Washington hospitals to share experiences and learn from one other and from patient safety experts."

Bravo and congratulations!

The moral component to transparency

Many of you have asked if I intend to continue this blog, now that I am stepping down as CEO of BIDMC. Yes. (I'll have to change the name. How about "The blog formerly known as . . . " or just a simple "Not Running a Hospital"?)

Please expect a combination of commentary on current events and issues. But also please expect an occasional lesson or two from my experience of the last nine years, all offered in the hope of being helpful to others in the field. I apologize in advance if some portions seem self-aggrandizing or self-praiseworthy. I don't mean them that way, but sometimes, to be historically accurate, I'll have to include a few good things about myself!

Here we go. Act 2.

In a comment on a post below, author Charles Kenney asks:

Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

Back in 2008, the Boston Globe published a story entitled, "Errors test openness at Beth Israel Deaconess." There had been a series of errors at our hospital, and many in the city were questioning whether our policy of transparency with regard to clinical outcomes was sustainable. Some felt that it would inevitably result in a loss of confidence in the hospital, followed by a loss of business, and financial pressure to be less open about such matters.

I felt that transparency was essential as a way of holding ourselves accountable to the standard of care we espoused. I also believed that public trust would increase, not decrease, for a hospital that was open about its errors and its commitment to improvement.

But this had not yet had a market test, and so we were taking a chance (although we were already saving lives.) In later years, the strategy was rewarded in a business sense by the decision of Atrius Health to create a new clinical affiliation with BIDMC, transferring treatment of half of their patients from another tertiary hospital in Boston. I recall Gene Lindsey, Atrius CEO, calling me in March of 2009: "We really like what you are doing in quality and safety, process improvement, and transparency. That is consistent with our values. Would you have the capacity to receive a large share of our patients needing tertiary care?"

But that was later. At the time of this story, there were many doubters. How reassuring then it was for me to receive a number of comments that were helpful in maintaining my confidence about our approach. I want to share some of those with you now. As you will see, these observers nailed the issue, and I am grateful for the fact that these people contacted me at the time.

You need to understand that CEOs live in a somewhat isolated world, so this kind of feedback and encouragement is extremely important. (For those of you working in other hospitals, remember that!)

Dr. Lachlan Forrow, Director of the BIDMC Ethics Program, said:

Re today’s Globe:

There are few reasons as truly fundamental to be proud of being part of BIDMC these days as our ethical commitment to, and courage in, being “the transparency hospital.” If it weren’t hard, it wouldn’t be so important, or so worthy of feeling proud. One day it will be the ethical standard everywhere, in the same way as Beth Israel’s 1972 precedent in articulating and living by “Your Rights as a Patient” set an ethical standard every licensed health facility in the U.S. now emulates.

In our weekly meeting today of the core Ethics Support Service staff, we agreed we should prioritize in everything we do during FY09 the opportunities to building a BIDMC-wide for safety and for pride, and the challenges of maximizing those as the “transparency hospital” culture of openness, safety, trust, and pride.

Specifically we are including in this:

At each monthly unit-based ethics rounds asking staff to identify cases, ideas, and concerns related to building this culture at BIDMC, with emphasis on a “preventive ethics” framework;

Encouragement to each of our >60 “Ethics Liaisons” to incorporate the themes of openness, safety, trust, and pride in the FY09 “ethics project” each of them undertakes in their clinical or administrative area;

Including these themes regularly in our monthly BIDMC-wide Ethics Case Conferences and in Schwartz Center Rounds; and

Reviewing regularly in our monthly Ethics Advisory Committee meetings ways in which we can foster this culture at BIDMC.

Thanks, as always, for serving as out CEO (“Chief Ethics Officer”). Please let us know if you have any other suggestions for ways in which we can make BIDMC even more a source of pride for everyone here – staff, Board/volunteers, patients, and their families.

A prominent attorney in town wrote a colleague, saying:

Tough article but I think what he is doing is courageous and that he should keep it up. More hospitals should do the same.

