Tim's idea works!

I was a panelist today at the Ellison Pierce Symposium, a continuing medical education program run by Boston University School of Medicine. I had the pleasure of hearing a presentation by Timothy Babineau, President and CEO of Rhode Island Hospital and Hasbro Children's Hospital in Providence. Tim gave a concise and cogent description of the problems involved in implementing a strong quality and safety program in an academic medical center. There is a facetious expression that, "you've seen one academic center, you've seen one academic medical center," but I saw an awful lot of similarities between Tim's campaign and our own. Nonetheless, I'm always searching for new ideas, and he provided one: Start each meeting with "did we harm or almost harm a patient this week" as a way of emphasizing the priority of this topic in the institution and of keeping the issue in the forefront of people's minds.

About an hour after returning to BIDMC, I happened to have town meeting with a group of our housekeepers and food service workers, and I decided to try out Tim's idea. Now, please recognize that these meetings usually focus on lots of other things that do not include patient quality and safety. You might guess the normal topics -- salaries, benefits, transport to work, and such. Nonetheless, I started by reminding them of our overall goals of trying to treat patients in a safe manner, and pointed out that they have more direct contact with patients than virtually anybody in the hospital. I stated that the best way for us to avoid harm to patients is to call out lapses in our performance as we see them, and I promised that they would never get in trouble for mentioning these kinds of situations or incidents. Then I asked if they had noticed anything recently that raised concerns for them. The ideas and suggestions started to pour out! They demonstrated a remarkable sophistication and depth of understanding of concepts related to infection control and other quality-related protocols.

Thanks, Tim!

Thanks again, Emita

If you listen to segment 4 of Rachel Gotbaum's WBUR series, you will hear the story of how my mother took the time well in advance to make her own end of life wishes clear for us, her children. I wrote about this here a couple of years ago. As the fourth anniversary of her death approaches, I can think of no better tribute to her than the one provided by Rachel in her story. I like to believe that Emita would wish that her advice and example would prove helpful to you, your family, and your friends.

Swine flu resource center

A good resource on swine flu: Harvard Health Publications, produced by Harvard Medical School, has just created a flu resource center on its website, here. Among other things, it includes a Q&A with Dr. Anthony Komaroff, editor in chief of Harvard Health Publications, answering questions about the recent swine flu outbreak.

Going to Gemba

I have related below our efforts to spread the word about Lean techniques (aka Toyota Production System), for example to our residents, and apply them to the hospital setting. We're also conducting a similar set of training sessions for our senior management team.

For those not familiar with Lean, one of the concepts is "going to Gemba," where Gemba is the place that work is actually done, where value is created for the customer. By witnessing problems and work-arounds in real time, the team can have a better idea of how to solve problems to root cause and make incremental improvements in work flows. This is a critical part of a program of continuous process improvement, the theory behind BIDMC SPIRIT.

Here are (from top) Senior Vice Presidents Jayne Sheehan and Walter Armstrong following nurse Pam Moss, and Radiology Chief Jonny Kruskal following nurse Sarah DeCristoforo. The purpose of today's exercise was not actually to solve problems but to train our team in aspects of going to Gemba. As always, we all left with an enhanced appreciation for the dedication, outstanding work, and endurance of our nurses in the high-pressure environment of a medical-surgical floor.

Back to baseball

Boston is still pretty excited about this past weekend's sweep of the Yankees by the Red Sox, so I offer this post in commemoration.

Did I tell you how much fun our staff has providing first aid service at Fenway Park? Here's a picture of Michele Pruden, one of our new nurses, who finds that the placement of the red flower in her hair makes her fans/patients smile.

Also, a true story from Cyndi Casey, who covered the First Aid station this weekend. You might consider her a rabid fan:

And so I work the Sox Yanks Friday night game...very busy...lotsa business for ED at BIDMC--but I get a Yankee fan in the First Aid room with hypertension issues and etc....he had fallen in the men's room...needs to stay a while...ugh! I don't hold it against him for his loyalty to NY, but I dance around his stretcher and make him high five me when Jason Bay blasts his homer and I cheer to the old guy, "I LOVE MARIANO RIVERA." The guy cracked up. I love my job!!!!!!

New Schweitzer Fellowship blog

Check out this new blog from the Albert Schweitzer Fellowship.

Volunteer Recognition

BIDMC had 451 volunteers who donated 36,758 hours of their time and effort in 2008. We held a reception in their honor yesterday and presented awards for special contributions. Here are some pictures from the event.

The three women in red shirts are part of a program called "Neighbors Helping Newborns," which delivers handmade items and other donations to families with premature and other newborn babies. The young lady above them, Simona Tokchin, won the Youth Leadership Award. It is given to recognize leadership and service to a volunteer under 17 years of age who has donated a minimum of 100 hours.

The gentleman in the picture adjacent to Simona is Gerard Hayes, who won an award called the Debby Henry Award, named after a beloved former volunteer services director who died in 1995. It is awarded to the person each year who best exemplifies the spirit of volunteerism. It requires at least five years and at least 500 hours of service. Gerard helps out in our pastoral care and education program.

The group of three people are volunteers who help run the volunteer service office. Stanley Klein, seen alone, is active in our Prostate Support Group, and received recognition for 15 years of volunteer service. Near the top, you see Rodney Latney and Stephanie Harriston-Diggs, our director of volunteer services. Rodney won the Jack Arvedon award, named for a former volunteer who passed away recently. This used to be called our "rookie of the year" award and is given to someone who has contributed a minimum of 100 hours, and has shown the most flexibility, commitment, and positive attitude over their first year of volunteering.

At the very top is Cherry Moncreiff, one of the many other devoted people who spend time each week helping our patients and staff.

Quality of Death on WBUR

Rachel Gotbaum starts a new series on WBUR radio in Boston this week. It is entitled "Quality of Death: End of Life Care in America" and it will air for five days at 6:40am and 8:40am starting on Monday, April 27. There will also be a full Inside Out documentary with the same name that will air Sunday, May 3 at 8pm and Thursday, May 7 at 9pm.

Rachel has been working on this story for many weeks, and it is sure to be fascinating, thorough, touching, and important. If you can't hear it live, it will also be posted on the WBUR website and available to Utterli subscribers.

