Thursday, January 06, 2011

Resolve

As our biking group celebrated New Year's eve somewhere in the Atlas Mountains, the usual question arose as to each person's resolution for the coming year. I demurred from saying mine publicly because it seemed a bit pretentious to say, "I'm going to save some lives." But as I thought about it upon returning, I realized that my job as CEO of a Harvard-affiliated hospital requires something of that magnitude. Not that I am a doctor, but I am in a position to influence not only what happens at BIDMC but also, by example and advocacy, other places throughout the world. The same is true for the other clinical and administrative leaders of our hospital.

We can document that we have saved hundreds of lives at our hospital during the last few years by a full and sustained commitment to quality and safety, front-line based process improvement, and transparency. I hear from many of my readers that the stories you have read on this blog and our actions in this arena have changed the way in which you have thought about your own institutions and your practice of medicine.

Yet, when I was in London for the Risky Business conference and asked an audience of 300 people how many of their institutions would have disclosed the existence of a wrong-side surgery throughout their hospital and more widely -- in an attempt to learn broadly from the error -- fewer than ten people responded positively.

As our doctors, nurses, and administrative leadership team speak out at conferences throughout the world, they hear lots of questions, but the one they hear most often from the middle management of other hospitals is, "How can I get my CEO/Chief of Service/Board of Trustees to support me in the kind of culture change you have achieved?"

It is very hard for nurse managers or other mid-level staff people to steer from behind. For one thing, they are very busy doing their day-to-day work. For another, hierarchical organizations do not always respond kindly to suggestions from within the organization.

A physician friend of mine recently wrote with a hard-hitting analysis of this situation:

This is probably the worst time in history to try to advance a patient safety agenda given recent federal legislation, HIT meaningful use, Medicare and all other pressures preoccupying the profession. Nonetheless, it must be done and fast -- but may necessitate a different strategy. Many people working on this are special but far too nice and earnest.


Jim Conway has said:


"It is imperative that the top leaders in quality and safety assemble NOW, and collectively develop an aligned agenda that will allow us to realize our goals. And, in the process, they have the humility to shut up, listen, and learn from other industries that have figured it out a long time ago. We must stop the endless unaligned agendas and we must develop a common language and approach."


While he is absolutely correct, the crux of the problem as I see it is that changing culture is the only permanent fix, but will take so long, as does any major culture change, that it's impracticable given the scope and urgency of the problem. Right now the profession just doesn't see it as their problem and, given the political environment mentioned above and the fragmented nature of medical leadership, we must look to cultural education for the long term, not the immediate fix. They're just NOT PAYING ATTENTION, because they don't HAVE to. There are no consequences.


Therefore the only short term solution I see is one that mandates compliance in some way first, while working to change culture underneath. So the usual weapons of CMS, Joint Commission, legislation, etc. are the only way to achieve anything in the time frame needed.

So that brings me to people in your position. You have an opportunity to get these guys together and add some of those passionate e-patients and maybe get some real "sticks" (opposed to carrots) put in the Joint Commission standards to mandate change sooner rather than later. I can tell you in the community hospital world, which is quantitatively most of the world, this is all that administrators, and therefore reluctantly doctors, respond to.

Culture change and the long process of education will be the eventual answer, and there should be a specific agenda for that, too, as Conway indicates. But, as one of the previously unconverted, I can attest that it takes immersion, much repetition, relationships with "converted" people whom you trust and can ask questions, and time to "get" it. It certainly did me, and I count myself as a case in point.


That my friend might be right is hard to hear. Why? Because regulatory approaches, no matter how well intentioned, tend to lack finesse and often cause people to work on the wrong problems. They are certainly necessary, but they need to be informed by people on the ground.

Perhaps, as my friend suggests, the people on the ground will come from the burgeoning movement of patient advocates. At the IHI Annual Forum, we helped bring together a group of patient advocates. They and others have the potential to form a core group to move things along. But, the passion of these folks may also be their Achilles heel. To be effective, they will need to figure out a way to retain that passion but to make room for the kind of compromise among themselves that allows a political movement to grow. Other advocacy groups have done this in the past -- e.g., in civil rights and environmental protection -- but those movements were also characterized by periodic internecine battles. That is something to avoid here.