A respected cardiologist from one of the other Harvard hospitals said:

Read the article in Globe today and want to let you know that I think what you are doing is exactly correct. The pressures must be enormous, but I'm sure you will keep doing what you are doing because it's the right thing to do.

A knowledgeable industry observer in Boston said:

I didn’t expect to see the article on you and BIDMC. I must say that the juxtaposition of your commitment to transparency against a series that will focus on market intimidation and control, left me even more proud of you that I normally am aware. I am confident that your courage will benefit the rich reputation of the BIDMC as well as paving a course of correction for the market.

My colleague Bob Wachter, at UCSF, said:

You’re a brave man, and I know that what you’re doing is right and making things safer.

A former state legislator said:

Stay the course buddy. No one ever said it was easy to do the "right thing" eh? You're a pioneer and I'm proud of you!

Steven Spear wrote a letter to the editor and sent it to me:

Paul Levy and his colleagues at BIDMC are exactly the right track in calling out errors, and they are setting an example that should be emulated energetically at other hospitals. Delivering care requires coordinating harmoniously an extraordinary number of individual disciplines. This means anticipating myriad interactions of patient, provider, place, and circumstance, and anticipating perfectly all circumstances is impossible. However, by responding when things go wrong, those working in and responsible for care delivery processes can see their vulnerabilities, identify their causes, and rectify weaknesses, leading to ever improving efficacy, efficiency, and responsiveness. This is not a hypothetical assertion: Order of magnitude improvements in care have been recorded in Pittsburgh hospitals, at Ascension Healthcare and Virginia Mason Medical Center, and elsewhere. Those hospitals not pursuing the same degree of openness are not any less dangerous. They are simply not admitting the reality to themselves, their staff, and their patients.

A local search firm consultant and former colleague wrote:

You continue to have my continued admiration for your openness and willingness to tackle some of the tougher issues. Have faith that your strategy will prevail!

The Vice President for Nursing at another tertiary hospital in Boston wrote:

I feel compelled to let you know how much I admire your fortitude around the safety issues you are so committed to.

Do everything in your power to keep BIDMC intact as you see it….your patients will reap the result!

One of our urologists wrote:

Just a word of appreciation and encouragement re the transparency issue. It's important, and eventually will benefit everyone. Congratulations on having the courage to keep after it.

One of our Nurse Practioners in Hematology/Oncology wrote:

My husband read this article on the Globe and forwarded it to me. He is a physician who now is only doing basic science at Harvard Medical Center. We often discuss about my life working as a nurse practitioner at BIDMC. I do tell him how great my working environment is and that we try our very best to be a honest hospital and staff to our patients and to each other.

Yesterday, after reading this article, he as once a resident and an ICU moonlighting attending for a year, was very proud of what you have achieved for our hospital. I wanted to say another thanks to your efforts and I am pretty sure that majority of BIDMC family support you all the way!

A member of the BIDMC Board of Directors wrote:

I believe we are changing the way medicine currently operates. I am so proud to be a part of this hospital. We are the future, cutting new ground, getting out the kinks so that others can follow. And they surely will be forced to do the same. I like choosing rather than being forced by outsiders. Trail blazers never have it easy. Who would want easy?

One of our young nurses wrote:

I am taking an Ethics course right now. We are talking about medical Ethics. The "CEO" of Beth Israel came up. All the recent stories came up (deaths, errors etc).

Our hospital was applauded for our transparency. The professor spoke and said that Beth Israel is "leading the way" towards a new future. I referenced your name, and blog, and said that I was proud to be employed by such a forward thinking institution.

What you are doing for our hospital is so important. It transcends beyond our own walls. It is aligning with a standard that I believe will eventually be embraced by the majority. I am not surprised that we are challenged the way we are with all the negative press. All great leaders are tested, as are their ideas! I believe that the good will always shine in the end...I guess we just need to be patient. I am learning a lot from this...