Listen to promo's below. First one is: "How much support does the American health care system provide patients as they face the end of life?" The second one: "Are American doctors too focused on extending the life of every patient?"

Blog Rally for Roxana Saberi and others

Thanks to T at Notes of an Anesthesioboist for getting this going. A group of bloggers is holding a blog rally in support of Roxana Saberi, who is spending her birthday on a hunger strike in Tehran's Evin Prison, where she has been incarcerated for espionage. According to NPR, "The Iranian Political Prisoners Association lists hundreds of people whose names you would be even less likely to recognize: students, bloggers, dissidents, and others who, in a society that lacks a free press, dare to practice free expression."

Hearing reports like these has prompted us to do a ribbon campaign. Blue for blogging.

Please consider placing a blue ribbon on your blog or website this week in honor of the journalists, bloggers, students, and writers who are imprisoned in Evin Prison, nicknamed "Evin University," and other prisons around the world, for speaking and writing down their thoughts. Also, please ask others to join our blog rally.

Yet another argument to support PCPs

I have addressed -- in the context of medical malpractice claims -- the importance of changing the reimbursement system to provide better compensation for primary care doctors. "The first line of defense in proper patient care is the primary care system, yet this portion of health care delivery is systematically undercompensated and undervalued in the medical payment spectrum. We have relegated primary care doctors to a triage function, requiring them to see a large number of patients in a short period of time."

Here's another reason. A story in today's Boston Globe by Liz Kowalcyzk cites a study of crowding and overuse of emergency rooms in Massachusetts. Dr. Peter Smulowitz, the study's author and an emergency room physician at BIDMC, concludes that the problem stems at least in part from the same problem: "We have to pay primary care doctors what they're worth and increase the network for primary care from doctors and other providers."

Caller-Outer of the Month Award #4

Our Board of Directors met yesterday and presented their fourth Caller-Outer of the Month Award. There were two recipients, Holly Dowling and Susan Keefe, nurses in our hematology-oncology outpatient clinic.

As I have noted previously, the purpose of the award is not to recognize someone who has solved a problem, but rather to recognize someone on the staff who has noticed a problem and called it out. The idea is that call-outs lead to root cause analyses that enable us to fix problems systematically rather than engaging in work-arounds. Our Board of Directors created the award as part of our BIDMC SPIRIT program to encourage people to call out problems to make our hospital a better place to work. (Beyond the recognition, the award is accompanied by two really good tickets to a Red Sox game.)

The story here was that Susan, a new employee, noticed that the rubber gloves she was asked to wear in the unit were thinner than gloves she had worn in her previous place of employment. She called this out to Holly, her group leader, and Holly then proceeded to investigate. It turns out that the supplier had mistakenly sent the wrong kind of gloves. Although other people had noticed that their gloves had changed, no one else had thought to call out the issue.

The problem is that OSHA requires a heavier grade of gloves for people working with chemotherapy drugs because of the potency of those drugs. If the medication gets on skin, it can be absorbed. In a clinic like this, with a number of younger women nurses who might be pregnant or might be planning to get pregnant, this could be particularly dangerous. The attentiveness shown by Susan and Holly quickly resulted in a review of the situation, determination of the root cause, and fixing the problem.

Cancer screening advice

Dr. Kevin Pho offers the opinion that not all cancer screening tests lead to better cancer treatment:

Here's a excerpt: "As much as we'd like to believe that early detection automatically leads to better care, that is not always the case. There cannot be a one-size-fits-all approach. Persuasive arguments can be made for and against screening, and the decision is a highly personal one. But patients must be better informed of the potential consequences either choice can bring."

Your thoughts?

Blood Donor of the Game

The American Red Cross, the Boston Red Sox, and BIDMC have had a partnership for several years to encourage blood donations in New England. It is called "Blood Donor of the Game" and honors a person in New England has donated blood. Winners receive two tickets to a designated game at Fenway Park, a special commemorative souvenir and a photograph, as well as special recognition.

The 2009 version of the program was announced at today's pregame ceremony. Here's a picture of Donna M. Morrisey, Director of Public Relations and Corporate Affairs for the Northeast Division of the ARC Blood Services; Jane Matlaw, BIDMC's Director of Community Affairs; and Guanah Davis, CEO of the Massachusetts Region of the ARC Blood Services.

I also caught this picture of Red Sox Manager Terry Francona, celebrating his birthday with two young fans at the park.

Trustees practice ethics

At BIDMC, we have a "bicameral" form of governance. Our 20-member Board of Directors has formal fiduciary responsibility for the hospital. They are aided by a 50-member Board of Trustees who run the various board committees (from finance to patient care to community benefits and so on.) The trustees meet quarterly as a group, too, to receive updates on hospital matters and to hear a presentation on some topic of general interest. In addition we also have a larger community advisory group, called the Board of Overseers, many of whose members choose to serve on board committees, too.

Today, a joint meeting of the Trustees and Overseers offered something new, a discussion on medical ethics led by Dr. Lachlan Forrow, Director of our Ethics Support Services. After Lachlan gave an ethics overview and introduction of our program, the Trustees and Overseers were given actual case studies to discuss and debate, much the way our staff does in our regular ethics conferences. Members of the ethics staff facilitated conversations at each table, and then Lachlan offered a summation.

Trustees and Overseers expressed great appreciation for the event, in that it provided an insight into the difficulties faced by caregivers when ethical issues arise during medical treatment. They also understood that they have an important role in setting the ethical standards for our hospital.

Update on BID~Needham expansion

A short story by Kathryn Eident on boston.com providing an update on the expansion of our community hospital in Needham. The highlight of the renovations is a 37,000 square foot addition that will double the size of the emergency room.

As noted by one of our staff: “In a period of five years the emergency room went from 9,500 patients to over 14, 000,” she said. “It’s not just a town hospital anymore. We’ve expanded services, we’ve seen a growth in the town and the communities around us and people are getting to know us better.”

Regular readers will recall that this expansion and the bonds to finance it were opposed by SEIU, both at the town planning board and in front of MA HEFA, one of the designated public agencies for coordinating the issuance of tax-exempt bonds by schools, hospitals, and other non-profit entities in the state. Fortunately, the highly professional staff and board at MA HEFA found no merit in SEIU's arguments.