Meanwhile, back in the C-suite, what's the role for me and other CEOs who wish to move this agenda along? Clearly, we must resolve to retain and expand our role as local champions for quality and safety, front-line based process improvement, and transparency in our own institutions. As heads of academic institutions, we should resolve to offer stories of our experiences to people in other hospitals, to help create a mutual learning environment. As industry leaders, we should resolve to encourage hard-hitting and effective regulation to move along a recalcitrant profession. And, we should resolve to develop the humility to trust that the patients have an important role in all this. We should invite them in, make them feel welcome, and shut up and listen when they show us a better way.

11 comments:

Pat Mastors said...

As one of the patient advocates privileged to attend the IHI summit, I appreciate the challenge you describe in welcoming patient voices into the mix. While we are seen largely as a "group", and may all ultimately want the same thing (better patient safety and patient-centered care), we are as different in our approach, agenda and methodology as those in the forefront of any group, including the medical profession. We need opportunities to get to know each other, find common ground and collaborate toward our mutual goals. IHI was a great start; you now know that if you want us, we will come.

Lori Nerbonne said...

Paul,

What refreshing words I woke up to this morning when I received notification of your blog post. "Mandates", "Sticks", and the need for rapid change instead of waiting for what we know to be a much-needed culture change.

Across the country, ambitious volunteer patien safety activists have been working in their respective states for years getting legislation passed that mandates infection and medical error reporting, medical board transparency, tougher fines for non-compiance, and a array of other patient safety measures and mandates. (I should ad that we've been mentored by Consumers Union Safe Patient Project and Stop Hospital Infections Campaigns.)

Intuitively, we've known through our collective experiences of suffering harm from the healthcare system that transparency, state and national mandates with teeth, and measuring and publicly reporting outcome data are the quickest, most effective ways to reduce harm and expose the facility leaders that are not investing in patient safety. In it's purest form, it is accountability for saving lives.

Having a respected healthcare leader like you taking a risk and putting such powerful (and not very well liked) words on your blog is admirable and I thank you.

I was also at the IHI Forum Summit with 60 other passionate patient safety activists and am proud to be in the trenches with them, pushing from the outside-in for rapid change.

Becky said...

From Facebook:

Wonderful blog. What if CMS paid higher reimbursement to hospitals that adopted a policy of transparency and disclosure in their mission statement? Positive reinforcement to do the right thing. It would be hard, of course, to regulate - but it would establish a standard tied to an incentive. NQF only suggests disclosure, Joint Commission suggests - no one says DO it. CMS can say DO it, and it will benefit your bottom line; even pennies on a dollar can make a difference when all those pennies are grouped together.

Bart Windrum said...

A year or two ago, when I stumbled across this blog, I was amazed and encouraged. Today Paul's post induces a little internal effervescence. This generally characterizes my post-IHI Patient Activist Leadership Summit state. The summit is likely to prove powerful in ways we don't yet know (but may begin to discover two days hence on our first month anniversary conference all). Already I experience new resolve, am working new realizations into presentations, and conceiving new actions that include outreach to providers and institutions.

I wonder, Paul, if you've given any thought to what an institution like yours, perhaps in association with an institution like Harvard, might do directly with the public? Perhaps teaching how to be a more knowledgeable patient-family when hospitalized. Intended to fill the gap between now and when every hospital becomes BIDMC's equivalent. Since it's clear that culture change, regulation, etc. will take time, might BIDMC have any interest and (financial?) ability to complete the transparency circle by addressing the public at large?

I can't yet find the right words to express that hospitals are at the meeting point. Running a Hospital, rightly, faces providers. Yet most hospitals express quite a lot directly toward the public, just not what matters to us when we arrive as patient-families. Maybe the expression is that for this bird to take flight, both wings—provider and patient-family—must be present and equally strong.

