Sunday, August 03, 2008

Next stage of transparency

Several months ago, we announced some audacious goals for BIDMC that were established by our Board, including elimination of preventable harm by 2012. We also promised that we would publish our progress towards that goal. We have now set this up on our website here. You can watch to see our data each quarter in each of the several categories listed.

When we were getting ready to publish these numbers, some of our trustees asked if we could put the numbers in terms of the percentage of cases in which there was preventable harm. By that measure, the number would be very, very small, about 40 cases out of over 200,000 in a calendar quarter, about 2/100's of a percent.

We said, "No, the point is to emphasize that each of the case involved an actual human being." Describing them as a percentage would dehumanize the physical impact on a real person, someone's mother, father, sister, or brother.

Last week, I was invited to give a lecture on this topic at the Harvard School of Public Health, and a different question was posed by a doctor in the class. "How can you set a target of zero," he asked, "when we know that zero is impossible?" I replied, "Putting aside the question of whether zero is impossible, the most motivational target is zero. If you say that we are trying to reduce, say, infections by 20 percent per year, people will feel satisfied if they meet that target. The idea is to establish creative tension for the organization by adopting an audacious goal. And, by the way, in certain areas, other hospitals have shown that zero is attainable for extended periods of time for certain types of error-avoidance."

At the other end of the spectrum, we are taking criticism from some people who see an inconsistency between these efforts at transparency and our lack of discussion or disclosure about particular cases. But we need to do that for reasons of patient privacy or for other legal reasons. For example, when a malpractice case is filed, we cannot and will not discuss that case publicly. For one thing, any comment we make can be construed as a violation of the patient's privacy. For another, as any lawyer will tell you, it is simply bad policy to discuss issues of this kind of litigation in a public forum. The plaintiff's attorney faces no such constraints, of course, and might perceive some benefit in holding a press conference to discuss the case. While we understand a reporter's desire to write a balanced story, our reply usually has to be, "No comment."

But outside of a particular lawsuit story, what are we going to say and disclose about all these cases of harm that are summarized on our website? The answer is that it depends. You can see from the chart that there are currently over 100 cases of preventable harm per year spread over several categories. As we have recently, when we think a specific case warrants wide public disclosure to help our staff be alert to a major challenge or teaching opportunity, we will give it wide circulation. Other specific cases will be given more limited distribution among our staff, consistent with their value in teaching about the need and means for quality improvement in a given sector of our hospital. And, in other situations, a pattern of several cases of a certain type might be presented to particular segments of our staff as a warning of a problem area.

We understand that our inclination towards transparency will garner criticism from some who think we are not being transparent enough when they have an issue or curiosity about a particular case. That is a by-product of what we have chosen to do, and we accept that.

Another by-product is that publication of these numbers may give the impression that we harm patients more than other hospitals. After all, we publish our numbers, and they do not. And many cases we publicize to our staff will inevitably be considered newsworthy by the local media. This, in fact, is why doctors and hospitals often don't like to talk about this stuff. Fundamentally, they don't want to be judged by the general public and the media, whom they deem to be unqualified observers of the medical scene.

Anyway, I want to assure you that there is no indication whatsoever that we harm patients more than other hospitals. (In fact, we know that our figures for certain types of hospital acquired infections are well below average.) But please remember that every study or analysis ever done indicates that hospitals rank highly among the country's public health hazards. Don't think that you are more safe in a place just because they don't talk about their errors. We believe that the only way to improve in this arena is to be open and honest about your mistakes and thereby enable people to learn from them.

16 comments:

Jennifer said...

Hi Paul,

I couldn't find a way to contact you on the site, so I apologize for using the comment form to ask you a question.

I came across your blog and I have a blog at www.nursinghomesurveyor.com that is about nursing homes, hospitals, and other health facilites from a surveyor/investigator perspective. I think it would be beneficial for us to exchange blogroll links. Please let me know if you are interested. If you are interested, I'll post your link on my site right away.

Thanks!

Jennifer

www.nursinghomesurveyor.com

Paul Levy said...

Thanks, Jennifer. Done!

Anonymous said...

Dr Mr Levy, i am enjoying your blog and thanks for answering a question I was having as to why the hosp was not acting on recent newsreports about a case. i now have clarity and your blog does help clear those questions.

Anonymous said...