By the way, some observers want to know if there any connection between MA HEFA's failure to knuckle down to the SEIU and the current administration's plan to merge the agency with another. SEIU members monitor every meeting of the MA HEFA board, and the union has made a habit around the country of trying to block public financing for hospitals they are trying to organize.

Would you take a one-time donation?

Much has been made about the fact that our staff have made sacrifices to help avoid layoffs here. In addition, many employees have made cash donations to help the cause.

But, here's the latest twist. A staff member writes:

At dinner last night I was telling my husband about all the meetings we’ve been having to think of cost-saving measures, and how we were hoping to get the number of possible layoffs down even more. My ten-year-old son (Mark, shown here) suddenly looks up, all concerned, and says, “What???” Then he very seriously said, “I’ve saved $10. Can I give that to save someone’s job?”

2009 Boston Marathon

Patriots' Day is celebrated as an official state holiday in two states, Maine and Massachusetts, (although also observed to some extent in Wisconsin), to commemorate the Battles of Lexington and Concord in 1775. After a reenactment of the battles, the next major event of the day (before an annual Red Sox game), is the Boston Marathon. Starting in Hopkinton and ending downtown, the 26.2-mile route attracts 25,000 official runners, several "bandits", and probably a million spectators.

In addition to individual runners, there are teams of people who are sponsored by friends and associates to raise money for a number of charities. Shown above are BIDMC's Doug Horst and Ruth Bisschop, who raise money for the American Liver Foundation.

I also show a couple costumed runners and our friends Sandy and Mike Feller, offering water to runners.

I wish for you that you may die on the journey

At a marvelous concert yesterday by Renée Fleming, 2600 of us in Boston's Symphony Hall heard her favorite collection of 20th Century music. One was a piece by André Previn, entitled "The Giraffes Go to Hamburg," based on a text by Isak Dinesen from her book Out of Africa. Excerpts:

In the harbor of Mombasa lay a rusty German cargo steamer, homeward bound. Upon the deck there stood a tall wooden case, and above the edges of the case rose the heads of two Giraffes. They were going to Hamburg to a traveling Menagerie.

The Giraffes turned their delicate heads from one side to the other, as if they were surprised, which they might well be. They had not seen the Sea before. They could only just have room to stand in the narrow case. The world had suddenly shrunk, changed and closed round them.

They could not know or imagine the degradation to which they were sailing. For they were proud and innocent creature, gentle amblers of the great plains; they had not the least knowledge of captivity, cold, stench, smoke, and mange, nor of the terrible boredom in a world in which nothing is ever happening.

Crowds will be coming in from the wind and sleet of the streets to gaze on the Giraffes....

In the long years before them, will the Giraffes sometimes dream of their lost country?

Where are they now, where have they gone to, the grass and the thorn-trees, the rivers and the waterholes and the blue mountains? . . . Where have the other Giraffes gone to, that were side by side with them when they set going, and cantered over the undulating land?

. . . Good-bye, good-bye, I wish for you that you may die on the journey, both of you, so that not one of the little noble heads, that are now raised, surprised, over the edges of the case, against the blue sky of Mombasa, shall be left to turn from one side to the other, all alone, in Hamburg, where no one knows of Africa.

Take me out to a different ball game, please

It would just seem wrong if I were not to mention yesterday's game between the Cleveland Indians and the New York Yankees, which ended with a score of 22-4, and included a 14-run inning. What a tough start for the pitcher, Chien-Ming Wang:

"In three starts, Wang is 0-3 with an earned run average of 34.50. He would need to throw 48 2/3 consecutive scoreless innings to reach a 3.79 E.R.A., his career mark before this season."

In a marvelous understatement, the manager, Joe Girardi, said, “We have an off-day, and it’s something we’re going to have to discuss, how we’re going to decide to do this. There’s some room to play with some things.”

All this prompted me to take a visit to the Baseball Almanac to see other record-setting innings. There are some with 15, 16, and even more, but most occurred in the early part of the last century. Not many in the recent past.

I've always been intrigued by the lopsided scores that can occur in baseball. The Red Sox, for example, started the season with an 8-2 pounding in Oakland, with 5 runs scored in the second inning. You can see shoulders slump and flat-footed playing after a big bad inning, and it is unusual to have a comeback after a team falls behind by that much. On the other hand, the Sox did that this past week, pulling out a 10-8 win after trailing Baltimore by 7 runs in the second inning.

The ancient rivalry continues this week when the Yankees arrive at Fenway Park. I am predicting much closer scores.

Stand by me -- Worldwide

Sent by a friend, and I am happy to share with those who haven't seen and heard it:

Here is a link to one of the best pieces of sound engineering work I think I have ever seen. It is a composite audio/video of song whereby additional tracks were laid in by different singers and musicians from different places around the world. The finished product is tremendous!

The song itself is that classic standard "Stand By Me" originally released in 1955 by The Staple Singers and released again in 1961 by the Drifters. This composite version is a real toe tapper.

Here come the sludge!

Another in our occasional retrospective pieces about my years (1987-1992) as Executive Director at the MA Water Resources Authority, the region's water and sewer authority. This came in the form of a Facebook message from George Goldstein, a former MWRA guy, who sent me the attached picture of me in the pit (before I was joined by Eric Buehrens and Lorraine Downey) to turn off the line that had been sending sludge into the ocean:

There's a whole story behind that. For a whole week they couldn't get the new sludge line to flow. I was always called in when all else fails. I told them to turn the main valve in the other direction. They said, "But it's a right hand valve"! I said, "Humor me and just do it". They turned it clockwise like I told them. Well, the contractor ordered a left hand valve by mistake. Meanwhile there were sample taps open all along the line to see where the problem was. The built up pressure let loose and everyone standing by was totally covered with the worst smelly digested sludge. It was a Kodak moment.

