Thursday, April 09, 2009

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.

40 comments:

Anonymous said...

Dear Mr. Levy,

I read in today’s Boston Globe about the MSRA outbreak among patients of Beth Israel Deaconess Medical Center’s obstetrics and newborn services unit.

My wife is scheduled to give birth at Beth Israel Deaconess this autumn. I am therefore extremely concerned about this story. While I have not had previous experience with Beth Israel (my wife’s delivery will be our first exposure to the hospital), I have been underwhelmed by the seriousness with which the medical profession appears to be addressing infectious disease controls at other facilities.

(In recent times alone my father contracted MSRA at one facility in New York and my grandmother’s roommate contracted MSRA at another facility in California. I am aware that this is occurring with alarming frequency throughout the country.)

In hospitals and doctors offices there are not routinely alcohol cleaners in every room. Public restrooms in medical buildings often lack hot water or paper towels with which to open and close doors. Surfaces in public areas are disinfected infrequently if at all. Doctors do not routinely wash their hands after interacting with patients and shaking hands. Hospital garments are worn outside of the hospital — and street clothes inside (including ties on men, which studies have shown are rarely cleaned and carry many germs). I have observed all of these conditions personally in multiple high-end facilities in Boston and elsewhere.

I am disappointed to read that Beth Israel Deaconess is no better, and may be worse, than such industry norms.

There appears to be a cultural failure across the industry and what is needed is not ‘improvement’ but rather zero tolerance for 19th century attitudes towards infectious disease control within a profession that should know better and should be setting an example for the rest of the populace.

My wife will enter Beth Israel in just a few months. That is short time to dramatically address and completely eliminate the practices that give rise to the inattentive transmission of MSRA and other illnesses — but I ask you to do so with bold steps at every level of hospital personnel and practice.

Please, Mr. Levy, insure that my wife and baby leave your hospital with only good memories of Beth Israel Deaconess Medical Center — not with diseases contracted there.

Thank you for your understanding, your help and your personal attention to make certain that Beth Israel is the leader in combating MSRA as it is the leader in so many areas of medical achievement.

Anonymous said...

Paul,

While its nice to see this transparency there really is no excuse for the hospital falling short in this way. As someone who has had personal experiences with the hospital I know that there are some wonderful/skilled people who deserve to be affiliated with BI (a Harvard hospital). However, there are many who should not be affiliated. I think the hospital needs to do a better job of ensuring that it has the best people in all positions to ensure that issues like this don't arise. If you want to be considered one of the best facilities in the world you need to hire the best, act like the best, and not have issues constantly occurring. I am sure that you and your staff are working on this and as I said the transparency is appreciated but actions and results are what count. Blogging and being open about the many issues that BI has is not enough.

Paul Levy said...

Dear Anon 4:17,

While every organization has people who do not perform to professional standards and deserve to be disciplined, I believe that number at BIDMC to be extremely small. You use of the term "many" is inherently imprecise, but if you mean what I think you mean, I disagree mightily. And see below for more thoughts.

Anon 3:49,

I agree completely with you about the need for quality and safety improvements throughout the medical profession and in hospitals. Please check this blog elsewhere and also www.bidmc.org for many examples of improvements we have made in this arena. This remains a very good place to have a baby (see post above this one for some of the reasons), and we look forward to welcoming your new one this fall!

To both of you, our transparency with regard to clinical matters is the most effective tool that any organization can use to improve. If you do not admit in a public fashion the areas needing improvement, they will not get the attention they deserve.

To this point -- "If you want to be considered one of the best facilities in the world you need to hire the best, act like the best, and not have issues constantly occurring." -- we are considered one of the best in the world, and we aim to hire the best and act like the best. But how do you know who is really "the best" when most institutions hide their flaws and their self-improvement efforts? You will continue to read about "issues" here because we chose to make them known as part our effort for continuous self-improvement.

Frankly, I think you should be more concerned about hospitals that give the impression, through silence, that all is well. As has been documented over and over by national studies of all kinds, all is certainly not well in American medicine and hospitals. One reason is a pervasive tendency to admit what is failing.

Anonymous said...

I am due any day now at BI and after reading this article am petrified. Besides hand washing and sanitizer what can i do to assure my newborn and I leave with no serious staph infections. I am truly nervous and don't want to have this taint my experience.
Please, please advise.

Paul Levy said...