Given that the lawsuit in the matter you allude to was filed a good month after the transgressions, which led to the firing of an impaired surgeon and has prompted at least two state investigations, how do you square this time lapse with your avowals of immediate and personalized transparency toward patients and others concerned with the hospital and its performance?

Paul Levy said...

I was not referring to any particular lawsuit in this post. To do so would contradict the point I have just made about not discussing lawsuits. Accordingly, too, I will not respond to your question.

Anonymous said...

I would point out to anon 5:00 that lawyers are the direct cause of lack of transparency in many industries, not just health care. They invariably advise their clients not to discuss anything with anybody, more as a self-protective mechanism than anything else. This could be called "defensive lawyering", covering the attorney's rear end to avert any accusations of malpractice. Just like 'defensive medicine', huh?
The other issue is that the media often pick and choose which aspects of a case they will emphasize, thereby creating a false impression of the situation.
Having been on the inside of some of these situations on the medical executive committee of a hospital which wound up in the media several years ago, I can vouch that Paul hasn't much choice in this matter.

Our society's universal suspicion of cover-ups since Richard Nixon is understandable but not always accurate. I suggest you look to Paul's record of transparency throughout this blog to make your judgement.

nonlocal MD

Scott Hodson said...

I work with hospitals around the country, and must say that your approach to transparency is one of the best I have seen. The topic is prominent on your website, and now reporting of the incidence of preventable hospital acquired conditions ... that is terrific.

Your organization clearly understands that a strategic investment in process, infrastructure, organizational talent, and culture change required to achieve transparency and have demonstrably higher quality and patient safety can have a positive ROI. One client of mine undertook a Quality Revolution three years ago. Since its inception: system market share is up over 5 points, cost is measurably lower in areas where PI teams have attacked more serious “gaps”, and in a recent study conducted by the Network for Regional Healthcare Improvement, which combines Hospital Consumer Assessment of Healthcare Providers and systems scores with CMS clinical quality data, they went from “middle of the pack” to #1 in the country. (Mayo was #2.)

I hope that in the future you will comment on the impact you believe BIDMC's quality and transparency orientation has had on your market competitiveness.

jeff said...

Hi Paul,

I've enjoyed reading your blog for over a year now. I am in school right now with the intention of working in your capacity at some point in the future.
I just read your 'Nut Island Effect' article for a class of mine. Can I ask, how and when did this 'effect' become clear to you?
thanks!

-Jeff

Anonymous said...

i'd like to point out to nonlocal MD that if he took the time to read the background of a particular case already in the public domain hereabouts, he would be aware of overt transgressions that precede the arrival of lawyers in the matter by three-plus weeks. thus, here is a case where transparency at the get-go would have cleansed the slate before legal redress was sought. which is why the back-patting contortions on this blog are especially aggrieving to those who have followed the matter.

Anonymous said...

anon 5:55;

Since I am nonlocal, I do not follow the Boston news scene by definition and therefore have no clue as to what you refer. I am merely pointing out that whatever case you are talking about is by no means unique to Boston. I do not know Paul personally, but have expressed many times before that I wish he had been the CEO at my hospital system, far from Boston. Be careful what you wish for.

Taki said...

Hi Paul,

As always, a pleasure reading your blog. One concern that crossed my mind - and perhaps I haven't done enough of my homework here - but I would be worried about the preventable medical errors that occur in a hospital but aren't identified. It would seem to me that given the complexity of providing clinical care that there could potentially be many cases in which a patient is harmed but, for any number of reasons, the harm is not identified by medical staff or the patient's family.

Any thoughts here?

Thanks again,

Taki

Anonymous said...

I would like to ask about BIDMC's "whistle-blower policy". Does BIDMC have such a policy, what protection does it provide, and does it go far enough to enable staff to stop a patient from being harmed? How would an employee working in an OR be able to use this policy in real-time without leaving the OR or abandoning the patient?

Anonymous said...