The story typifies the kind of ad hoc decision-making and process control that characterized the operation of the long-serving people in the agency and its predecessor agency, the MDC. I memorialized this kind of behavior in a Harvard Business Review article, "The Nut Island Effect," in March 2001. A precise of the article follows. Perhaps running a sewer agency is good training for running a hospital, after all:

The team that operated the Nut Island sewage treatment plant in Quincy, Massachusetts, was every manager's dream. Members of the group performed difficult, dangerous work without complaint. They needed little supervision. They improvised their way around operational difficulties and budgetary constraints. They were dedicated to the organization's mission. But their hard work led to catastrophic failure. How could such a good team go so wrong? In this article, the author tells the story of the Nut Island plant and identifies a common, yet destructive organizational dynamic that can strike any business. The Nut Island effect begins with a deeply committed team that is isolated from a company's mainstream activities. Pitted against this team is its senior management. Preoccupied with high-visibility problems, management assigns the team a vital but behind-the-scenes task. When trouble strikes and management is unresponsive, team members feel betrayed and develop an us-against-the-world mentality. They stay out of management's line of sight, hiding problems. Management, disinclined in the first place to focus on the team's work, is easily misled by team members' skillful disguising of its performance deficiencies. The resulting stalemate typically can be broken only by an external event. The Nut Island story serves as a warning to managers who concentrate their efforts on their organization's most visible shortcomings: sometimes the most debilitating problems are the ones we can't see.

Sloane Fellows Report

A few years ago, we created a program to provide advanced management training to upper- and mid-level managers who have the potential to be the next generation of senior leaders at our hospital. The Sloane Fellows are named after our last Board Chair, Carl Sloane, who has had a lifelong interest in providing mentoring and development to young folks.

The curriculum includes training of a variety of sorts both on and off campus, including presentation skills. The Fellows also engage in real-time management projects that can be helpful to the hospital. They must work in an areas outside of their usual scope of activities, so they are forced to stretch substantively and in terms of creating new personal relationships. At the conclusions, they deliver oral reports of their activities and summarize key lessons learned along the way.

I've been attending these sessions, and they have been terrific. Here are pictures of two from yesterday. Lynn Darrah, from Radiology, gave a presentation about optimizing use of the operating rooms. Pat Henderson, from Network Development, talked about trying to understand the rationale for the design and scope of M&M (mortality and morbidity) conferences across multiple departments.

Putting his foot down

Lovely compliments about our Obstetrics staff. Click on the image to read a larger version. I have omitted the parents' names from the signature line at their request, but they said it was all right to include Michael's name and "signature."

This Briton's got talent

We take a break from hospitals to refer you to this link on YouTube about Susan Boyle, a contestant on Britains Got Talent. It is making the rounds throughout the world. Watch it all the way through. It is heart-warming and shows the danger of prejudice and stereotyping.

Leapfrog Reports

The Leapfrog Group has issued the following release today. As you can see on the site, we do quite well on the Leapfrog Standards and have for some time, and they are certainly worthwhile, but they do not address real questions of process improvement in the hospitals, which are more complex and probably ultimately more meaningful. As you can see on this blog, we are working on those challenges and reaching out to the world's leaders in this arena, but truthfully very few mentors or examples exist for comparison and assistance. And, most organizations who focus on such matters are not well attuned to the environment of academic medical centers.

Few Hospitals Meet Standards for First National Measures of Hospital Efficiency for Heart Attack Care, Bypass Surgery, Heart Angioplasty, and Pneumonia

Detailed Hospital by Hospital Results Available at www.leapfroggroup.org/cp

WASHINGTON, April 15 /PRNewswire-USNewswire/ -- Though it has been 10 years since the Institute of Medicine's Landmark report on the failure of U.S. hospitals to adequately protect patient safety, too many hospitals still have failed to implement standards known to improve quality and save lives.

According to the 2008 Leapfrog Hospital Survey, released today, only 7% of hospitals fully meet Leapfrog medication error prevention (CPOE) standards and low percentages of hospitals are fully meeting mortality standards (see below).

"As the Obama administration and Congress consider health care reform options, it is clear we have a long way to go to achieve hospital quality and cost-effectiveness worthy of the nation's $2.3 trillion annual investment," said Leapfrog CEO Leah Binder. "According to our data, a majority of hospitals have significant safety and efficiency deficits."

"As the President has often stated, a reformed high value health care system needs to be cost-effective. Unfortunately, few hospitals are meeting Leapfrog's newly established efficiency measure standards the first such data available in the public domain," said Binder.

Among surveyed hospitals, efficiency standards defined as highest quality and lowest resource use are met by only 24% of hospitals for heart bypass surgery, 21% for heart angioplasty, 14% for heart attack care, and 14% for pneumonia care.

Other highlights of the 2008 hospital survey, include:

-- Relatively low percentages of reporting hospitals are fully meeting volume and risk-adjusted mortality standards, or adhering to nationally endorsed process measures for eight high risk procedures, where following nationally endorsed and evidence-based guidelines is known to save lives:

    --  43% for heart bypass surgery

    --  35% for heart angioplasty

    --  32% for high-risk deliveries

    --  23% for pancreatic resection

    --  16% for bariatric surgery

    --  15% for esophagectomy

    --  7% for aortic valve replacement

    --  5% for aortic abdominal aneurysm repair

-- Sixty-five percent of participating hospitals do not have all recommended policies in place to prevent common hospital-acquired infections (HAIs).

-- Seventy-five percent do not fully meet the standards for 13 evidence-based safety practices, ranging from hand washing to competency of the nursing staff.

-- Only 26% and 34% of reporting hospitals are fully meeting standards for treating two common acute conditions, heart attacks (AMI) and pneumonia, respectively.

-- Only 30% and 25% of hospitals are fully meeting standards to prevent hospital-acquired pressure ulcers or hospital-acquired injuries, respectively.

"In spite of huge opportunities for improvement, many hospitals are, in fact, demonstrating quality excellence and serving as role models," said Binder. "We need to take the lessons learned from the best hospitals and use these to move the status quo forward so all Americans have access to safe, cost-effective care."

Notable improvements by surveyed hospitals in 2008 include:

-- Thirty-one percent of hospitals now meet the Leapfrog ICU staffing standard, up from just 10% in 2002.

-- Hospitals with all of Leapfrog's recommended policies in place to prevent common HAIs jumped from just 13% to 35% between 2007 and 2008.

-- Sixty percent of hospitals have agreed to implement Leapfrog's "Never Events" policy when a serious reportable event occurs within their facility.