Having just written this, the Rod of Asclepius and Staff of Caduceus come to mind. Not to twist the metaphors, but these two symbols are themselves intertwined in some minds. Maybe Asclepius needs Caduceus' wings.

Just musing. Any possibilities here?

jonmcrawford said...

No offense, but just including it in the mission statement doesn't do a thing. Perhaps rewards for those who do so and then show some evidence of transparency? Doubt there's a single hospital nationwide (worldwide?) where *nothing* goes wrong, so there should be some evidence somewhere.

Pat Mastors said...

I so appreciate Paul putting a stake in the ground for quality, transparency and safety, and I also appreciate and am grateful for our collective strength as patient advocates, due so much to the hard work of CU and the folks who pulled together our participation in the IHI conference. It is clear that more and more we are becoming part of the conversation. But sometimes I read about us and our contribution and feel we are seen as "them" - apart, a bit scary, an unknown quantity brimming with unpredictable volatility (of course many of us get to that place because no one has been listening to us!). Couldn't you sense in Orlando the reticence that crept into some medical people's demeanor when they learned you were a patient advocate? And yet, when they had an oppotunity to really listen to some of us, they developed empathy. They saw us differently. They "saw" us. Not as rates of MDRO infection or incidents of failure to rescue or "that group", but as Helen, Alicia and Patty.

Though we advocates share seats on the boat, and are working toward rowing in unison, we are also individuals who have been dealt the cruelest of hands and are trying to turn it into something positive, each in our own ways. We are exactly like anyone on the "other side" who has not yet had a mother, father, child, spouse or loved one suffer from serious medical harm. The more we are seen as unique, reasonable individuals - doing the best we can when dealt a crappy blow - the more those we are trying to convince will see themselves as one medical oversight or procedural slip away from joining our side. This was the point I was trying to make in my earlier post. The good guys - and there are many - must know us. They must feel comfortable inviting us further inside the door, asking us questions, and coming to trust us. And that is our collective challenge. How to do that?

Is the answer activism and raising a ruckus? Or collaboration, fostering trust and empathy? Is it Ghandi and MLK? Or Susan B. Anthony and Louis Farrakhan?

That said, it wuld be disingenuous to believe we would even have the luxury of asking these questions without the legislative work, the tireless letter-writing, emailing and congressional visits, the op-ed pieces, lawsuits, door-knocking, photocopying, testifying, depositions, videotaping, and blood, sweat and tears of so many who have already given so much. The only thing I am sure of is that I feel the tide juuuuust beginning to turn, evident in the leadership and the drive toward transparency promulgated in Paul's blog post.

So, dear colleagues, how do we best wield our energies to ride this tide?

Bart Windrum said...

Pat, you raise an existential question of us (MLK or Farrakhan). Interestingly, the most emotional person by far I observed at the conference was a provider professional who relayed, in a Jim Conway's session, the chaos and shock she and her patient-family endured during their hospitalization. I wish I would have had the presence of mind to jump up and say to all "There. This is harm. Harm endures, it's not just clinical. This lady's—your colleagues'— angst is residual, existential harm." Unfortunately, the thought occurred to me only later.

Pat, we *are* scarily unpredictable because we are system outsiders, beholden to no one and nothing beyond our loved ones' memories. The very fact that we exist in providers' midst ought to speak volumes about our accessibility and humanity.

In *addition* to the mix/mingle model we partook in as conference attendees, I continue to think that an org like IHI should—on its own, in concert with other orgs, and via stimulating other orgs—find ways to elevate us singly and in groups/panels as presenters of major sessions to both provider and lay audiences. Yes, ePatient Dave did a keynote. He does important and great work, but seems that his focus is "this is how well ePatients can play in the medspace." I think that most of we PAs' focus differs—this is how egregiously harmed our patient-families are as a result of immersion in the medspace, and this is what we now see must change to improve the chances that no one else will be harmed.

This is a challenging message from any point of departure, let alone from system outsiders. I think the truth is that we're, each and all, Farrakhan's in waiting beneath an outer layer of MLKs. Depends upon how we're treated and responded to.

