Thursday, March 08, 2007

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:


Anonymous said...

The Quality and Cost Commission created by Chapter 58 is taking proposals for quality metrics. Have you submitted this idea, or any others?

Anonymous said...

May be the best post yet. Keep at it!

Anonymous said...

Sounds sensible, but what about the NY Times story just the other day on how rapidly the various hospitals react when someone enters the emergency room with what looks like a heart attack. Boston Medical Centeras way ahead of the BID (and all others in the Boston area). Are we working on this (and other things we are low on on the HHS measures).

bladelink said...

Good for you for making your results public. I agree that it's a key first step in making improvements. It's also an important step closer in letting people buy health care the way they buy everything else -- based on quality and price, or total value.

Anonymous said...

While "zero line infections" sounds like a good idea, life is not that simple. As a Critical Care Fellow, I am passionately interested in line infections, and I believe that the number of line infections should be zero, for patients we are continuing to try to return to his or her life. However, often we will draw blood cultures when a patient first enters the Unit, and then, in concert with the patients known prior stated wishes and his or her family, we decide to withdraw active medical intervention.
Then a blood culture comes back positive.
The compassionate and correct thing to do at that point is to leave the line in, not to change it and subject the patient to a needless and painful procedure. Thus in my unit, I will never have "zero line infections", and I think that is a marker of compassionate, sensitive care, not carelessness.

The Critical patient said...

The more of this kind of publicity that can be generated the better, because it leads to some debate about patient care, as evident here, some agree, some don't, but that is OK, as long as everyone is talking about making it better.

I started a blog on patient informatics the other day, because as much as you fill a void with your blog, I decided that a patient informatics focus and advice could be useful to someone trying to make a healthcare decision. Check it out!

Foster Kerrison
The Critical patient.

Anonymous said...

There is support for your approach in the recent book "Redefining Health Care: Creating Value-based Competition on Results" (M.Porter and E. Teisberg, Harvard Business School Press, 2006)
It says, in part; "The quality and cost of health care have suffered mightily from the lack of meaningful results information."(p.55)
"The nation can no longer afford to wait for perfect information to be developed. Nothing will drive improvements in information faster than making existing information widely available. A concerted strategy to develop and disseminate comparative information on results is an urgent priority...." (p.60)
Parenthetically, they mention your institution favorably on pp. 164 and 165.
I recommend this book to all. Its central precept is that competition in health care is essential, and all players should be evaluated on "value" - defined as health outcomes per dollar expended.

VtSki56 said...

This post resonated with me because you understand that you are truly on "a journey to zero." I first heard that phrase as an engineering COOP, working for an industrial gas company (Praxair Inc.). Their stated goal was to reduce injuries to zero they also firmly believed that there was no such thing as an accident. The CEO at the time, Dennis Reilley was adamant that every employee must return to their family that evening and he followed through on this belief. Through linking bonuses and profit sharing to safety for every employee of the company, holding quarterly safety meeting, and beginning every meeting at every level with a safety message he effectively created a culture where safety was the top priority. Adverse events, again, very few things are accidents, and near misses were investigated. Controls were put in-place through engineering safeguards, additional training and communication to prevent similar occurrences. As a young engineer I could not have asked for a better place to begin my industrial experience. After one year, I was fully engrained and remain engrained in the belief that every adverse event is preventable. Now as a not as young medical student I hope I this belief will dominate medicine in my lifetime.

Many will say you can’t compare medicine to industry; the medical complex is much more complicated, it would be impossible to control for every situation in medicine and achieve zero adverse outcomes. I don’t believe that, I have been in other companies who harbor the same feelings about industry and undoubtedly their injury rates are much higher then Praxair’s. Just because it is not easy does not mean it should not be done.

So this would be my challenge: Continue on your journey to zero with central line infections but expand. Zero lost work days due to back injuries, Zero lost opportunities for health care providers to wash their hands, Zero needle sticks just to name a few. The beauty of your position is that you can not only affect the numerous patients and employees today but also in the future at many hospitals, because if you can create an atmosphere which believes in zero young medical students, residents, nurses who are trained at your hospital will bring the belief in zero with them for their entire careers.

Paul, thank you for your blog… It is a real pleasure to read.

Peter S. said...


I have just found your wonderful blog. Don't always agree with you but the dialogue is interesting. In reading through a number of posts at one sitting--including ones about hospital acquired infections, apology and medical malpractice, I wondered how BIDMC handles situations in which one of your patients dies from a HAI? Do you apologize? Do you hold your breath and hope the hospital isn't sued? Do you tell the family these kinds of deaths just happen? How are you thinking about the intersections of these issues?

Abby said...

Did Matthew ask you before he published your piece. He took one of my comments on Massachusetts health reform and published it as a breaking news story without asking. Of course, I didn't mind, but I wondered whether you were aware of your "promotion."

Paul Levy said...

Yes, he did. But, I view all postings as fair game for reprints anywhere.

Anonymous said...

It is important as as pushes for increased volumes and procedure numbers, that inappropriate procedures are not encouraged or tolerated,
This is a time where hospital administration needs to provide close oversight over its physicians. I wanted to bring your attention to what has become common knowledge in the medical community about inappropriate procedures in certain divisions. I can speak of one particular physician who shamelessly does unnecessary procedures opening arteries right and left) and self refers procedures where one is judge jury and executioner, but I am certain others exist.
The administration should provide more oversight via several mechanisms including random external peer reviews, billing inquiries, ethical interviews at a time of increasing productivity pressures

e-Patient Dave said...

Finally found a capture of the clip that doesn't have the background static:

e-Patient Dave said...

Heh - all this led me to rent the movie from Amazon to watch on my snazzy wifi-equipped TV (cough, vintage 2011...). The "these things happen" scene happens at 16:30.

Then around 29:40 Jonathan Winters says this, which might find a home somewhere else on this blog:

"EVERYbody has to pay taxes. Even businessmen - that rob and steal and cheat from people everyday, even THEY have to pay taxes."

Some might say Wall Street fixed THAT one.

(Boy, there's a huge amount of sexism - and I don't just mean cheesey peeking at skirts, I mean outright insults to women.)

Paul Levy said...


Thank kind of sexism used to be considered funny.

e-Patient Dave said...

I know. Same sort of thing as in the final scene where Eddie Anderson (Jack Benny's "Rochester" valet) goes flying through the air and lands in Abraham Lincoln's lap.

It was a REAL time trip to watch that film - all 2:40 of it, including a 5 minute black-screen intermission, with ditty singing "Have a Coke or a smoke, or remember a joke"... not a seatbelt to be found in any car, and Jim Backus playing a pilot how chides Mickey Rooney for not making Old Fashioneds right.

I might go so far as to say that film was a snapshot in time - late-in-life cameos from dozens of actors / actresses going back as far as vaudeville, and released months before the Beatles hit and all hell broke loose.

As I say, I'd never seen the thing before. In one sense it's a really good lesson on how thoroughly things CAN change in 50 years.

e-Patient Dave said...

Oh yeah -

With all those unthinkable differences, four things still stood out as identical to today:

1. Coke signs (identical!)
2. The Budweiser logo
3. Casual discussion of corrupt officials
and, of course
4. "These things happen!"