I suggest you talk with your OB if you have any doubts. I can assure you that the staff is extremely diligent about these matters, especially now.

Anonymous said...

While this outbreak, as it is called, is a scary event, what is more scary to me is that it was the community-associated strain. It used to be that MRSA was acquired and spread in hospitals. Now a certain strain is out in the community and often is brought IN to the hospital by patients. In fact,it is the predominant type of superficial staph infection encountered in emergency rooms now. So honestly, you are being exposed to it everywhere, like on grocery cart handles, etc.It can be carried asymptomatically in the nasal passages.
I have to support Paul's contention that it is what hospitals DON'T tell you that you should be scared of. No doubt such outbreaks have occurred elsewhere but not been publicized; it is human nature to be afraid of what is drawn to our attention, but "ignroance is bliss" so to speak.
I also wager that BIDMC will now be the safest hospital in Boston to have a baby, since the staff will be incredibly paranoid about a recurrence.

nonlocal MD

Anonymous said...

I wish to correct one detail of my previous comment. The following quote comes from an association of infection control practitioners in Nebraska:

"Fomites (bed linens, towels, pajamas, dishes, etc.) have not been implicated as vectors in the transmission of MRSA. Environmental surfaces, in most instances, are not important vectors of MRSA."
Thus my statement about grocery cart handles was probably overstated. However, certainly athletes' locker rooms, etc. have been the source of outbreaks.

nonlocal MD

Anonymous said...

I suspect the majority of the infant infections are infections of the circumcision wounds. Since infant circumcision is a cultural practice and does not have health benefits, I would strongly suggest the hospital suspend all infant circumcisions until this outbreak is under control. These circumcisions can be performed in the pediatrician's office after discharge under safer conditions.

.

Anonymous said...

What I don't see mentioned anywhere is the fact that so many people have MRSA and are walking around in public and not isolated or taking any precautions not to infect others. For example, the father of the poster above and his grandmothers roommate were allowed to leave the hospital and interact with the general public I assume, and not told to never be around non infected people, so why are the hospitals always to blame, when the MRSA is widespread in the general population. It seems to me that if MRSA is to stop, then are infected people to be isolated like in TB wards?

Anonymous said...

The BIDMC memo says that "all identified infections have been successfully treated."

But today's Globe reports that a father said his wife is currently on antibiotics at home after being hospitalized on intravenous antibiotics."

Paul Levy said...

I'm not permitted to comment on a specific case, and, since the source is anonymous, I'm not sure who it is anyway.

But to your point, if I may take a guess as a non-doctor, the course of antibiotic treatment usually goes on for some time, even after symptoms are gone. Perhaps that is why different language has been used.

KevinT said...

I believe that a major problem with communicable diseases, both hospital and community acquired is that there is no seperation between environments. I have several family members and friends who work in the health care industry. I always notice how they go from working out at the gym, getting dressed into their hospital uniforms and heading to the hospital. I also notice how they will leave work at the end of the day to pick up their children at a daycare center in the same garments they have been working in all day. I have heard many first hand stories of these family members and friends wondering how their child/spouse caught MRSA. It's not rocket science...There is no barrier at the entrance of a hospital in which we can accuratly identify between CAI and HAI. Yes, this is a common bacteria in which most people already carry, everywhere they go, usually without problem until they come in contact with a vulnerable victim.


“All staphylococci tested survived for at least 1 day on all fabrics and plastics. Staphylococcal viability was longest on polyester (1-56 days) and on polyethylene plastic (22 to >90 days).” – Survival of Enterococci and Staphylococci on Hospital Fabrics and Plastic, Journal of Clinical Microbiology, February, 2000

I believe alot of these issues would cease to exist with preventative measures taken to reduce the transmission route from surfaces to humans. There are options available for these problems, most people, including hospital staff, facility managers, and patients are just not aware of them. I'm not sure if this is the appropriate place to mention or not but I know of cutting edge technologies to help with the problems everyone here is discussing. If interested I would be more than happy to share.

Jim Conway said...

Paul, we have a great non-profit in Massachusetts called the Partnership for Healthcare Excellence. It has three goals: educate consumers about variations in care, educate them on how they can make more effective decisions about care, and activate consumers to drive improvement in care. As you know, IHI estimates there are 15 million incidents of harm in American hospitals every year. In the quality and safety journey of BIDMC you are moving to confront the full extent of harm at the BIDMC and to design systems that mitigate the chance of it happening again. The appropriate transparency which your are bringing, in the spirit of the PHCE, shines a light on the variation, is educating consumers, and is increasing accountability from consumers as well as clinicians (well evidenced by postings on this blog.) It is hard and good and will further drive improvement in quality and safety not only for BIDMC but the community.