Comments from a 25 yr+ experience as an OR Nurse Leader: (this was modified from my original post on the Globe's White Coats Blog)

THESE ARE GLOBAL COMMENTS: Which are not meant to imply what BIDMC does now; or did with any particular case involving a wrong site surgery. As an OR Nurse my prayers & concerns go out to the patient & family of this case; AND especially to the OR surgical team directly involved in this patient's care. It is my hope that each one of you is getting the support you need after this event. As hospital leaders we must also recognize that there are "other victims" with tragic medical errors, the staff directly involved in this patient's care. I don't have a citation readily available while I blog; but do recall research validating the development of PTSD after being involved with a medical error. With today's technology, information about such events traverse the globe in hours. Preliminary details are released WELL BEFORE a full root cause analysis can be scheduled much less conducted. To continue to maintain a healthy patient safety culture extreme care must be focused on the aftershock of the event and rumor control. I totally agree with BIDMC'S commitment to transparency, as this helps to take the stigma out of human error and provides an environment where all HC members feel safe to report errors.

Mr Levy, you & your organization are truly early adopters and are setting great examples for HC organizations across the country to emulate. Realizing at the time of your initial post regarding the Wrong Site Surgery, all information, details, etc were not fully vetted... and due to our legal system some of this information may have become protected or gagged. Additionally the readers must also understand that HIPPA, a federal government law protecting the patient's privacy with respect to healthcare information, also may have limited the degree, timing and amount of information BIDMC can legally provide to the media. With this level of understanding of the relatively limited amount of public information available, consider the following comments.

Not one surgical team member (surgeon, anesthesia, nurse, scrub tech, etc) comes to work in the morning desiring to harm a patient. Research has shown it is not the surgical team member who makes the mistake, it is a failure of SYSTEMS.

In getting a patient ready & to surgery, there are many different systems operating, and hand offs with many different people communicating information..... in other words many chances for a breakdown in the system such as a piece of information not being typed into a computer correctly; that can happen.
 Am I justifying or trying to make light of this tragic error? No absolutely not, many hospitals are calling this a NEVER EVENT, or some refer to the time out protocol as RED RULES, meaning without exception the policy must be followed to the letter by ALL MEMBERS. It has been my experience since the Universal Protocol was crafted by the JCAHO in 2003 many times ALL members of the surgical team who preform the "time-out" do NOT have same attention to detail, fervor, or belief in the effectiveness in this process. Please note that I have purposely not specified which members do and which how do not, as in my opinion the resistance to adoption and adherence to the protocol is not endemic but epidemic.


Am I justifying or trying to make light of this tragic error? No absolutely not, many hospitals are calling this a NEVER EVENT, or some refer to the time out protocol as RED RULES, meaning without exception the policy must be followed to the letter. I applaud BIDMC's audacious goal of ZERO PREVENTABLE HARM EVENTS BY 2012. WHAT A GREAT stretch goal for your team to lock-in on! I also agree with the federal and state regulatory stances in some states to deny reimbursement to hospitals for care rendered involving a patient with a wrong site surgery.

It is my opinion that this will provide the much needed momentum to enable hospital administrators to provide the teeth needed for the OR leadership to enforce compliance following the protocol. I have heard anecdotally of surgeons who refuse to do the time out stating "this will never happen to me I have been a surgeon for 20+ years..." Such was the case at a Rhode Island hospital last fall. These are the exception, as there are also many more surgeons who are advocates of the protocol & will partner with nursing to help get their colleagues on board. Additionally in the spirit of transparency, their are a few nurses and anesthesiologists who may not respect the need for the time out & conduct their own abbreviated versions as they too think "it will never happen to me".

I am familiar with the tools out there to help the hospital leadership to determine if a medical error was the direct result of a human error, or a systems issue; versus neglect or wonton failure to follow hospital policies. It is great that you included a post talking about Just Culture, as today's healthcare consumer does not understand this, and as you have said neither does our justice system. With this all being said, if a medical error is directly traced back to a member of the surgical team conscious decision NOT to follow the policy, the James Reason Model would state that this person is culpable for their act(s) and could/should be punished. It is important to note that a Just Culture is not a Free Get out of Jail Card, nor does it render a HC team member "Blame Free"; which was an earlier term frequently cited in the safety community.

I feel compelled to add one caveat here, a bit of unsolicited advice for all hospital administrators reading this blog: after crafting or reviewing a superb Universal Protocol Policy (which I would recommend covering all departments it covers in one policy, hence only ONE place to find it), have your legal & risk folks sign off on it; then have ALL HC providers working in your organization review it and sign a document attesting their receipt, understanding of it, along with their intention to follow all portions of the policy. This may sound a bit draconian, trust me it is not; as I have had worked with an institution after a wrong site surgery event, during the Root Cause debriefing; the surgeon had moved & did not get the updated policy; when a nurse reviewed the policy a week prior to the incidence on the Intranet it was the OLD version missing key components, and anesthesia stated "I did not know I had to review hospital policies, we don't have any anesthesia policies, and it is the surgeon who conducts the informed consent". These signed documents of attestation must go on file with in the organization.


