Sunday, January 09, 2011

The moral component to transparency

Many of you have asked if I intend to continue this blog, now that I am stepping down as CEO of BIDMC. Yes. (I'll have to change the name. How about "The blog formerly known as . . . " or just a simple "Not Running a Hospital"?)

Please expect a combination of commentary on current events and issues. But also please expect an occasional lesson or two from my experience of the last nine years, all offered in the hope of being helpful to others in the field. I apologize in advance if some portions seem self-aggrandizing or self-praiseworthy. I don't mean them that way, but sometimes, to be historically accurate, I'll have to include a few good things about myself!

Here we go. Act 2.

In a comment on a post below, author Charles Kenney asks:

Isn't there a compelling -- perhaps even overriding -- moral component to transparency?

The answer, of course, is yes. Doctors and others pledge to do no harm. How can you be sure you are living by that oath if you are unwilling to acknowledge how well you are actually doing the job? As scientists, how can you test to see if you are making improvements in evidence-based care if you cannot validate the "prior" against which you are testing a new hypothesis? At the most personal, ethical level, how can you be sure you are doing the best for people who have entrusted their lives to you if you are not willing to be open on these matters?

Back in 2008, the Boston Globe published a story entitled, "Errors test openness at Beth Israel Deaconess." There had been a series of errors at our hospital, and many in the city were questioning whether our policy of transparency with regard to clinical outcomes was sustainable. Some felt that it would inevitably result in a loss of confidence in the hospital, followed by a loss of business, and financial pressure to be less open about such matters.

I felt that transparency was essential as a way of holding ourselves accountable to the standard of care we espoused. I also believed that public trust would increase, not decrease, for a hospital that was open about its errors and its commitment to improvement.

But this had not yet had a market test, and so we were taking a chance (although we were already saving lives.) In later years, the strategy was rewarded in a business sense by the decision of Atrius Health to create a new clinical affiliation with BIDMC, transferring treatment of half of their patients from another tertiary hospital in Boston. I recall Gene Lindsey, Atrius CEO, calling me in March of 2009: "We really like what you are doing in quality and safety, process improvement, and transparency. That is consistent with our values. Would you have the capacity to receive a large share of our patients needing tertiary care?"

But that was later. At the time of this story, there were many doubters. How reassuring then it was for me to receive a number of comments that were helpful in maintaining my confidence about our approach. I want to share some of those with you now. As you will see, these observers nailed the issue, and I am grateful for the fact that these people contacted me at the time.

You need to understand that CEOs live in a somewhat isolated world, so this kind of feedback and encouragement is extremely important. (For those of you working in other hospitals, remember that!)

Dr. Lachlan Forrow, Director of the BIDMC Ethics Program, said:

Re today’s Globe:

There are few reasons as truly fundamental to be proud of being part of BIDMC these days as our ethical commitment to, and courage in, being “the transparency hospital.” If it weren’t hard, it wouldn’t be so important, or so worthy of feeling proud. One day it will be the ethical standard everywhere, in the same way as Beth Israel’s 1972 precedent in articulating and living by “Your Rights as a Patient” set an ethical standard every licensed health facility in the U.S. now emulates.

In our weekly meeting today of the core Ethics Support Service staff, we agreed we should prioritize in everything we do during FY09 the opportunities to building a BIDMC-wide for safety and for pride, and the challenges of maximizing those as the “transparency hospital” culture of openness, safety, trust, and pride.

Specifically we are including in this:

At each monthly unit-based ethics rounds asking staff to identify cases, ideas, and concerns related to building this culture at BIDMC, with emphasis on a “preventive ethics” framework;

Encouragement to each of our >60 “Ethics Liaisons” to incorporate the themes of openness, safety, trust, and pride in the FY09 “ethics project” each of them undertakes in their clinical or administrative area;

Including these themes regularly in our monthly BIDMC-wide Ethics Case Conferences and in Schwartz Center Rounds; and

Reviewing regularly in our monthly Ethics Advisory Committee meetings ways in which we can foster this culture at BIDMC.

Thanks, as always, for serving as out CEO (“Chief Ethics Officer”). Please let us know if you have any other suggestions for ways in which we can make BIDMC even more a source of pride for everyone here – staff, Board/volunteers, patients, and their families.

A prominent attorney in town wrote a colleague, saying:

Tough article but I think what he is doing is courageous and that he should keep it up. More hospitals should do the same.