Earlier this week the citizens of Massachusetts learned about the 338 serious reportable events that happened in Massachusetts in calendar 2008. Through your transparency, public reporting, regulatory agencies, and voluntary efforts, people will learn that these 338 events are but a tip of an iceberg of defects, variation, harm and suffering for patients, family members and healthcare staff. They will also learn of the work of courageous organizations on a journey to eliminate them.

Thanks to all at BIDMC for the journey you are taking

Jim Conway
SVP, IHI

Anonymous said...

Public display cannot be the sole driver for quality improvement. Hospitals must develop robust internal mechanisms to ambitiously increase reporting, aggressively analyze events from near misses to serious harm, and walk the talk of process improvement. This takes serious investment and accountability. The system should be driven towards catching every event and improving vulnerable systems before the DPH and CMS tell you to. Otherwise, BIDMC is as unsafe as the next institution. Just more vulnerable to bad press.

Anonymous said...

BIDMC certainly has a long and steady history of providing excellent and compassionate care to our community. I applaud the fact that you have been so forth right and accessable to the community relative to this issue as well as others in the past. I believe such is testimony to your commitment to make the necessary adjustments and improvements. That said I was wondering just how much focus is placed on the quality of cleaning, and sterilization practices at BIDMC. I have read many reports of patients being at risk as a result of inferior procedures / policies related to the reprocessing of reusable medical devices and instruments. Just recently several patients in the VA system were infected with hepatitis C as a result of inadequately cleaned / sterilized endoscopes. What sort of measures does BIDMC have in place to ensure proper cleaning and sterilization practices are adhered to? What sort of credentials / training do the people who perform these duties have?

Paul Levy said...

Anon 12:42,

I agree completely. Transparency without programs and systems is just a window on an inadequate system. See elsewhere on this blog for lots of commentary on the things we have been doing in that regard. And, actually, we have seen an increase in internal reporting over the last couple of years in our place. But, this is also a never-ending process of improvement.

Anon 1:50,

That would take a long answer and covers many things. I'll try to address that in a future post. Thanks for bringing it up.

Jill--Unnecesarean said...

When your hospital is surgically opening 42% of all pregnant women's abdomens, I know that you'll work hard to eliminate the risk of infection for all of the c-section moms and babies who are at a much higher risk than the other 58% of new moms.

Anonymous said...

MRSA is everywhere. Pediatric offices are swamped with it. And not from just your hospital. What a time for this to come out with the financial troubles your institution is facing. Of course there could be a "conspiracy theory" or two....Union driven? Financial gurus bringing this out at this time; close the maternity ward and save money by laying off all the staff in that department?
It is really too bad the other large hospitals in Boston (or any hospital for that matter) are not "transparent". The public would be horrified to learn that MRSA outbreaks occur there too! OOPS...SHHH.

Gene Lindsey, MD said...

I applaud Paul and his organization for their transparency on this issue. BIDMC has been on a journey to "Quality" for some time. The first step on this journey, which many of us in health care are taking, is to be open about the errors and defects which inevitably occur. BIDMC under Paul's leadership has been consistently transparent and ready to engage in repair, rather than blame, as errors have been identified.

As a physician who has practiced in hospitals for over 30 years, I know from my own experience that issues like this one unfortunately occur every day in every hospital. We sympathize with the patients who have to suffer when issues like this occur, but we all benefit from the openness of BIDMC to reflect on their defects as well as their accomplishments.

Gene Lindsey, MD
President and CEO,
Harvard Vanguard Medical Associates, Atrius Health

Anonymous said...

It seems to me that the hospital is given too much credit for its "transparency." This has been a concern since November -- being investigated at least in Dec -- well it is April right now and this is the first the public is hearing. Transparency seems to coorelate to the anticipated negative publicity hitting the street....

Anonymous said...