Even in 2008, with all the advances in technology, and many positive socio-cultural advances in society, the medical model retains its hierarchal structure, and some may go as far to refer to it as patriarchal. WIth that being said some members of the surgical team (Nurses, Surgical techs, Nurse Anesthetists) have been "pressured" by surgeons to not conduct the time out with the rigor it is due. Unfortunately many OR staff fear retaliation (loss of job, poor treatment such as horizontal violence; in future by the surgeon) if they attempt to stand up to the surgeon). Additionally many hospital administrators when enforcing the protocol are faced with some surgeons threatening to take their cases down the street if they make them comply.

Again let me stress that these surgeons are the EXCEPTION and not the norm. The lay public may not understand this pressure...think back to a time in your doctor's office when you wanted to ask them a question. You may have been frightened to ask, as you did not want to infer that you did not trust their skills. Not quite the same level of scrutiny or pressure, hopefully you get my idea. Additionally the surgical team is expected to move quickly between cases, so the patients don't wait long with out food, & the surgeon has a busy office full of patients waiting to see them.

JCAHO (Joint Commission of Accreditation of Hospitals Organizations) who surveys hospitals across the nation to ensure they are running safe; now says the majority of reasons wrong site surgeries continue to happen is failure of the hospital staff (doctors, nurses, anesthesia, surgical techs) to follow the procedure. 99.99% this not a negligent act by any member of the surgical team, it is a break down in systems; some of which is driven by the medical culture; excessive emphasis on efficiency causing team members to cut corners, highly complex delivery system with multiple hand-offs or communication points, and finally the lack of zero tolerance rules backed ( w/ severe penalties for any member of the team) by senior hospital administration.


Until ZERO TOLERANCE rules are in effect & are enforced to wrong site surgery (as well as other preventable medical harm events) will continue to happen, even in one of our best hospitals like BIDMC.


So as to not to appear pointing fingers just at Surgeons, my fellow OR nursing leaders must back their front line care givers. However, I am not naive to think that is all that is necessary; clear policies that outline the specific steps must be crafted by OR Directors, who in turn will need to reference denial of reimbursements to their senior administration, to take the next step towards zero tolerance. The OR staff nurse, surgical technician, or Anesthesia assistant must feel empowered enough to start the time out if necessary or to correct a fellow surgical team member who is not in compliance. If we see a stranger abut to step into ongoing traffic, most humans would feel and act on the urge to prevent them from taking that step..... why should this be any different.

Having worked as a circulating nurse, I too have felt the pressure of a surgeon asking me every 1 to 2 minutes "can I bring my patient into the room now" and know how easy it is to give into their nagging. We have always taken pride in the fact that we are the patients advocate while they are asleep during surgery. I also know how second nature it is to ask the patient "when was the last time you had anything to eat or drink" everyone of us just does this every time......the Universal Protocol or Time Out needs to become an every day, every patient habit just like checking if they ate!

Hospital administrators need to understand the OR metrics better. I wish I had a dollar for every turn over time spread sheet I created, scrubbed, and presented! Best case scenario you can improve turnover time by as much as 2-5 minutes per case. the complexity of all the variables contributing to turn-over time is probably just as complex as a patient having surgery! So looking at some really simple numbers; if you shave 3 minutes per case on a Blocked surgeons room who averages 4 total hip replacements a day; you have saved 12 minutes of OR time. Yes OR time is expensive, however you can not schedule another OR case in that time frame. OR turn around time is more about perception, and efficiency in the operating room is impacted more by the following tactics: 1) on time first case starts, 2) accurate surgical scheduling, 3) Well run hospital run Pre-Admission Testing programs, with the highest % of all surgical patients going thru it; and 4) dedicated surgical teams to either a surgical service or surgeon. So Administrators give your OR nursing leadership a break and do not emphasize fast turn overs as this only increases chances for a poor hand off of key information. And when a surgeon or anesthesiologist comes complaining to you back your OR leadership team.

OR leaders out there a way to combat the turnover perception issues with the surgeons is constant communication. To aid in this there are many OR software packages that have patient tracking modules that can send text messages to phones, email or pagers.