IHI said they want to elevate PAs to greater visibility. To my mind that verbal shorthand includes elevating our audibility (two sides, same coin). All we can do is what we do and wait to see what further initiative IHI takes as a result of this delicious melange we've all engaged in.

Margo Corbett said...

Pat, I like your questions as to the kid of activists we are or are goig to be? I suppose we are a combination of allof them as individuals, but what tact do we want to take as a group. I hope we have a good discussion about this in the near future.

Paul, Thank you for your goals of transpency. Facing ( admitting to), reportig and doing things to prevent future errors is so very critical. I was reviewing some of my past copies of doctor's notes in preparation for an appoitment last week. In it the doctor said, " margo 'seems' to feel she experienced a medical error". The doctor couldn't "seem" to admit to himself that I almost died because of the error. Upon reading it I once again, felt put down and disrespected. Besides the physical damage and the impact on my health the past 26 years, I still find my trust is very low for physicians to properly diagnose and do what is right. I question and question and then question again.

That lack of trust has now been extended deeper into the healthcare system. In the weeks since my return from the IHI Forum, I have had lengthy discussios with a radiologist because I was sent for a diagnostic mammogram and they only did a partial exam. The results came back with abnormalities they weren't the least bit concerned that only one quardrant of one breast had been examined. They were playing the percentages of "what usually needs to be done" rather than looking at my individual situation and needs.

This week I talked to a doctor in the pathology group who may be examininng the tissue that will be removed and he too was playing the percentage game about how the tissue will be tested - even after admitting that reading the slides is an art, not clear cut and knowing the diagnosis for this problem is a difficult one to make even with additional testing. It was okay with him that they are right 95% of the time doing just the basic test and he seemed very comfortable about not taking the testing to the next level. All of the literature I have found indicates further testing is mandatory to make a definitive diagnosis. Be assured I will be having a long discussion with my surgeon before anything is done and will be sure the right testing gets done by the right lab. I have a medical background, kow where to look for information, etc. What about all the people who don't even know the first question to ask?

It's sad so much work at all levels of the medical system has gone to playing the percentages gamei.e. what works for the majority - and writing off the rest of us who need a closer look. These principles and guielines are going to kill a lot of people.

Charles Kenney said...

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

Paul Levy said...

I have long felt so, too.

Anonymous said...

Mr. Levy:

I am a patient who currently sits on your institutions ICU Patient Family Advisory Council (PFAC); and honored to be doing so. It has been touching to witness the passion and commitment of the employees leading this council. They actively listen to the patient and family voices of the council and put the recommendations into action at a fast and furious rate. Their engagement extends far beyond the CMS mandates and being the nice thing to do. They recognize improving the patient and family experience will ultimately improve clinical safety and clinical outcomes.

Mr. Levy, I’m sure care provided at one of your neighboring ICU’s is provided with similar competence and quality but will it be provided with equal importance to the patient family experience? BIDMC’s ICU will be known for caring for patients and families in totality; which ultimately be the patients and families facility of choice.

I know I’m over simplifying and you are likely working on having the same level of buy in I describe above occur throughout your entire institution. I applaud you in this endeavor. In order for this to work it is crucial physicians, “mid-level” providers fully engaged in the process of the patient and family experience; and I don’t just mean those leading advisory groups.
There appears to be a disconnect in those leading groups such as the one I describe above and those that do not (and, don’t just mean your institution). I know time constraints and the demands to see more and more patients has caused the patient experience to get lost. However, 80% of healing, diagnosis comes from history and the human connection (that takes an unhurried conversation/appointment) and the other 20% comes from technology. I don’t know how to lessen the time constraints and the push to see more patients faster. I only know it is essential. I can’t help but wonder if competence and outcomes are similar at neighboring institutions than the ultimate decision for patients to choose a healthcare facility will be based on a hospital that is devoted to deliver care that is first rate, and patient and family centered.
Clearly, the importance of the patient and family voice is at the core of the employees leading your ICU PFAC but I can’t help believe that your belief in transparency has made it possible for them to lead the way for the patient and family voices to be heard.. Thank You!!!