Dear Mr Levy,
I was greatly disturbed by todays Globe article on many levels. I work here at BI, and I know we do great work and I know that the Globe has their money to earn with sensational stories. But what angered me the most is Ken Sands statement. "Sands said that hospital workers who are not vigilant about the new infection-control policies run the risk of being fired." This comment contradicts everything the I thought the BIDMC stood for, teamwork, individual responsibilty, shared governance, and responsible leadership. To have the management threaten its workers instead of supporting them is ridiculous. The proper response should have been that we are working as a team to correct the issues. And if pressed Mr Sands could have stated that we would reinforce the education with specific individuals if necessary. In this time where we are already afraid of layoffs and budget cuts, added to the stress of the CMS visit, to have Mr. Sands threaten me was more than I can tolerate without speaking out.

Paul Levy said...

Thank you for this comment, which goes to the heart of things I have been thinking about these last few days. We do pride ourselves on teamwork, individual responsibility, shared governance, and responsible leadership, and those have to continue to be key principles under which we operate. But maybe, just maybe, we pride ourselves too much in that regard and don't also apply standards of behavior in certain areas as strictly as we should.

As a non-MD and non-RN, I have never understood how health care providers fail to follow simple rules of hand hygiene and other sanitation. As you know, this is a pervasive problem in the field. Many people would ask why it should have to be our place to reinforce the education of people with regard to these techniques, when part of their certification as doctors or nurses includes training in the areas of germ theory and infection control?

So, how do we enforce the latter without giving up the former? Please offer your thoughts.

Anonymous said...

Having worked at BIDMC in nursing and nursing administration for more than five years, I can unfortunately attest to the absolute fact that our "transparency" is directly related to "risk management". There are MANY secrets here, and we are reminded of "how to communicate" with the "outside sources" constantly. BIDMC needs to look inward, and upward in the nurising administration, and how they treat the working staff. Some of us feel that we should write a book about how WE have been treated while patients, how families are treated and how this is a Physician, research and money driven institute, not a patient driven institute. But then we would be out of jobs...

Paul Levy said...

Part of the problem with anonymous comments like this is that it is not possible to validate whether the person actually is who they say they are and, more substantively, whether what they say is true, or whether they are motivated by factors not related to the case in point.

Nonetheless, I have posted this comment. In response, I say that all I know is what I hear from many, many patients and many, many staff -- that they love BIDMC for the quality of the care offered and for the caring work environment. The Boston health care market is very competitive, and if these things were not true, people would have voted with their feet to receive care elsewhere and to work elsewhere. Instead, our growth in patient volume has generally exceeded the regional average, and turnover among staff is very low.

Anonymous said...

Re: Anonymous April 11 at 1:35 PM
Re: Comment about Sands "threat of firing"
I had a long professional career in an organization where quality was an essential part of our product (not health care and not BIDMC). One of the certainties of any acceptance of poor quality is that you will continue to get what you accept.

I have to agree with Mr. Sands that if employees, after training and emphasis on following infection control policies, continue to act contrary to those policies and contrary to the interests of the patients, then those employees should be fired. A policy of teamowrk and shared governance does not confer immunity from punishment for repeated actions that hazard the health of patients.

There should be reasonable corrective action for occasional errors but there must be serious consequences for repeated disregard of requirements.

Anonymous said...

The comments regarding termination threats illustrate the high-wire balance aspect of systemic quality improvement programs - while talking about a blame-free culture, teamwork to improve, etc., one can inadvertantly empower those few who take advantage of these attitudes to no longer feel personally accountable. Then when management suddenly gets tough, they sputter about how management is only giving lip service to quality improvement.
I believe Paul has previously published a chart which attempts to define lapses and errors vs. deliberate disregard of the rules, with the resultant consequences for each. I'm afraid lack of handwashing is a fairly black and white example of deliberate disregard of the rules. To the extent to which it contributed to the MRSA outbreak, the consequence must be punishment - it's as simple as that.
As to why lack of handwashing continues in hospitals, this is an old question with much written about it. Only continued research and feedback will eventually provide an answer that works for everyone.

nonlocal

Anonymous said...

As to anon 2:17's comment about secrets, it was my observation during 21 years of hospital-based practice (well away from Boston or from academia) that the nursing services in hospitals are often an entity apart from other hospital departments, with their own cultures, unwritten rules and yes, secrets. I have no idea why that is; I am just offering it as an objective observation. It may well be that the precepts promulgated by Paul and his administration in the rest of the hospital have not completely penetrated the nursing administration as a whole - this would not surprise me based on my experience elsewhere.