Redundancy has been purposely placed throughout the protocol that is done from the time the patient decides to have surgery (by verifying the correct side/site) all the way into the operating room. At multiple points within the hospital before arriving at surgery to ensure nothing falls through the cracks. In the OR, when the final time out is conducted; the patient is asleep on the OR table, prepped & draped; and the ENTIRE team ACTIVELY participates; including ANESTHESIA; by stating patient name, date of birth, surgical procedure, side (if applicable) and site. the patient's position, and if all supplies are ready AT WHICH time the ENTIRE team visualizes the site marked by the surgeon (marked in the preop area before entering OR). The absolute last time the correct site/side is operated on.

OR nurses like to view the surgical team as an intra-dependent team, meaning that the surgery can not take place if one of the team members are not present. The circulating nurse is the 'conductor" in charge of keeping the harmony of the room, anticipating the need of the surgical team, and advocating for the safe care of the patient. Nursing plays a vital role in the OR and we need to empower the nurse at the bedside to "stop the line" if necessary.


Here Here for your audacious goal! Do not overlook the significance of changing the academic medical culture, so that ALL providers contribute on an equal level to the patient's safety. The days of the Captain of the Ship are almost gone, at least from a malpractice perspective... funny that the medical malpractice community has torn down this obstacle, albeit if it was driven by greed.

One last challenge: Why not list all of BIDMC's wrong patient, wrong procedure, wrong site/side surgeries (with the appropriate privacy data omitted), SEPARATE from the category entitled "Preventable Harm in association with surgery or other procedure"? It is the blogger's opinion that this is the most egregious error in the public & the medical community's eyes, which can help "normalize" the humanness inherent in our systems. We all know that the incidence of such events have been and continue to be under-reported; depriving the medical risk community to learn. This data could be aggregated over time; with key identifying data points omitted along with aggregated data of the lessons learned on your website? The lessons learned must be more specific than simply stating ' failure to follow policy". the medical community needs to know & understand the mitigating factors preventing compliance as well as best practice measures that have remediated the issue.

FOR THE READERS OF THIS BLOG:
Oh one last challenge...this is a bit more philosophical. Challenge your Nursing leadership (Nurse, Surgeon, Doctor, Anesth, Tech, etc) to come up with a creative way to directly observe compliance in conducting the timeouts in your organization that is not offensive, that will instill pride in performance, and let our patients know that it is done the same way, every time an invasive procedure is done in your organization

Finally One Last Comment for the JCAHO:
Re-write the Universal Protocol and make it more prescriptive (ie describe the redundant steps checking from the nursing unit, preop, into the OR) in the protocol while allowing for organizational/FACILITY/Infrastructure differences (ie; provider titles, caregivers involved, names of departments, or use of a hallway outside of procedure room if they don't have a pre-op area), and lastly be VERY SPECIFIC about who, what they actively do (ie say a script), exactly when the final time out occurs (ie patient preped & draped asleep on OR table), and EXACTLY what elements are checked during this final time out (ie if site is required to be marked, all members of surgical team at final time out must visualize this). Until this level is dictated by our regulatory partners in collaboration with all interested professional societies these events will continue to happen to our surgical patients.

Mr. Levy Keep up your blog and please keep pushing the transparency envelope

Vintage OR Nurse Leader

fun said...

Paul

I am very impressed with your organization's transparency. I am the administrator of a hospital on the West Coast and we have embarked on a similar journey after having Dr. James Rinertsen visit us recently. We are primed and ready to move in a very similar direction.

I will be in Boston at the end of the month and would love a chance to pick your brain over a cup of coffee. Thanks again for serving as a role model for healthcare delivery. Your hospital is very fortunate to have you on board. Let me know if you might have a few minutes.

Anonymous said...

My wife recently had CABG. Because of her clinical issues and our distrust of our local hospital, she went to a hospital about two hours away.

I was very happy to see that the ICU posted in a visible area their quality goals, benchmarks, and trends.

Contrast this with our local hospital (which I call Nosocomial General) where she has got MRSA and a decubitus.

Paul Levy said...

Jeff,

I noticed the Nut Island problem a year or more after I left the agency, when I happened to mention to an engineer friend how impressed I had been by the staff at that facility -- and he told me that the work they were doing there was wrong! At that point, I did a bunch of research and interviews and wrote the article and gave the phenomenon a name.