A respected cardiologist from one of the other Harvard hospitals said:

Read the article in Globe today and want to let you know that I think what you are doing is exactly correct. The pressures must be enormous, but I'm sure you will keep doing what you are doing because it's the right thing to do.

A knowledgeable industry observer in Boston said:

I didn’t expect to see the article on you and BIDMC. I must say that the juxtaposition of your commitment to transparency against a series that will focus on market intimidation and control, left me even more proud of you that I normally am aware. I am confident that your courage will benefit the rich reputation of the BIDMC as well as paving a course of correction for the market.

My colleague Bob Wachter, at UCSF, said:

You’re a brave man, and I know that what you’re doing is right and making things safer.

A former state legislator said:

Stay the course buddy. No one ever said it was easy to do the "right thing" eh? You're a pioneer and I'm proud of you!

Steven Spear wrote a letter to the editor and sent it to me:

Paul Levy and his colleagues at BIDMC are exactly the right track in calling out errors, and they are setting an example that should be emulated energetically at other hospitals. Delivering care requires coordinating harmoniously an extraordinary number of individual disciplines. This means anticipating myriad interactions of patient, provider, place, and circumstance, and anticipating perfectly all circumstances is impossible. However, by responding when things go wrong, those working in and responsible for care delivery processes can see their vulnerabilities, identify their causes, and rectify weaknesses, leading to ever improving efficacy, efficiency, and responsiveness. This is not a hypothetical assertion: Order of magnitude improvements in care have been recorded in Pittsburgh hospitals, at Ascension Healthcare and Virginia Mason Medical Center, and elsewhere. Those hospitals not pursuing the same degree of openness are not any less dangerous. They are simply not admitting the reality to themselves, their staff, and their patients.

A local search firm consultant and former colleague wrote:

You continue to have my continued admiration for your openness and willingness to tackle some of the tougher issues. Have faith that your strategy will prevail!

The Vice President for Nursing at another tertiary hospital in Boston wrote:

I feel compelled to let you know how much I admire your fortitude around the safety issues you are so committed to.

Do everything in your power to keep BIDMC intact as you see it….your patients will reap the result!

One of our urologists wrote:

Just a word of appreciation and encouragement re the transparency issue. It's important, and eventually will benefit everyone. Congratulations on having the courage to keep after it.

One of our Nurse Practioners in Hematology/Oncology wrote:

My husband read this article on the Globe and forwarded it to me. He is a physician who now is only doing basic science at Harvard Medical Center. We often discuss about my life working as a nurse practitioner at BIDMC. I do tell him how great my working environment is and that we try our very best to be a honest hospital and staff to our patients and to each other.

Yesterday, after reading this article, he as once a resident and an ICU moonlighting attending for a year, was very proud of what you have achieved for our hospital. I wanted to say another thanks to your efforts and I am pretty sure that majority of BIDMC family support you all the way!

A member of the BIDMC Board of Directors wrote:

I believe we are changing the way medicine currently operates. I am so proud to be a part of this hospital. We are the future, cutting new ground, getting out the kinks so that others can follow. And they surely will be forced to do the same. I like choosing rather than being forced by outsiders. Trail blazers never have it easy. Who would want easy?

One of our young nurses wrote:

I am taking an Ethics course right now. We are talking about medical Ethics. The "CEO" of Beth Israel came up. All the recent stories came up (deaths, errors etc).

Our hospital was applauded for our transparency. The professor spoke and said that Beth Israel is "leading the way" towards a new future. I referenced your name, and blog, and said that I was proud to be employed by such a forward thinking institution.

What you are doing for our hospital is so important. It transcends beyond our own walls. It is aligning with a standard that I believe will eventually be embraced by the majority. I am not surprised that we are challenged the way we are with all the negative press. All great leaders are tested, as are their ideas! I believe that the good will always shine in the end...I guess we just need to be patient. I am learning a lot from this...

And, the most delightful was this note from my choreographer daughter, Rebecca, who was very used to getting critical reviews of her concerts:

I think that most of the health care industry is secretive and hard to navigate. BIDMC is friendly, the doctors are usually correct, and they treat people like humans. The main issue that you are dealing with, is HUMANS run the hospital and they are imperfect vessels capable of mistakes. These mistakes in this year are bigger ones, and because of your communication with the city and media people noticed. I mean, they notice all of the good things too...they just tend to forget because Boston loves scandal.

If your instinct tells you that total transparency is the right thing to do, which I assume is what it did, then continue being transparent, and just do your job to the best of your abilities. In my opinion, I think it's pretty great that you are willing to talk openly about what happened. Maybe people just want to hear that whoever is responsible feels badly about what happened.