"Progress on patient safety is moving too slowly," according to Binder. "Consumers and purchasers of health care want hospitals to implement safety standards and procedures known to improve quality and reduce unnecessary injury and death. The safety goals Leapfrog promotes are achievable. More hospitals should be meeting the Leapfrog standards for common and high risk procedures."

The voluntary Leapfrog Hospital Survey results are as of December 31, 2008, and include 1,276 hospitals in 37 major U.S. metropolitan areas, representing 48 percent of the urban, general acute-care hospitals (53 percent of hospital beds in these areas),

Last year, Leapfrog launched an updated Web site to make it easier for consumers to review and compare vital local hospital safety information, including all of the measures referenced in the Survey.

Individual hospital results can be viewed and compared with other hospitals here.

The Leapfrog Group. On behalf of the millions of Americans for whom many of the nation's largest corporations and public agencies buy health benefits, The Leapfrog Group aims to use its members' collective leverage to initiate breakthrough improvements in the safety, quality, and affordability of health care for Americans. The Leapfrog Group was founded in November 2000 by the Business Roundtable and is supported by its members, the Robert Wood Johnson Foundation, The Commonwealth Fund, the Agency for Healthcare Research and Quality and other sources.

Thomson Healthcare provides data collection, analysis and support services to The Leapfrog Group. The leading provider of decision support solutions that help organizations across the healthcare industry improve clinical and business performance, Thomson Healthcare products and services help clients understand healthcare markets, access medical and drug information, manage costs, and improve the quality of healthcare. Thomson Healthcare is part of The Thomson Corporation (NYSE: TOC; TSX: TOC).

Good timing

A timely message from The Joint Commission arrived this afternoon:

Today, The Joint Commission is releasing “Measuring Hand Hygiene Adherence: Overcoming the Challenges,” to help health care organizations target their efforts in measuring hand hygiene performance. The monograph is designed to address “everything you ever wanted to know about hand hygiene measurement but were afraid to ask.” The aim of the monograph is to broaden understanding of the issues and provide practical solutions for strengthening measurement and improvement activities.

The monograph is the result of two-year collaboration with major infection control leadership organizations in the United States and abroad. . . . Free copies of the monograph are available on The Joint Commission Web site or by calling (630) 792-5800 (option 5), or sending an e-mail to customerservice@jointcommission.org.

I haven't had a chance to read all 200+ pages yet, but plan to, and you can bet it will be required reading here. Meanwhile, here is the forward:

Why would anyone write such a lengthy monograph about measuring adherence to hand hygiene guidelines? More importantly, why should anyone read it? The practice of hand hygiene has long been recognized as the most important way to reduce the transmission of pathogens in health care settings. Measuring adherence to hand hygiene practice is fundamental to demonstrating improvements both at an organization and a national level.

However, measuring health care worker adherence to hand hygiene guidelines is not a simple matter. Differing opinions and misinformation abound. We invite you to consider whether the following statements are true or false.

1. Everybody knows when to clean their hands.
False. While most of us know when to perform hand hygiene in our personal lives, health care workers who come in contact with patients or the patients’ environment are expected to perform hand hygiene many more times throughout the encounter. These indications for hand hygiene are described in professional guidelines and policies. Within a single encounter with a patient, there can be several times when hand hygiene should be performed. Studies show that continuing education is needed to inform and remind health care workers of the indications for hand hygiene.

2. It is easy to determine whether a person has cleaned his or her hands.
False. It may be obvious if someone is performing hand hygiene, but it is also important to consider how well the person performs hand hygiene and whether the person used the appropriate product. A quick rinse under the sink or brief rub between palms with alcohol-based hand rub may not be thorough enough to eliminate potential pathogens. Professional guidelines describe the proper techniques that should be used as well as when to use soap and water instead of hand rub.

It is also important to link the action of hand hygiene with the indications for hand hygiene described in the professional guidelines. It is possible that a person performed hand hygiene when he or she didn’t need to or that the person did not perform it when needed. Finally, even if you don’t see a health care worker performing hand hygiene, consider the fact that it may have been done prior to coming into the room or outside of your field of vision. You may want to consider asking a health care worker about it if you are unsure.

3. People who don’t perform hand hygiene when they should are careless or lazy or both.
Usually false. The vast majority of health care workers continually strive to do the right thing and try very hard to avoid harming patients. As described by Voss and Widmer, expecting perfection and 100% adherence is unrealistic, and we must “put an end to the reflex response that health care workers are neglectful of hand hygiene, which, far from helping, only demoralizes them further.” Studies have shown that organizational characteristics such as leadership involvement, reminders, convenient availability of products, and staff workload have a big influence on hand hygiene performance. Health care organizations need to integrate hand hygiene into routine procedures and have in place strong systems to support, monitor, and promote the correct behavior.

4. A hospital that reports a 95% rate of compliance with hand hygiene guidelines is better than a hospital that reports 75% compliance.
Unknown (could be true or false). Don’t be misled by statistics. Unfortunately, there is no standardized method for collecting and reporting rates of hand hygiene compliance. Organizations measure compliance in many different ways and in many different areas of an organization. Some organizations consider each indication for hand hygiene and sample groups of health care workers throughout the organization. Others measure more narrowly—for example, measuring whether hand hygiene was performed before and after care in the intensive care unit. The compliance rate is greatly influenced by what indications are chosen for measurement as well as where and how compliance is measured. As with any other performance measure rate, one should only compare rates to others that have defined, collected, and reported the same data in exactly the same way.

5. Observing care is the only way to get a valid assessment of hand hygiene guideline adherence rates.
Not necessarily true. Observation of care has important advantages, such as allowing you to directly link the activity of hand hygiene to the indication for hand hygiene. However, the observation method also has inherent limitations and potential biases (such as the Hawthorne effect, in which people change behavior because they know they are being observed). Collecting reliable observation data requires a highly structured method of both observing care and documenting data. Other methods, such as measuring product consumption, have different strengths and weaknesses. Using multiple measurement approaches helps to verify findings. Unfortunately, there is no perfect method for measuring hand hygiene adherence, and it is important to acknowledge the limitations of the measurement method used when rates are reported.