And, the most delightful was this note from my choreographer daughter, Rebecca, who was very used to getting critical reviews of her concerts:

I think that most of the health care industry is secretive and hard to navigate. BIDMC is friendly, the doctors are usually correct, and they treat people like humans. The main issue that you are dealing with, is HUMANS run the hospital and they are imperfect vessels capable of mistakes. These mistakes in this year are bigger ones, and because of your communication with the city and media people noticed. I mean, they notice all of the good things too...they just tend to forget because Boston loves scandal.

If your instinct tells you that total transparency is the right thing to do, which I assume is what it did, then continue being transparent, and just do your job to the best of your abilities. In my opinion, I think it's pretty great that you are willing to talk openly about what happened. Maybe people just want to hear that whoever is responsible feels badly about what happened.

The greatest piece of feedback I ever got was, "be cool".

Oh, and just remember, you are never as bad or as good as the newspapers say.

I love you,
Becca

The value of standard work

"The most important thing we can teach our residents and trainees is the value of standard work."

Imagine if that were the philosophy in every academic medical center. It is the philosophy at the Mayo Clinic, according to Dr. Stephen Swensen, Director for Quality. Dr. Swensen commented on these matters during last week's IHI Annual Forum. I was not able to attend his session, but a colleague did go and reported back to me.

For years, I have been hearing about the quality of care given at Mayo and was having trouble learning what distinguishes the place. I should have figured it out. The simple summary of process improvement is that you cannot design and implement improvement if there is too much variability in your process. Why? First, you cannot design an experiment for change unless you are confident that your change is being applied to a relatively uniform "prior." Second, you cannot measure improvement compared to a base case if there is not base case.
Dr. Swensen talks a lot about the "cottage industry" and "farmers' market" approaches to medicine, as opposed to the Mayo way of standard work, decision support, and forced protocolization. Mayo has a Clinic Clinical Practice Committee that has the authority to set practice standards and methods across the organization. When improvements are discovered, there is rapid diffusion of learning.

When it comes to residents, they must be bronze-certified through Mayo Quality Academy before treating patients. This includes training on simulators before being allowed to practice procedures (like central lines) on patients.

Dr. Swensen also discussed four conflicts in academic medical centers that prevent truly patient centered care:

• Physician Autonomy - As mentioned, a high variation environment is inherently unsafe.
• Financial conflicts - Some care receives higher payments; there are financial conflicts between the doctors and the hospital; and fee-for-service creates conflicts of interest.
• Research - The well-intentioned focus on the mission that "we're here to advance knowledge" can interfere with care.
• Education - The well-intentioned view that "we're here to provide training opportunities" lets trainees practice on patients and causes care to be organized around the training program, rather than vice versa.

As I heard this, I thought about our place. While we have instituted some standard practices, it is clear that we have not gone as far as we might. On the financial front, we have started to move away from fee-for-service, but there is not a uniform payment system across all of our payors. And his comments about research and teaching are often likely to be valid.

I will state immodestly that we are viewed as one of the leaders among academic medical centers with regard to quality, safety, and process improvement. If we still have so far to go, after several years of concerted effort, the academic medical sector as a whole has miles to travel.

Dr. Vollmer and his team continue to tell all

Transparency of clinical outcomes has now become part of the culture at BIDMC, and that is nowhere as evident as in our outcomes for pancreatic resection surgery. These are difficult procedures, where surgical skill matters, but where use of a standardized plan of care (or clinical pathway) makes a large difference.

Our website contains a clear exposition of the results in our hospital. As noted by Doctor Charles Vollmer in our Department of Surgery,

"This summary reflects our initiative for total transparency of the real outcomes from our practice which are available to anyone through our institutional website. We believe this is a unique approach in our specialized field of pancreas surgery, and I would even contend it is rare to see anything like this for any general surgical domains around the country."

Credit for this approach also clearly goes to Dr. Mark Callery, chief of our general surgery division, and also a major practitioner in this particular field.

You can find the website here. The new numbers are about to be posted. Here is a sneak preview, showing the changes from 2007 through 2010.