So, anon 2:17, my advice, from my estimation of Paul's integrity, would be to contact him confidentially and fill him in. You both might be surprised to learn things you didn't know.
Not that I am fomenting mutiny from afar, but just TALK, if you are authentic and truly desire change.

nonlocal MD

Anonymous said...

Dear Mr levy,
I am Anonymous April 11 at 1:35 PM:
I agree with you that there is certainly a professional and more importantly, moral responsibility to adhere to infection control guidelines. Of course if someone blatently disregards policies after re-education, there would be grounds for termination. But I think we are missing the crucial middle step.
I cant imagine that anyone here has ever blatently ignored steps to prevent infection. Mr. Sands implies that our lapses were due to laziness or carelessness. I think there is a huge difference between procedural errors and practical errors. At our staff meetings we were told that many of the deficiencies cited were procedural issues, not individual breaches in technique. I have many individual examples of this, but am hesitant to post them on a public forum. There is a difference between knowing what to do properly, and deciding not to do it despite knowing it.
I think the answer is to review the procedures, enforce the teaching, and deal with individual lapses in infection control on an individual level.
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 dont let this disintegrate further into a atmosphere of fear and punishment. Please use this as a tool for internal review and reflection. We are the best hospital in Boston... we have the best staff. There is no need for the hardline tactic of Mr Sand.

And to the Anonymous above: I think we disagree on the motives of individuals. I truly do not believe anyone has knowingly and willingly disregarded infection control policy or procedure, and willfully placed a patient in harms way. We are all human. Quality is essential here too, in fact it saves lives everyday.
Thank you for your time, Mr Levy.

Anonymous said...

Records of MANY audits will show that most of the offenders of the strict "pump in, pump out" policy (upon entering any patient room, staff and visitors must use waterless hand cleaner), as well as the policy of Universal Precautions are ATTENDING AND RESIDENT MDs. This, is, for a fact, true in the surgical ICU's, to the point of offenders being issued "tickets", for years without further consequences. Will these MDs be fired? I would be glad to give credible and specific examples, only an employee would be aware of. As I previously said, the problem is not with the wonderful and excellent care that the nursing staff provides; it is with nursing management and the basic philosophy of who is first at BIDMC, the needs of the patient or the needs of the "Teaching Institute" and "maximizing throughput".

Paul Levy said...

Dear Anon 5:25,

I think you have it exactly right, when you say: "Please don't let this disintegrate further into a atmosphere of fear and punishment. Please use this as a tool for internal review and reflection." You will be hearing more from me on that front in the next few days! Thanks for being so forthright, eloquent, and clear.

Anonymous said...

Anon 5:33;

Yep, you are dead right about the docs being among the worst offenders. And yes, firing them is problematic, isn't it. Perhaps shame would work - read their names out loud at staff meetings, or in a newsletter or something. I can just hear the gnashing of teeth that would ensue! But seriously, there should be some consequence, even to the almighty attendings, otherwise there is a double standard. Some brainstorming might be in order.

nonlocal

Cares said...

As a BIDMC worker I welcome transparency efforts and leaders brainstorming with employees to better understand problems, find workable solutions: most recently, Infection control.

Meanwhile, an unfortunate juxtaposition of two front page stories in today's (4/11/09)Boston Globe: infection and transplant might suggest Partners is free of infection problems.

The comment submitted to the Globe today by a Partner's employee, however, is telling and perhaps deserves more attention from regulators:

Excerpt...
FransBevy wrote:
I work in a Partner's Hospital and I can tell you the focus is on clean,clean, clean all the time for the nurses and ancillary staff. We have monitors who patrol frequently looking for lapses and believe me, they are addressed.
Now all this is for the nurses and other staff but NARY A WORD to the doctors. They round in and out of patient rooms with not a thought to hygiene. They touch, poke, prod and change dressings and we're lucky if we can get them to use gloves. 4/11/2009 7:11 AM EDT

http://www.boston.com/news/local/massachusetts/articles/2009/04/11/state_details_safety_lapses_at_beth_israel/?page=2

Ken Sands MD said...

I would like to comment on my quote in the Globe written as "workers . . . run the risk of being fired." I believe the specific question asked by reporter Steve Smith was "Are you prepared to discipline employees who do not follow policies." I believe my answer was "I can imagine situations where, if there is a pattern of knowingly choosing not to follow established infection control practices, that we would be prepared to take disciplinary action." I did not use the word "fire" and it is worth noting that there are lots of forms of disciplinary action short of termination of employment.