6. Excellent hand hygiene will reduce or eliminate health care–associated infections.
Partially true. In fact, the Centers for Disease Control and Prevention and the World Health Organization consider inadequate hand hygiene to be one of the most important contributors to infections. There are, however, many factors that influence whether a patient becomes infected. Other factors include such things as patient severity of illness, equipment and environmental sanitation practices, and adherence to recommended practices (for example, using maximal barrier precautions during central line insertions).

We hope these answers have piqued your interest in the content of this monograph. This monograph is designed to address the saying “everything you ever wanted to know about hand hygiene measurement but were afraid to ask”. Though easy answers are few, we hope this monograph will broaden your understanding of the issues and provide practical solutions for strengthening your measurement and improvement activities. We welcome your comments and suggestions for improvement.

Sincerely,
The Consensus Measurement
in Hand Hygiene Project Team

Looking for your help

A short introduction is called for here. Over the past two years, I have shared things with readers of this blog that usually are not made public by the CEO of an organization. I have done so because I think the issues facing hospitals are of sufficient societal import -- i.e., beyond the particular interests of our own hospital -- that they warrant public attention and discourse. Further, I believe that academic institutions like ours have a responsibility to provide educational materials to others, and what works better at that than real time case studies of what we are going through?

In so doing, I show us for what we are in real time, warts and all. This makes us vulnerable to nasty anonymous commenters in the blogosphere, as well as to people who think they benefit from embarrassing us and making us uncomfortable. And, even a few of my board members have said, from time time, "Transparency is one thing, but did you have to post that?" The answer is that this is an experiment in real time, but that I believe BIDMC ends up being a stronger, more effective, more efficient, and more humane organization for having done so.

Here comes the next example, an email I sent out over the weekend to our staff, entitled "Looking for your help." It is self-explanatory. As always, I welcome your comments:

Dear BIDMC,

As you can imagine, I've been giving a lot of thought to the events of the last several weeks with regard to the MRSA infections and the lapses found by DPH and CMS in our hospital with regard to infection control. We have already made some changes in response to those findings that should be quite helpful, but I want to draw back a few steps and ask your indulgence to think through the issue with me in a more comprehensive way.

Let me start with a story. I have a friend named Tom Botts, who works with Royal Dutch Shell. Tom and his folks had put in place the world's most extensive safety program for people working on oil rigs. Much to his dismay, two workers went to the wrong part of a rig called Brent Bravo and did something totally contrary to all their safety training and were killed. It would be all too simple in a situation like that to blame the two workers for being inattentive to the safety rules, but Tom and his colleagues did something different. They engaged in what he called a "Deep Learning" exercise and discovered that the problem lay not in well-intentioned people who made mistakes, but in the leadership of the organization for failing to fully understand what it would take reduce the chance of errors.

Here's an example of one of his conclusions:

"A system full of well intended, competent people working world class systems trying their best to meet expectations can produce fatalities."
Probably the most profound learning for me. In the Brent Bravo story, there were no obvious ‘villains’, but rather a number of causal patterns that came together to produce a tragedy. The whole point of Deep Learning for each of my senior leaders and me was to be able to see ourselves in the system and what causal patterns we could have been able to break (if we had a better appreciation for the unintended consequences of our many well intended decisions). Key questions: Am I asking the right questions? Am I curious enough?

(If you would like, you can read other parts of the story and Tom's other lessons on my blog here.)

So, now let's go back to BIDMC. That there were flaws in our infection control procedures and techniques is quite evident from the DPH/CMS report. Let's not deny those. But let's also assume that the well-intentioned and highly trained people in our hospital were extremely unlikely to have made these errors intentionally. As one of our nurses said to me, "There is a difference between knowing what to do properly, and deciding not to do it despite knowing it." And then she said, "I truly believe we are the best hospital here in Boston. That is why I choose to work here. We are open with our mistakes, as that is how we are able to learn and progress. It hurts to see our name slandered, and our reputation diminished over this. Can we do better? Yes. And we are already. Our policies are being rewritten, and our procedures reviewed. This is an issue that is in EVERY hospital. Please don't let this disintegrate further into an atmosphere of fear and punishment. Please use this as a tool for internal review and reflection."

Although we have made a full and complete response to the DPH/CMS findings, we are in the business of continuous improvement here, and I want to see if we can do better still . . . with your help. In the past several weeks, we have seen the power of our joint action in adopting budget and personnel actions that reflect our deepest values of caring and compassion. Our town meetings and chat rooms and emails produced a result that solved a serious budget problem . . . and by the way, brought great national acclaim to our hospital.

I would like to try to do the same here. I don't think large-scale town meetings fit the bill for this exercise, and I also don't think the imprecision of chat rooms and emails would work in this case, either. Instead, over the next several weeks, I will convene a series of focused discussion groups with those of you who would like to join me and a small group of Chiefs and Vice Presidents. Your task will be simple and direct: Tell us what we don't know that we should know to help make it more likely that future quality and safety problems will be diminished. We'll then take what we learn from you and do our best to construct the training, procedures, and infrastructure that will move us along in this journey.

In the next few days, you will see an email setting forth a schedule for these meetings, and you will be able to sign up for one that is convenient for you. I welcome and treasure your participation.

Sincerely,

Paul

Just when you thought you were sure . . .

. . . that you knew everything there was to know about your family, you learn something. This is the Bridgeport (CT) Telegram from May 12, 1922, and it is about my grandmother. My sister, our family genealogist, found it somehow. It's hard to read, so here's the text:

Mrs. Rose Levy Bound Over on Bigamy Charge
Mrs. Rose Levy of Grove Street was arrested yesterday morning on a charge of bigamy. Believing her first husband Isaac Grannick of Philadelphia had died eight years ago she became the wife of I. Levy. Recently the first husband came to Bridgeport and confronted his wife threatening prosecution. She reported his threats to the authorities through her counsel and her arrest followed. In City Court yesterday morning she was bound over the the Superior Criminal court in $100 bonds.

Now, this was six years after my father was born, so I guess she was a bit surprised. We will probably never know if she really thought Isaac was dead or whether, in the tradition of certain Eastern European Jews, she just considered him dead for some injustice that he had done her.

Unfortunately, we have not yet found the sequel. Was she found guilty or innocent? I'm also not clear, though, what the penalty was back then for bigamy. How would you handle the existence of the son by the second marriage? Do you force a divorce on the first couple and then re-marry the second couple?