Volume of Procedures: 82; 73; 86; 89
Mortality Rate: 1.2%; 0%; 3.5%; 1.1%
Length of Stay (Median): 7.5 days; 8 days; 8 days; 7 days
% of Patients Requiring Admission to an ICU: 8.5%; 12.3%; 17.4%; 11.2%
Blood Loss During Surgery (Median): 300ml; 300 ml; 275 ml; 200 ml
% of Patients Requiring Post-Op Blood Transfusions: 14.6%; 26%; 12.9%; 19.1%
Reoperation Rate (within 3 Months): 6.0%; 6.8%; 7%; 3.4%
Readmission to Hospital (within 90 days) Rate: 13.4%; 25%; 29%; 11.2%
Central Venous Line Infection Rate: 0%; 0%; 1.2%; 1.1%
% of Patients Receiving Immunizations Prior to Discharge (for Splenectomy): 100% (all years)

As I have said previously with regard to another topic, if we can post these rates for BIDMC, why can't people from other hospitals? Why can't the insurance companies post them? Where are the public health advocates on this topic? The data are collected regularly by all hospitals. We must 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.

Some people have argued that transparency will lead to doctors trying to avoid the high risk cases. I know from personal knowledge of some of their patients that such is certainly not the case with Dr. Vollmer and his colleagues. Note, too, that they make no attempt to risk-adjust the metrics above. These are all-in figures.

No such thing as random failure

Joseph Gavin, Jr., who died in November, was an aeronautic engineer who was intimately involved in the design of the first manned craft to land on the moon. He was also a key player in the rescue of the Apollo 13 astronauts. He was a remarkable fellow, and I had a chance to hear a tribute to him during this past week's meeting of the MIT Corporation. (He was in the class of 1941.)

One of the quotes ascribed to him during the presentation was, "There is no such thing as a random failure."

In this discussion board, a commenter says, with regard to that quote, "Amazing when you look at things now, that in the avionics industry of the time 'random' failures were acceptable! As he says, there is (almost) no such thing as a random failure... Everything has a cause, and in a safety critical system (or one-shot system like this), every failure cause has to be designed out..."

It strikes me that there is a parallel with medical care. I have discussed the problem of "These things happen" that often characterizes the delivery of care. I noted:

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.

The science of process improvement can be applied to the delivery of care, as it has been to other high performance service and manufacturing industries. I hope my readers will excuse the degree to which I focus on this topic, but I cannot imagine a more important subject to cover.

This week, several thousand people will be attending the IHI Annual Forum to learn and trade information and stories along the theme of Taking Care. Maybe, if we learn well enough, we can say that "these things" no longer happen.

Here's Ethel Merman, to make the point in her own way. (If you cannot see the video, click here.)

Enthusiastic Transparency

The State of Washington posts a variety of information about hospital infection rates. The latest addition to this is the publication of surgical infection rates. The website provides data on infections following three important types of surgeries: cardiac, orthopaedic, and hysterectomies. The Washington State Legislature required the data to be collected and made public in House Bill 1106 in 2007 and House Bill 2828 in 2010. Here is a section of the press release from the Washington State Hospital Association:

“Washington’s hospitals are enthusiastic participants in providing this new information about surgical infection rates,” said Carol Wagner, vice president for patient safety at the Washington State Hospital Association. “We believe that public reporting helps hospitals improve, assists consumers in making good decisions about hospital care, and creates collaboration between hospitals and quality experts.”

“Hospitals are dedicated to the care and comfort of our patients. In most cases, the data show good results, though there are also areas for improvement. Our member hospitals are working hard to implement changes to stop surgical infections, and we expect the results to get better and better,” concluded Wagner.

Washington State’s infection reporting program is considered a national leader. The National Conference of State Legislatures highlighted Washington, along with nine other states, in its recent report, "Lessons from the Pioneers: Reporting Healthcare-Associated Infections."

Note, too, the publication of central line infection rates and ventilator pneumonia infections.

I like the sound of that: enthusiastic participants. Congratulations to the WSHA for their part in helping bring this about and to the Washington legislature for their leadership.