Source material on quality, safety, and patient satisfaction

As a follow-up to the post below on the quality, safety, and patient satisfaction goals established by the BIDMC and BID~Needham Boards, I thought some of you might be interested in reading the material that led to the votes. It is a bit long, but descriptive of the issues that were considered. For some of you, this might be more than you want to know. For others, it might provide primary source information that could be valuable for your own institutions. My hope is that more hospitals will find themselves moving in this direction, and if the accompanying memo helps in your own consideration, please feel free to use it. (In the memo below, the LEAD program refers to a partnership between our hospitals and Blue Cross Blue Shield of MA, under which auspices the Board training program was held.)

In my next posting, I plan to give you a sense of the internal feedback that I have received since making this announcement.

To: BIDMC Board of Directors and PCAC Members
BID-Needham Board of Trustees and PCAC Members

From: Lois E. Silverman, Chair, BIDMC Board of Directors
Seth Medalie, Chair, BID-Needham Board of Trustees
Robert Melzer, Chair, BIDMC PCAC
Paula Ivey Henry, Vice Chair, BIDMC PCAC
Christoph Hoffmann, Chair, BID-Needham PCAC
Paul F. Levy, CEO, BIDMC
Jeffrey H. Liebman, CEO, BID-Needham
Ken Sands, MD, Senior Vice President, Healthcare Quality
Stan Lewis, MD, Senior Vice President, Network Development
Dianne Anderson, Senior Vice President, Clinical Operations

Re: LEAD Board Program Follow-up

Date: November 30, 2007

Dear Board Members,

Following our immensely engaging LEAD retreat last month, a group of us got together to draft a proposal on quality and safety goals for both hospitals for your formal consideration.

It was clear from the retreat discussions that there should be two ambitious overarching goals for both institutions: One for the quality and safety of care and another for patient satisfaction.

The group agreed that the Board’s role is to set an expectation for organizational performance for these two areas. Management is then expected to devise programs for achieving these goals, and to determine the metrics against which performance will be measured. We anticipate that the structure of the Board meetings will change to include systematic reviews of the programs related to these goals on a quarterly basis.

On the patient satisfaction front, we propose the following goal:

BIDMC and BID-Needham will create a consistently excellent patient experience. We will measure ourselves based on national benchmarks and, by January 1, 2012, be in the top 2% of hospitals in the country, based on national survey responses to “willingness to recommend.” For this goal, BID-Needham will measure itself against national peer group hospitals and BIDMC against a national dataset of all hospitals.

A top 2% goal means that effectively nine out of every ten patients rate the hospital in the top tier category on national surveys for willingness to recommend. BIDMC is presently performing in the top 10-15% range, on average. BID-Needham is in the top 30%. This goal represents a steep climb in performance for both institutions.

Formulating a goal for quality and safety proved more challenging, as there is a broad spectrum of definitions for harm and error, and consequently a broad range of implications for goal setting. First, there is a distinction between preventable and non-preventable harm. The latter type occurs when a patient is harmed as a result of a cause that could not have been predicted or prevented, such as the administration of a drug resulting in an adverse reaction that a patient’s history would not have indicated. Preventable harm, on the other hand, occurs when there is a failure on the part of either an individual or a system to render ideal care, such as when the administration of an incorrect dose or medication results in an adverse outcome causing actual injury to the patient.

It should further be noted that there is a distinction between harm and error, and that not all errors result in harm to the patient. For example, an incorrect dose of a particular drug administered to a patient might not affect the patient. The Institute for Healthcare Improvement (IHI) reports that only 10 to 20% of errors are ever reported, and of those, 90 to 95% cause no harm to patients. While much can be learned from all errors, many (including IHI) recommend that institutional governance focus on those causing actual harm. The theory is that by discussing openly those events actually experienced by patients, a hospital begins to foster a culture of safety that shifts from individual blame for errors to comprehensive system design and therefore lasting improvement in safety.

The first step in identifying harm is to develop a clear definition. Our small group reviewed several definitions of harm, ranging from IHI’s very comprehensive definition of all harm, including preventable and non-preventable harm, to the Ascension Healthcare System’s quality goal of no preventable harm. We felt that we needed to focus our resources where we can have the greatest impact, on eliminating preventable harm. At the same time, we wanted to maintain an organizational awareness of all harm, including non-preventable adverse events, and to seek to reduce our overall incidence of harm. The goal that we propose for quality and safety, therefore, is:

BIDMC and BID-Needham will eliminate all preventable harm by January 1, 2012. We will accomplish this by continually monitoring all preventable and non-preventable occurrences of harm, and continuously improving our systems to allow the greatest opportunity to reduce harm.

To determine and clarify how we would actually measure harm, we propose a modification of the categorization developed by the National Coordinating Council for Medication Error and Reporting and Prevention, known as the “NCC-MERP” Framework, to consist of the following categories of evidence of harm:

- Required hospitalization or extended hospitalization
- Permanent harm or disease progression
- Patient death

We feel that focusing on these categories will give us the greatest opportunity to achieve a meaningful and sustainable reduction in harm, while making the best use of our resources. The occurrence of harm that falls into any one of these categories would qualify for individual case review. In addition, while the boards of our institutions will focus on “preventable harm,” we also expect our respective PCAC committees to develop systems for periodic assessment and reporting on the occurrences of harm that are not within the categories listed above.

It is important for the Boards and the respective organizations to understand that these goals represent a far-reaching aspiration for our hospitals and for the level of care that we seek to provide. We must acknowledge that getting there will be a three to four year journey that will require further strengthening of our culture of safety and transparency. It will mean further bolstering our efforts to create an environment where caregivers feel safe discussing the occurrence of harm.

We discussed and propose the following timeline: At the December Board meetings, each Board will discuss and vote on these proposed goals and the attached resolution. Management would then be charged with outlining specific programs with measurable milestones to achieve these goals. In January, staff will be asked to present to their respective PCAC committee a timetable for these programs for the following year, along with a trajectory of performance towards the end goals. Upon review and approval by the respective PCAC committee, the action plans and milestones will be brought to the Board at its first subsequent meeting. A quarterly review of progress towards these goals would then become a regular element of each institution’s Board and PCAC meetings. In addition, the Compensation Committee of each hospital will be charged with building these quality and safety goals into the annual incentive plans for senior management.

We welcome your feedback and questions on these proposed goals, and look forward to our discussions at the December Board meetings.