In the 20+ years I knew her while I was growing up, I never heard mention of this incident. What have you found in your family history that was news to you after years of ignorance? Please submit stories.

Retake that PK!

Our youth soccer leagues get started today on a blustery spring New England day, and a friend uses the occasion to send the following note to our cadre of adult referees:

I know some of the kids think we are "old farts" but this article from the BBC is interesting, especially on a "windy" day in Newton. Sunday League football in England is the equivalent of our Over The Hill Soccer League. Enjoy.

Dropping by NECN

Did you ever wonder who is in charge of the business news you read in Boston? Well, here they are. While I was waiting to tape an interview on This Week in Business at New England Cable News, the first segment of the show was being taped. It is called the "Monthly Business Editors' Roundtable." From left to right, you have the hosts of the show -- Paul Guzzi, CEO of the Greater Boston Chamber of Commerce, and Mike Nikitas, an NECN anchor -- and then Frank Quaratiello (Business Editor of the Boston Herald); Shirley Leung (Business Editor of the Boston Globe); and George Donnelly (Editor of the Boston Business Journal).

The topic today was the future of the Boston Globe, and it is a discussion worth hearing. My segment was about the steps BIDMC has taken to avoid layoffs in the face of budget shortfalls. The show will be broadcast on Sunday at 12:30. It is also available after broadcast on NECN.com and the Chamber's blog, too.

As I was leaving, I was nabbed by Latoyia Edwards, an NECN reporter and anchor, for a quick interview on our recent MRSA problem and DPH report. Here she is while a cut-away is being filmed.

Future leaders

I joined a group of Harvard undergraduates today at their class, "The Quality of Health Care in America," co-taught by several medical luminaries -- David Blumenthal, Don Berwick, and Warner Slack and Howard Hiatt (shown here). A great conversation ensued about transparency and process improvement. There were several pre-med students in the class. Perhaps this course will give them the impetus to focus on the quality of the health care delivery system when they become doctors.

A good birth!

A lovely letter about our staff from a new mother:

In Wikipedia, a nurse is defined as a healthcare professional focused on the detail-oriented care of individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. While that may be true by definition, my nurses at BIDMC for my stay with my new son Julian from March 26 to 28 were so much more than that.

My labor and delivery nurse was Cheryl Sirois. She was an extremely friendly and outgoing woman, and I knew right away that I was going to enjoy my delivery and have no worries. She never seemed distracted or left me alone for long periods of time. Her 9 years of labor and delivery experience showed when she spoke up on my behalf and informed the Anesthesia team that I would prefer not to have a student administer my epidural. I had had a bad experience with one of my other deliveries and even though I had agreed early on for a student to give me the medication (I was having a bad contraction at the time!) I had changed my mind, yet was to nervous to speak up. Cheryl said no worries and informed the team my wishes to have the chief resident administer the epidural/spinal tap. I am so grateful for Cheryl's advocacy. I had a great pain free birth.

I, as well as my newborn son, experienced superior care while staying in room 767. My recovery was difficult in the early hours as I experienced heavy bleeding and the passing of large clots over my first night. Bonnie Biederman was my overnight nurse during this alarming night. She was calm and collected, friendly and efficient. I was scared at the thought of having to have an internal to check for clots. She made me feel secure and was right there through it all as I squeezed her hand, then her elbow and then her whole entire arm! I was thankful to have an experienced nurse for my overnight care that night. She had a busy night with many other patients but always managed to check in and make sure I had all that I needed. I am very lucky to have had her during that traumatic time.

My next morning, I was even more blessed to have the care of Suzanne Sweeney. What a breath of fresh air she is and the perfect nurse to have after a horrible and scary evening before. She was kind and funny, always laughing and friendly. After having such a rough night, she was just what I needed! I happened to pass another large clot while she was on duty and became worried. She calmed my fears and said it was okay and there was no concern. She was always there to check in on my needs and would return with supplies and a smile. She mentioned more than once to me that she loves her job, and I believed her! This woman loves what she does and it shows.

Suzanne continued to care for me the following day. How lucky was I to have her two days in a row! She has a special gift with handling newborns. Watching her talk with my son Julian was heartwarming. He responded to her immediately. She has a terrific bedside manner and I wish everyone that comes through Beth Israel Deaconess for labor and delivery could experience even a sliver of Suzanne's care!

You are lucky to have these professional women on your team. Please know that their care was exceptional. As stated above, a nurse is defined as a professional focused on the detail-oriented care of individuals, families, and communities in attaining, maintaining, and recovering optimal health and functioning. While these women certainly fulfill this definition, they all went above and beyond their job requirements and made my stay at Beth Israel Deaconess comfortable, fun, reassuring and stress-free.

Thank you, Beth Israel Deaconess, for hiring such a top notch team!

DPH and CMS help out

While we are justly proud of many of our quality and safety initiatives at BIDMC, we have to acknowledge that we still fall short in a number of ways. The memo below, distributed to our staff yesterday, contains an example.

Just as we view transparency around our clinical outcomes as an important management tool, we view transparency about regulatory activities, findings, and requirements in the same way. If a regulatory agency finds that we are doing things wrong, why would you want to keep that conclusion secret from the staff? After all, the doctors, nurses, and others are the ones who ultimately must correct the problem, and we trust their ability to evaluate and act on legitimate criticisms received by us.

In a previous post about the Joint Commission, I stated: "If the Joint Commission did not exist, we would want to invent it. An objective outside review of this sort is extremely helpful to a hospital as it strives to provide better and better care to the public." Ditto for our state and federal regulators.

Here's the memo:

To: BIDMC Community

From: Ken Sands, MD
Senior Vice President,
Silverman Institute for Health Care Quality and Safety

DeWayne Pursley, MD, MPH
Neonatologist-in-Chief
Interim Chief, Obstetrics and Gynecology

Marsha Maurer
Vice President, Patient Care Services
Chief Nursing Officer

We are writing to share important information about some serious clinically related issues at BIDMC over the past few months. To begin, we will give you some background, and then we will fill you in on what happens next.