The greatest piece of feedback I ever got was, "be cool".

Oh, and just remember, you are never as bad or as good as the newspapers say.

I love you,


Anonymous said...

Paul, I am delighted to discover that you have not missed a beat in the high quality posts. I look forward to even more enlightening ones when you can further speak your mind.
As to the blog name, I look forward to a contest on Facebook or something! :)

You could not have selected a more important topic for your first 'next phase' post. Reviewing the book on Virginia Mason you recently recommended, I looked up 'transparency' in the index and found 3 citations, all pertaining to either financially-related transparency or to transparency within the organization - none encompass the public, morally imperative, uncomfortable type of transparency you address. And, your followup period demonstrates that in fact it did not hurt your hospital, did it. And the recent NEJM article in which the hand surgeon disclosed his wrong site surgery demonstrates that physicians' concerns can be successfully addressed.

So the question remains - when will this become an everyday process throughout the country to accelerate the criminally slow pace of progress in patient safety, and who now will follow your lead?

nonlocal MD

Charles Kenney said...

Anonymous notes that in my book about Virginia Mason Medical Center, the transparency references in the Index connect to financial issues; that ``none encompass the public, morally imperative, uncomfortable type of transparency you address.'' A slightly deeper by Anonymous would have brought to light a section of the book recounting a tragic medical error made at Virginia Mason in 2004. This incident, in which a patient died, was disclosed publicly immediately by the leaders at Virginia Mason. The Seattle Times newspaper noted that Virginia Mason ``took the unusual step of publicly explaining, and apologizing for, the error.'' Virginia Mason's commitment in these matters is to disclose quickly and fully. One of the Virginia Mason physicians said at the time that the broader medical community cannot learn from events that are hidden. Thus, disclosure advances knowledge and perhaps prevents similar mistakes elsewhere. This story is contained within Chapter Four of the book, ``Safety Crusade.''

Anonymous said...

I apologize to Charles Kenney for being sloppy and looking in the index before I had read the book, which I had just received! Thank you for the correction and the book is next on my reading list. However, I believe the point stands that this is by no means a common practice - unless the evidence corrects me on that also.

nonlocal MD

Jeffrey N. Catalano said...

While efforts at transparency are always to be commended, we must understand that so long as peer review meetings about why an error occurred, whether it could have been prevented, and who is responsible remain confidential from the patient whose own body has been impacted, we will never achieve true and full transparency. A patient has a moral right to all information about why she is suffering and how it happened. We would not tolerate protected non-disclosure in other industries and should not accept it in the medical profession.

Anonymous said...

Mr. Catalano;

While I understand your point, I have been involved in peer review activities and can attest that, without the protection of nondiscovery of peer review, we simply would not obtain the necessary facts of an incident and therefore forfeit the opportunity to make systemic improvements. The malpractice risk is obvious. Look to the aviation industry for a parallel situation.
Perhaps as an attorney you could suggest solutions to this dilemma.

nonlocal MD

Jeffrey N. Catalano said...

When I represented physicians in the '90s and even after representing patients, I believed that the peer review confidentiality provisions served an important role. However, I have since learned that peer review protections have done nothing to improve patient safety, as evidenced by the recent study in the NEJM. Instead, the secretiveness of these meetings excludes the patient from obtaining valuable information. While it may seem that attorneys are only interested in obtaining this information so we can use it to sue, the truth is that many of us are in this profession because we want to seek ways to improve health care and physician-patient relationships by encouraging full disclosure. Your argument, although frequently made, is an implicit acknowledgment that physicians place individual concerns over being sued above improving health care and disclosure -- something physicians would have a hard time tolerating if they or their family were the victim. As VP of the Mass Bar Assoc and as a member of the Mass Academy of Trial Atty's Executive Board, I am always seeking means to work with the medical community to achieve a common goal -- less harm and deaths from medical errors. One suggestion is to amend the peer review statute to require PR information to remain excluded from evidence at trial, but available to the patient himself.

Kerry O'Connell said...

I have never understood why healthcare cannot comprehend that non-disclosure policies inflict lifelong emotional harm on patients that often exceeds the original physical harm. Non disclosure is not merely unethical it is barbaric. If providers were truly honest with themselves they would admit that their own lifelong guilt caused by non-disclosure was not worth the few sheckles that they may have saved avoiding litigation. Disclosure is the only sustainable choice that will preserve and health and soul of medicene. Thank you for standing up for the unfortunate few that continue to experience medicene's dark side.