I believe the philosophy at BIDMC is to hire excellent people, give them the tools and training they need, and have a shared expectation of excellence. I believe this works the vast majority of the time, but in those situations where an employee is clearly choosing not to meet expectations, then we need to be prepared to hold that person accountable. I believe that this is what we that work at BIDMC would expect of each other, and what our patients expect as well.

Anonymous said...

Paul,

In the Boston Globe article, "Sands said that hospital workers who are not vigilant about the new infection-control policies run the risk of being fired."

I think I know how you feel about a just culture, but this makes it sound like BI is more punitive...

Paul Levy said...

See Ken's comment above.

Anonymous said...

As a BIDMC patient who is scheduled for a sugical procedure this month, I would find it useful and reassuring to see, if one exists, a chart showing infection rates across the various hospital services.

If the OB cluster sited in the Globe and in this blog are isolated, hospital wide data would show this. I know from previous blog entries that the hospital has has great success in creasing the rate of central line infections but I have not seen any information about the rate of other types of infections across various services. Is such information currently available?

Anonymous said...

You say you are looking to identify others who have contracted MRSA after delivering @ your hospital. Other than go in for care what should someone who has contracted MRSA do?

Paul Levy said...

Please call Patient Relations at 617-632-0364. They should be able to answer most questions. If they cannot, they will direct you to someone who can.

Anonymous said...

Dear Mr. Levy,

I am commenting on an April post, in hopes such comments on older posts may still be received by you.

I was the first commenter on your April 9 post about MRSA at BIDMC (http://runningahospital.blogspot.com/2009/04/dph-and-cms-help-out.html).

I mentioned then that my wife was due to give birth at BIDMC this autumn -- and indeed she is. All has gone well and we are looking forward to entering BIDMC in the next few weeks.

I write now to let you know that the improvements and attentions you promised in your April posts will be looked for attentively during our stay.

I trust that there have been periodic reminders and tools of oversight and checks to enhance and improve your processes during this time.

Many thanks to you and your team for keeping my wife and our baby safe at BIDMC.


p.s.: I was very surprised to read in the NYT that flue vaccines are not generally required in many hospitals (http://www.nytimes.com/2009/09/21/nyregion/21vaccine.html). I would have assumed that all health care workers, especially those working with vulnerable populations, would be obligated to protect themselves and others by taking the vaccine. I hope that BIDMC requires this step.

Anonymous said...

Dear Mr. Levy,

I had written again on 9/22 following my earlier response to your 4/9 post, regarding my wife's then-upcoming delivery at BIDMC.

I wish to now provide some brief feedback and commentary regarding her delivery -- which occurred without incident; mother and baby are happy and healthy (with appreciation to your doctors and staff).

All-in-all our experience was excellent. Processing and paperwork were smooth and efficient. The delivery room doctors were professional and personally attentive. And the delivery room nurses were particularly good -- caring, encouraging, alert, engaged and supportive.

One doctor in the delivery room (not the main OB/GYN) sneezed into her hand, not into the crook of her arm. Though she wore a mask for the procedure, given that she was touching things in the room, she needs to be encouraged to sneeze into a tissue or the crook of her arm -- not into her hand, and if she does, it should be washed immediately.

On the maternity floor, the attention and support were similarly good: attending physicians were frequent and caring; the facilities were very good -- not better than very good (not excellent), but very good. The food was weak but the selection was decent.

When I moved a chair in the room, there was dirt under the chair.

We were impressed with the "voice call button," which made for very efficient interactions with the nursing staff.

Five out of the six nurses with whom we interacted were excellent: patient, caring, attentive, knowledgeable -- with a seeming attention to hygienic practices.

One of the six (not a terrible ratio, but not what it should be, either) was less than wonderful: rushed, curt, peremptory, brusque, a poor listener -- and, a coincidence (?) the only one who did not routinely clean her hands upon entering the room, even after being asked if it were appropriate that we should ask all of our guests to do so. (She did not get -- or take -- the hint.)

Bottom line (or our experience): we were happy and impressed with BIDMC, and thankful that our baby was delivered healthily and without complication for infant or mother.

Thank you, sir -- for this experience, and for the ongoing improvements to make the hospital even better.