What Has Occurred
First, between last November and March, BIDMC experienced several occurrences or “clusters” of methicillin-resistant Staphylococcus aureus, or MRSA, infections that have affected some of our patients (19 newborns and 18 mothers) days to weeks after discharge from our obstetrics and newborn services. These infections have been, for the most part, superficial skin infections and breast infections. It is important to note that no babies in our Neonatal Intensive Care Unit have been affected.

We are thankful that all identified infections have been successfully treated, in most cases with antibiotic cream or pills. We are working to identify any other patients who may have been affected. It appears that these clusters of infection have not impacted other parts of the hospital.

As with other hospitals and institutions that have experienced similar groups of MRSA infection, it is often impossible to identify a singular source or explanation. We have determined the bacteria to be the most common type of “community-associated” MRSA, meaning that the origin of the bacteria is most likely outside BIDMC. Despite extensive investigation, we have been unable to determine how it has spread. However, we have taken many steps within our obstetrics and newborn services to address this situation, including testing our employees and patients and strengthening our efforts on hand hygiene and sterilization.

We promptly reported these occurrences to the Massachusetts Department of Public Health (DPH) and the Boston Public Health Commission (BPHC) and continue to work closely with them. In addition, to help us with this ongoing challenge, we are working with the national Centers for Disease Control and Prevention (CDC), and we welcome their expertise and knowledge of similar situations. Our outreach has included communications with affected patients, patients who we believe have not been affected but were here at the same time as the affected patients, pediatricians and current patients in our obstetric units.

Second, during the course of a DPH visit regarding the MRSA matter on behalf of the federal Centers for Medicare and Medicaid Services (CMS), investigators observed instances when our infection control practices failed to meet our own standards. In addition, they had concerns about our system for reporting infection clusters to leadership bodies within the hospital.

What Happens Next
We have received the official CMS report and are putting together what is called a Plan of Correction to show how we will correct any and all deficiencies that were identified. We will make both their full report and our response available to the BIDMC community when they are filed within a couple of days. But as a result of the findings, a more vigorous, hospital wide survey by CMS will be coming to BIDMC in the near future for their own review and inspection of our policies and procedures. Every physician and employee must be prepared to welcome the CMS surveyors and show them the good work that we know BIDMC staff are doing every day.

Some Observations
We take the report on our lapses and the expected CMS visit very seriously. When we make this report available to all, you may find reading the report makes you uncomfortable. It is difficult for a group of expert and dedicated staff like our colleagues in Obstetrics and Newborn services to go through this process. They have worked extremely hard over the past few months to battle these MRSA infections and to re-dedicate themselves to the most rigorous infection control processes.

Yet the truth is any one of us at any time could be subjected to the same scrutiny and observation and we each need to ask ourselves how we would fare in this situation. This is an important learning experience for every one of us as we deal with the patients and family members who put their trust in us.

There is much to be proud of at BIDMC with our efforts to control infections. We have virtually eliminated central line infections and ventilator associated pneumonia over the past few years by implementing and standardizing major new processes. Each year, the outstanding clinicians at BIDMC provide quality care with exceptional outcomes to tens of thousands of patients.

The serious nature of the initial survey does not change those facts. But it does require that we continue to commit ourselves to providing the highest quality care to every patient who counts on us for their health care needs. Ultimately we believe the changes we will put in place as a result of this experience will make us stronger and better caregivers.

Reprise: St. Thomas Charoset

A repeat of my grandmother's recipe for charoset, that sweet stuff we eat at Passover. Enjoy!

In memoriam: Doctor Harvey Goldman

It was somehow appropriate that Harvey Goldman died yesterday, in that it was to have been Opening Day for the Boston Red Sox. It felt even more appropriate that the game was postponed, though, for it would not have seemed right for it to have taken place without him.

Harvey was an avid fan who went to most games. He sat in the family section at Fenway Park, down the left field line in the outfield, where alcoholic beverages are prohibited. He told me that there he could have relative peace and quiet during the games and not have to worry about someone spilling beer over him. As I sat through the rescheduled game today, I often thought of him because the view from my seat looks directly across to where he used to sit. He would bring books and academic journals with him to the game, to read during the inning breaks, so as not to waste time.

My favorite memory of Harvey, though, was two or three days after I had a routine colonoscopy, when two or three polyps had been snipped off. We happened to meet on Longwood Avenue as we walked toward the hospital. "Good morning," I said, "How are you?" "Fine," he replied, "and so are you. I did the histology on your samples yesterday."

As noted by our Chief of Pathology, Jeffrey Saffitz, "Harvey was a giant in the field of gastrointestinal pathology and a true icon in our department and in the Harvard pathology community. His dedication to teaching and patient care was legendary. He touched the lives of literally thousands of medical students, residents, fellows and colleagues in so many wonderful ways. He will be greatly missed."

Doctors' Diaries on NOVA

NOVA Producer Paula Apsell at Boston's WGBH reminds me (and now you!) of the following:

I am writing to alert you to a special NOVA two-hour miniseries to be shown on WGBH Channel 2 at 8 PM on Tuesday, April 7th and the following Tuesday April 14th.

For the past 21 years, NOVA has been following a group of 7 aspiring young doctors from their first day at Harvard Medical School through internship, residency and out into the world as practicing physicians. The resulting documentary, called Doctors' Diaries, reveals in illuminating detail the joys and sorrows, sacrifices and rewards that go into becoming a member of the medical tribe. I think these programs might be of special interest to you and I hope you will be sure to tune in or set your DVR.

Check local times for your own PBS station.

Blog Rally to help the Boston Globe

We have all read recently about the threat of possible closure faced by the Boston Globe. A number of Boston-based bloggers who care about the continued existence of the Globe have banded together in conducting a blog rally. We are simultaneously posting this paragraph to solicit your ideas of steps the Globe could take to improve its financial picture:

We view the Globe as an important community resource, and we think that lots of people in the region agree and might have creative ideas that might help in this situation. So, here's your chance. Please don't write with nasty comments and sarcasm: Use this forum for thoughtful and interesting steps you would recommend to the management that would improve readership, enhance the Globe's community presence, and make money. Who knows, someone here might come up with an idea that will work, or at least help. Thank you.

(P.S. If you have a blog, please feel free to reprint this item and post it. Likewise, if you have a Twitter or Facebook account, please add this url as an update or to your status bar to help us reach more people.)